Fail safe or Fail unsafe?

The blowout preventer that failed in the BP oil rig disaster was meant to be fail safe. But why did it fail? There is an excellent video from the NY Times explaining what could have gone wrong. Layers of protection analysis is supposed to find these weak links, but in my experience, LOPA depends heavily on the time available for the team to do it, the experience of the team and finally what is done with the recommendations. Watch the NY times video in this link.

Vacuum hazards - Another one bites the dust!

I came to know yesterday of an incident in India where a pressure vessel collapsed due to vacuum. The hazards of vacuum in vessels that are not designed for them is great. Please see my earlier post on the subject.

Dangers of Solvents inside confined spaces

The CSB has released an excellent video of 5 deaths occurring in a confined space in a hydroelectric plant in USA. The workers were using MEK (Methyl Ethyl Ketone) , a highly flammable solvent inside a confined space when it caught fire most likely due to static electricity. The CSB report has raised three points:
1.The contractor selected for the job was selected based on the lowest quotation even though his safety record was poor.
2.The current OSHA standard for confined spaces (CFR 1910.146) does not specify what additional precautions must be taken for working in a permit-required confined space with a potential flammable atmosphere, nor does it limit entry based upon measurable criteria such as a specific maximum percentage of the LFL, even though OSHA defines an atmosphere as hazardous when it exceeds 10 percent of the LFL.
3.There was no proper emergency plan for the work conducted
In India, the problems with contractors are numerous. Public sector units are required to go for three quotations and submit the job to the contractor with the lowest quote. This is also followed in some private players. Contractors are not trained adequately on the hazards of confined spaces. I know of at least three similar incidents in India where contractor employees died when flammable solvents caught fire inside a confined space.
See the video and report in this link.

Water and reactive chemicals = fire

A warehouse with old stored toxic chemicals has reportedly caught fire in Ukraine. The cause of the fire is due to rain water entering the warehouse and reacting with the chemicals stored and causing fire.
How well are your chemical warehouses protected from the elements?
Read the full article in this link.

Process Safety - Bhopal and BP- I Don't know!

It is eerie. 25 years ago after the Bhopal gas leak occurred, the then police chief met the security chief of Union Carbide and asked him what had leaked and what was the antidote. The answer was "I don't know". Cut to 2010. A news article mentions that "BP executives told U.S. investigators they didn’t know who was in charge of the doomed Deepwater Horizon rig in the Gulf of Mexico or who made key decisions before the vessel exploded in April, killing 11 workers and spewing millions of barrels of crude into the sea". The testimony from Wells, the highest-ranking BP executive to appear before the joint U.S. Coast Guard-Interior Department panel probing the catastrophe, frustrated Hung Nguyen, co- chairman of the panel, who said no one from BP has accepted responsibility for actions that led to the disaster.

“We’ve had so many vice presidents of drilling come before us, I can’t even keep track,” said Nguyen, a Coast Guard captain. “A lot of them answered ‘I don’t know, I’m not responsible’ for this or that. If everybody’s in charge, nobody’s in charge, is that correct?”
One interesting point mentioned by a manager was that he could not read the well cementing procedure in his blackberry due to its small size! Now did a blackberry cause the disaster?!!!!
Read the news article in this link.

PSM violations in refinery

OSHA has fined a Louisiana refinery for deficiencies in its PSM program.
Serious violations found include failing to provide accurate process safety information for piping and instrumentation diagrams, conduct incident investigations, provide written operating procedures, resolve recommended actions resulting from compliance audits, and adequately address the citing of control rooms and employees working in process units.
Read more of the article in this link.

Ammonia leak in refrigeration plant

An ammonia leak in a refrigeration plant in Alabama in USA has put 10 people in hospital including two in intensive care. It is reported that the was from piping.
Read more in this link.
As a spate of ammonia leak incidents have recently occurred from refrigeration plants in the USA, the CSB is investigating it in detail.

Process safety makes business sense!

A news item mentions that BP will pay a $50.6 million fine, negotiate another $30 million in penalties imposed by the Occupational Safety and Health Administration (OSHA), and undertake $500 million worth of repairs and upgrades at the Texas City plant where an explosion took place in 2005.
Under the agreement, BP will pay the $50.6 million fine and work out with OSHA how much of an additional $30 million in fines it should pay for other violations the agency has found on subsequent inspections at Texas City. BP will also spend $500 million to fix "process safety" problems it ignored on 28 separate plant processes.
Read more of the article in this link.

100 major oil and gas leaks from UK offshore

A news item reveals that there were nearly nearly 100 major oil and gas leaks from UK platforms in the past year. It is reported that there were 443 dangerous occurrences during the last year. Remember the Piper Alpha disaster in the North Sea in 1988. This data again reinforces my strong belief that technology alone will not solve our process safety problems. Its about people. Read the full article in this link.

Ammonia leak from broken pipe

An incident of a broken pipe leading to anhydrous ammonia leak has been reported in Lacona,USA. Authorities ordered a voluntary evacuation of the town. Just observe the lack of populated areas around the leak area. Catch this happening in India!
See the 15 photos of the leak and emergency response in this link.

