Strong oxidiser causes oil pipeline blast

A new report indicates that the pumping of a wrong chemical into a pipeline that had just completed unloading of crude oil. The report states that "An investigation has found that a desulphurising chemical was mistakenly pumped into pipelines after a tanker had stopped unloading crude at the port city of Dalian last Friday, triggering the explosion, the State Administration of Work Safety said in a statement posted on its website.The 0.9-meter-diameter oil pipeline exploded at 6 pm on July 16, triggering a smaller adjacent pipeline to also explode, the statement said.
The explosion occurred as workers from the Shanghai-based QPRO Inspection and Technical Service. continued to inject desulfurizer into the pipeline after the 300,000-ton tanker had finished unloading its oil at 1 pm.
Produced by the Tianjin-based Huishengda Petroleum Technology, the desulfurizer was strongly oxidizing, according to the statement".
Read more of the article in this link
For a translation in English of the same accident, read about "Management of Confusion" in this link!.

Update on "Spraying of pesticides into AC ducts - possible cause of incident"

The pesticide involved in the incident I had mentioned in my earlier post is reported to be malathion. Read the MSDS of malathion in this link

Management systems - on paper or by commitment?

I have always been of the view that management commitment is something that cannot be spelt out on paper that we can expect top management to follow. Paper based management systems will remain on paper unless top management throws its full commitment behind it. Commitment is intangible. It is seen at the ground when decision are taken by managers that have an effect on process safety.Top management are also human. They also can succumb to pressure from stakeholders. I will give you an example. A leading chemical manufacturer I visited had all management systems in place and certifications.During my field visit, I observed a safety valve on an equipment isolated as it was prematurely lifting (popping) and causing loss of production. This safety valve had no redundancy. When I spoke to the Plant manager,he mentioned that all systems remain on paper and when the actual decision on safety is to be taken, he is expected to take action to maintain production targets!
Interestingly, BP, after the recent oil rig disaster itself is of the opinion that management systems alone cannot control risks. I am quoting from the article: BP said "there can be no assurance" that a major global deployment of its in-house Operating Management System would identify all risks or provide information on the right actions to take when things go wrong. The rollout will be complete this year.OMS was introduced as a key safety step following the large explosion in BP's Texas City Refinery in 2005, which killed 15 workers and injured 170. The system is being implemented across BP operations in locally-tailored modules, following global standards. It is now in all US sites and will be rolled out by the end of the year to the remaining few sites elsewhere that do not yet have it.
The OMS system, described by BP as the "cornerstone" of its safety efforts, was developed by BP in-house, built around Microsoft SharePoint and Performance Point. It helps integrate local standards and management systems, set priorities, define processes and measure performance, and is accessible on BP PCs as well as mobile devices used by engineers on the rigs.
But yesterday BP said: "Even after implementation of OMS has been completed, there can be no assurance that OMS will adequately identify all process safety, personal safety and environmental risk or provide the correct mitigations, or that all operations will be in compliance with OMS at all times." Read the full article in this link.

What is the solution to this problem? Top management should pay attention to external safety audits as they indicate things that may not be spotted by internal audit teams. I have also seen some managements asking the external auditors to tone down their findings. Now this is hara kiri!Here the moral ethics of consultants and auditors come into play. Whatever certifications or management systems the company employs, there must be a threadbare audit of decision making and management's tracking of safety management systems. Its only the acceptance of facts that will prevent an incident.

Spraying of pesticide in AC ducts - a possible cause of an incident

The Hindu Newspaper has reported that employees in a manufacturing unit had to be hospitalised due to the possible spraying of pesticides into an AC duct.The root cause is still being investigated. This raises a larger question of product stewardship. Pesticide Manufacturers in India do post all the warnings in their product but how do we ensure that they are all followed?
Read the article in this link.

Process safety -Humidity causes an incident!

An incident where humidity was the main cause of an incident involving ammonium persulfate has been reported. The incident occurred in a blender in which ammonium persulfate absorbed moisture and started decomposing. This forced the evacuation of 500 workers. See the MSDS of ammonium persulfate in this link.
Read the article about the incident in this link

Two day Process Safety Management Training at Chennai on August 12th and 13th

I am pleased to announce a two day training session on Process Safety Management on August 12th and 13th,2010 at Chennai. The course is a highly practical one and the participants can implement what they have learnt. For further details please see this link
If you want the brochure and booking form to be sent to you, please contact me at bkprism@gmail.com

Hazardous waste facility explosion report

"A U.S. Chemical Safety Board (CSB) case study released today on the 2009 explosion and fire at the Veolia ES Technical Solutions L.L.C. facility in West Carrollton, Ohio, calls on the industry to improve safety standards covering hazardous waste processing, handling, and storage facilities. The Board also recommended that fire protection codes be revised to require companies to determine safe distances between occupied buildings and potentially hazardous operating areas.
The accident occurred on May 4, 2009, when flammable vapor was released from a waste recycling process, ignited, and violently exploded. The blast seriously injured two workers and damaged 20 nearby residences and five businesses. CSB investigators found that the north wall of the lab and operations building – where the victims were injured –was less than 30 feet from the waste recycling processing area where the flammable vapor was released.
CSB Chairman Rafael Moure-Eraso said, “This accident should not have happened. Our report notes that OSHA cited the company for inadequate attention to process safety management practices in the handling of flammable liquids. But in case of an accident, I believe it is absolutely critical that buildings at chemical facilities be sited safe distances from process equipment to maximize the safety of workers. We are making recommendations that would help ensure that operating areas with occupied buildings such as control rooms be sufficiently separated from process areas containing flammable liquids and gases that have the potential to explode.”
Read the report in this link.

Labs are as dangerous as process plants

Do not ignore safety in laboratories when concentrating on process safety. Many incidents occur in labs and R & D facilities. An incident in an university lab killed a girl when the pyrophoric chemical she was handling ignited. Investigate any incident in the lab or R & D with the same focus as an incident in the plant. Read more of the unfortunate incident in this link.

Update on Phosgene hose leak incident

A news report indicates that OSHA has cited DuPont and proposes fines for the phosgene hose leak incident that killed one employee. It is also interesting to note that one of the factors for the leak was physical corrosion below the manufacturers sticker label on the failed hose.
"OSHA said DuPont failed to:
-Properly inspect piping used to transfer phosgene.
-Perform a thorough process hazard analysis for its phosgene operation.
-Train workers on hazards associated with phosgene.
-Thoroughly inspect all high-risk sections of piping used to transfer oleum.
-Properly install energized electrical conductors.
The agency issues a serious citation when there is substantial probability that death or serious physical harm could result from a hazard the employer knew or should have known about".
Read more in this link

Gases can be deadly - Blast in coke oven

Thanks to Abhay Gujar for sending me this news to share with you.An explosion in a coke oven battery near Pittsburgh has reportedly injured 20 persons. "To make coke, coal is baked in special ovens for hours at high temperatures to remove impurities that could otherwise weaken steel. The process creates what's known as coke gas — made up of a lethal mix of methane, carbon dioxide and carbon monoxide".. Read more of the accident in these links:
Explosion At Pa. Coke Plant Under Investigation
Experts: Coke plants full of dangers, can be safe

Two people die in fertiliser plant fire

There are news reports that two people died and two were injured in a fertilizer plant fire in Libya on 11.7.10 when maintenance work was on. Work permit systems are enforced to prevent such loss of lives and I will post more details if I get it.

Cabon Monoxide - a deadly gas

A recent incident in the Durgapur steel plant highlights the danger of Carbon Monoxide (CO). Carbon monoxide is produced in ammonia, methanol plants, in refineries and in blast furnaces. Any improper combustion of fossil fuels will also lead to the generation of CO. CO binds with blood hemoglobin to form carboxyhemoglobin. Carboxyhemoglobin cannot take part in normal oxygen transport, thus reducing the blood’s ability to transport oxygen. Depending on levels and duration of exposure, symptoms may include headache, dizziness, heart palpitations, weakness,confusion, nausea, and even convulsions, eventual unconsciousness and death.Recently in the newspapers, there have been incidents of fatalities in cars where occupants have kept the AC running when the car was stationary. Leaks in the exhaust system allowed CO to enter the passenger cabin thus killing occupants. Read the report of the incident at the Durgapur steel plant in this link.

Public perception of Process Safety in India

Thanks to the media and internet and the demographics of India, a large number of the younger Indian generation are aware of the hazards of chemical industries and the importance of process safety management. In fact, the Bhopal disaster court judgment has raised awareness about the hazards of chemical industries. What can industries,industry associations and the Government do about it? I have a one word answer - transparency. Transparency in conduct of operations, transparency in incident investigation and sharing of incidents, transparency in law enforcement, transparency in environmental assessment processes, the list goes on.... The transparency International website indicates that for 2009, India has a corruption perception index of 3.4 on a scale of 1 to 10 where 1 is the most corrupt. We are at the bottom of the pyramid here! What does this have to do with process safety? Though the chemical industry is making an effort to improve safety and the public's perception of chemical industries, it will take a huge effort to really change perception. With daily newspaper reports of Government officials being caught taking bribes, a life has no cost in India unless it belongs to an influential person.
The recent Mangalore air crash has brought about some changes in investigating aviation incidents in India. In a similar way, a Chemical Safety Board on the lines of the US CSB (www.csb.gov) needs to be formed. All major chemical accidents need to be investigated independently and the reports be made public through the net.Meanwhile I keep praying that another Bhopal does not take place in India.

Mnagement systems and Process Safety

The Indian chemical industry is on a path of vibrant growth. Many chemical manufacturing units recognize the need to manage process safety as the consequences of a chemical accident today are enormous. However, organisations also need to realise that management systems alone will not help. Getting certified to ISO 14001,OHSAS 18001 or Responsible Care etc cannot by itself prevent a disaster. It is the Management of these systems that will prevent one!By this I mean how does the top management utilise these systems to prevent a disaster? In many organisations in India I have observed that when a key top management person like the CEO changes,and a new CEO arrives,these management systems may go for a toss if the new CEO was not as focused on them as the previous one! How do we ensure continuity of effective implementation of systems? My answer is that profits should never override process safety and other management systems. This is easier said than done! Read an interesting article in this link.

Chlorine Safety

The Aditya Birla company has a nice practical presentation on chlorine safety which you can access through this link.

Missing incident investigation deadlines

In many process safety audits , I keep observing that detailed investigation of incidents keep missing their deadlines. This speaks of the culture of the organization. When we don't learn from incidents, we will repeat them. I was reading a news item in Times of India which mentions about the investigation of the Mangalore air crash. I quote from the article " What happens when Directorate General of Civil Aviation (DGCA) officials violate their own rules? Nothing. It's been over a month and a half after Mangalore air crash and no preliminary investigation report has been released yet, though the country has a rule that puts a 10-day deadline for filing one. Little wonder, then that the rule concerning accident/incident investigation is hardly known in the aviation industry as it has almost always been violated.
If this can happen in the Indian aviation industry, I am worried!!!
Read the full article in this link.

Ticking time bombs!

The incident of old chlorine gas cylinder leak at Mumbai Port Trust raises a question. How many such ticking time bombs are still there? The Indian Gas cylinder rules are well written but I have observed that people give scant respect to gas cylinders. Domestic LPG cylinders being tossed about is one case. In the Mumbai Port Trust incident the FIR has been raised against "unknown persons". Isn't the port responsible for all hazardous cargo in its facility? I quote a NDTV news item "That is supposed to be an empty cylinder of chlorine, but sometimes you have residual chlorine which remains in the cylinder and that leaked out," explained Rahul Asthana, the Deputy Chairman of the Mumbai Port Trust.
How does one know it is empty unless it is confirmed? How did residual chlorine remain in the cylinders??
A friend of mine also points out that many chlorine cylinders are used in thermal power plants and municipal water treatment plants and that they store a large number of chlorine tonners. I am only reminded of Dr Trevor Kletz's statement " What you don't have cannot leak!"
Read the NDTV article in this link.

BP Oil Spill - an interesting take

I read an interesting article in Forbes.com where the writer mentions the following:
"The job of senior executives (or politicians and regulators) is to think the unthinkable. While few risks truly justify a "never failing" attitude, those that do should follow my five reliability principles:
1. Multiple things must line up before failure can occur (catastrophic failures are extremely rare).
2. Junior management error is the most frequent root cause. Why protect against something that probably won't happen?
3. Very carefully control configuration changes. In BP's case the drilling rig was being disconnected at the time of explosion.
4. Look for unintended interactions between adjacent systems. For instance, unexpected freezing conditions prevented the first BP well cap from working.
5. Be very, very careful toward the very end of long-term projects. On the day of the BP explosion plaques were being distributed to employees for seven years of uninterrupted safety".

Point number 2 in which the writer mentions that Junior management error is the most frequent cause is linked to organisational culture. With the Indian workforce becoming younger and younger, I observe a shift in the Plant manager's perception of risk. They are becoming more blind to risk due to inexperience and lack of training, and conflicting signals from top management (Top management talks about safety but does not back up its actions with resources). A recipe for disaster!
Read the full article in this link.

Hot Work Accidents

25 years ago, I was witness to an incident where a new pipeline was being prefabricated by supporting it on a "empty" drum. Unfortunately the drum had been earlier used for draining naphtha from a vessel and still contained naphtha vapours. We were inside the control room (about 40 meters from the hot work) when the welder started welding two pieces of the pipe supported on the drum. The explosion could be heard inside the control room. The heavy pipe was lifted 15 feet into the air and fell on the welder killing him.
The basic precautions for hot work include a written work permit system, monitoring the work place for combustibles/flammables, ensuring that no flammable material enters the hot work area/equipment by proper positive isolation,containing the sparks from the hot work and proper training of both permit issuer and receiver. In many plants I visit, the operations and maintenance personnel think it is the job of the safety officer to check these points. You must understand that is the primary job of both the permit issuer and the permit receiver to check all these points before they carry out the work.Let us not kill more people.

Texas City to the Gulf

An article "Blast at BP Texas refinery in 2005 foreshadowed Gulf disaster" by Propublica mentions the following about the BP Texas city refinery incident:
Soon after the merger, BP demanded a 25 percent budget cut across all its U.S. operations.
Among the reductions at Texas City:
* Cut inspectors and maintenance workers by the dozens to save just over $1 Million.
* Eliminate safety calendars: $40,000 in savings.
* Reduce purchases of safety shoes for employees: $50,000 in savings.
* Eliminate safety awards: $75,000 in savings.
An outside auditor that Parus had hired, produced what was probably the most damning internal report [2] ever to emerge from the Texas City refinery. After surveying more than 1,000 workers and interviewing hundreds, the auditors concluded that the plant's employees had an "exceptional degree of fear" of a catastrophe, and that "blindness" across the entire corporation prevented critical safety information from reaching the top levels of BP management. It also said that poor conditions at the plant created hazards "you would never encounter at Shell, Chevron, Exxon, etc."
The 62-page report included direct quotes from some of the workers:
"The heroes around here are the ones working to the production goals and who complete them early. 80 to 90 per cent of what gets recognized is doing it fast counts."
"Telling the manager what they want to hear, that gets rewarded. For example, one person who had cut costs, done a lot of Band-Aids with maintenance and had a quit-your-bellyaching, quit-your-complaining attitude was rewarded in the last reorganization. When his replacement was brought into his previous maintenance position, his replacement found that not a single pump was fit for service; air compressors, not one spare was fit for service."
"Units are 90% of the time run to failure, due to postponing turnarounds [maintenance]. So making money or saving money for that particular year looks good on the books. This is a serious safety concern to operating personnel. We do not walk the talk all the time. Costs and budgets are preached to reduce costs."
Read the full article in this link.

Corncobs to Ammonia

I read an interesting article that would be of use to my friends in the Ammonia Industry. A company called Syngest is setting up a plant to convert corncobs to ammonia.
"The bio-ammonia plant will turn 150,000 tons of corncobs into 50,000 tons of anhydrous ammonia annually, enough to fertilize 500,000 acres of land. The process involves a pressurized oxygen-blown biomass gasifier operating in an expanding bed fluidized mode. After the resulting syngas is cleaned, the carbon monoxide portion is shifted to maximize hydrogen, which is purified and catalytically reacted with nitrogen to make ammonia. Syngest has procured 75 acres for the plant, five of which will be used for the facility itself and the rest for biomass storage. The plant will require 10 percent of available corncobs within a 30- to 40-mile radius".
I was wondering that even after so many years,the production of ammonia still needs high pressures and temperatures.When will we see an inherently safer process?
Read the full article in this link

Process Safety and Bottom of the Pyramid!

I am borrowing a phrase from the late Dr Prahalad, Management Guru, when he was mentioning the fortune to be mined at the bottom of the pyramid.As far as process safety goes., misfortune lies at the bottom of the pyramid!
A news article mentions today that 9 IOC officials, including the GM of the oil depot have been arrested by the police for the Jaipur oil depot fire. The report quotes the incident investigation report by an independent panel which mentions that "human error, lack of safety procedures and design flaws were found to be the major reasons responsible for the fire.The basic or root cause is an absence of site-specific written operating procedures, absence of leak stopping devices from a remote location and insufficient understanding of hazards, risks and consequences,M.B. Lal, who chaired the independent inquiry committee, said. In a 2003 audit, the Oil Industries Safety Directorate found that the remote leak stopping device was not working at the Jaipur terminal. The inquiry found that despite the recommendation in 2003, the device was never operational in the last six years, he added".
Does it not speak of an organizational safety culture issue??
Read the article in this link.

Cost cutting Vs Process Safety

An excellent article in the Wall Street Journal mentions the following in the aftermath of the BP oil spill:
'Early on June 5, 2008, a piece of steel tubing ruptured on BP PLC's vast Atlantis oil platform in the Gulf of Mexico. The tubing was attached to a defective pipeline pump that BP had put off repairing, in what an internal report later described as "the context of a tight cost budget."
The rupture caused a minor spill, just 193 barrels of oil, but BP investigators identified bigger concerns.
They found the deferred repair was a "critical factor" in the incident, but "leadership did not clearly question" the safety impact of the delay. The budget for Atlantis—one of BP's most sophisticated facilities— was "underestimated," resulting in "conflicting directions/demands."
Until the April 20 explosion of the Deepwater Horizon oil rig in the Gulf, Mr. Hayward repeatedly said he was slaying two dragons at once: safety lapses that led to major accidents, including a deadly 2005 Texas refinery explosion; and bloated costs that left BP lagging rivals Royal Dutch Shell PLC and Exxon Mobil Corp.
An internal BP presentation from December 2007, early in Mr. Hayward's tenure, noted that there had been 10 "high potential" incidents at BP facilities in the Gulf since the start of that year, including one December case in which a worker suffered an electric shock but survived. A common theme, the report found, was a failure to follow BP's own procedures and an unwillingness to stop work when something was wrong.
"As we enter the last two weeks of 2007, we are experiencing an unprecedented frequency of serious incidents in our operations," Richard Morrison, vice president for Gulf of Mexico production, wrote in an email to staff. "We are extremely fortunate that one or more of our co-workers has not been seriously injured or killed."
Read the full article in this link