Traces of phosphine gas reported emanating from MV Chitra

News reports indicate that traces of phosphine gas emanating from the damaged MV Chitra which was involved in a collision with another ship at Mumbai Port is delaying salvage efforts. The ship was reportedly carrying Aluminium phosphide, which is used as a pesticide and rodenticide. Aluminium phosphide on reaction with water generates phosphine. Wikepedia reports the following on phosphine:Phosphine gas may form explosive mixtures with air and can self ignite. The gas is heavier than air. When phosphine burns, it produces a dense white cloud of phosphorus pentoxide – a severe respiratory irritant.[8]
Also, Wikepedia reports the following about Aluminium phosphide:
In October 2002, Sir Derek Bibby, 2nd baronet and great-great-grandson of the founder and past chairman and president of the Bibby Line shipping company, aged 80 and terminally ill with leukaemia, committed suicide by consuming aluminium phosphide - the poison, hours later, caused his body to emit dangerous fumes forcing the evacuation of the hospital department where his body was being held.[4]
In February 2009, two children died in Jeddah, Saudi Arabia after a neighbouring house was fumigated with aluminium phosphide.[5]
In February 2010, two sisters died in Layton, Utah after the area around their home was treated with fumitoxin to get rid of rats. The two sisters, ages 4 years old and 15 months, died just three days apart from each other after experiencing identical symptoms.[6]
See the following links for further information
News item about phosphine gas leak
Aluminium phosphide
Phosphine

Dangers of turbine overspeed

In 1983, I was nearly killed when a 100 HP steam turbine driving a naphtha pump catastrophically disintegrated due to overspeeding caused by the choking of the pump suction strainer. I was standing near the turbine when I heard it suddenly speeding up. I managed to hide myself behind a concrete pillar before the turbine disintegrated. The mechanical overspeed trip malfunctioned and did not work.
Understand that rotating equipment have speed limits and make sure that your overspeed trip mechanisms are working properly.
I was saddened when I came across a news item about an incident in 2001 when a person was killed due to an overspeed of a turbine when it was being tested.
Read more about the incident in this link "Machinist Struck and Killed by Fragments from Ruptured Steam Turbine Housing"

Dangers in silos or bins

OSHA has reportedly fined a grain handling facility fined $721,000 after a worker was engulfed in a storage bin. The OSHA news item reports as follows:
"OSHA fined Cooperative Plus Inc. $721,000 after a near tragedy in February, when a worker in a storage bin was trapped in soybeans up to his chest in 25 degree weather. The worker was ultimately rescued after a four-hour ordeal. OSHA issued 10 citations against the Burlington, Wis., farmer-owned cooperative after inspectors concluded that the employer had willfully disregarded safety requirements by exposing workers to the risk of being engulfed and suffocated in grain storage bins. Two of the citations were for multiple egregious violations for failing to provide workers entering grain storage bins with body harnesses and lifelines and failing to provide an observer while other workers entered the grain bins. See the news release for more information about this case and OSHA's new grain storage bins fact sheet* for more information on engulfment hazards".
Unfortunately, this type of incident happens with disturbing frequency in the grain handling industry. In the last 10 months, OSHA fined two grain handling facilities more than $3 million after separate incidents in which a 17-year-old who had just graduated high school and a 52-year-old husband and father were engulfed and suffocated in grain storage containers. Last month, two Illinois teenagers (ages 14 and 19) were suffocated after being engulfed in a grain bin they had entered. A third young worker was hospitalized after being trapped in the bin for 12 hours.
OSHA has published a useful fact sheet on the hazards in silos, which is given in this link

Gas cylinder explosion incident

Treat your gas cylinders with respect. The Gas cylinder Rules are very clear in specifying the safety precautions to be taken. Gas cylinders not properly handled are ticking time bombs. An incident of gas cylinder explosion killing one person in Pune has been reported and the plant manager has been arrested. Please see the news articles in these links:
Gas cylinder explosion
Plant manager arrested

Process Safety Management - Its not all technical!

A huge wave of interest in Process safety generally occurs after a major incident. The Jaipur oil fire,the BP oil spill, the Bhopal gas disaster court verdict and other incidents have sparked a huge interest in process safety.The management of process safety does require a lot of technical competence. However the MANAGEMENT of Process Safety requires just that - its about people. Just pause back a bit - Bhopal - 1984.... reasons for the incident - cost cutting without assessing risks, ignoring warnings,poor emergency response planning... the list goes on. One or more of the same reasons keep coming up for the recent incidents also! Technology has changed rapidly and we have Safety Integrity levels, redundant systems, more reliable equipment etc etc but still accidents happen. Why? Because wrong decisions are taken by a human being. Whatever administrative frameworks we design and provide for risk based process safety, one day a human being is going to override the administrative framework and take a decision that ultimately causes an incident. I was jokingly mentioning to participants of a process safety seminar that as long as people exist, the job of a process safety management consultant will be in demand!Have a safe day!

Fire in Plastics Godown in Kolkata

Thanks to Abhay Gujar for sending news about a major fire in a plastics godown in Kolkata. Do we give the same importance for emergency preparedness to godowns and warehouses that store hazardous materials as we do for chemical manufacturing units? See a video of the fire in this link.

6 workers drown in Lucknow Ketchup Factory

Alas, it's happened again. A worker fell into a ketchup tank in a ketchup factory in Lucknow, India. In the process of trying to save her, another 5 co-workers lost their lives. In any confined space entry, the job of the man watch is to call for help if anybody inside needs to be rescued. Train your operators on rescue techniques and most importantly train them to overcome the natural feeling of going inside the confined space without proper protection to rescue a fallen co-worker.
Read more of this incident in this link.

Dangers of chemical reactions

Unexpected chemical reactions are dangerous and can kill.Whenever a new product is envisaged, it must be taken through a proper management of change process, including understanding of process chemistry.Even though this incident happened in 2008, it underscores the importance of knowing what you are doing. Read about the incident in this link.
More recently, another accident occurred at a chemical factory at Ankleshwar where two people died. Read about the incident in this link.

OSHA will not ban Gas Blowing of pipelines

A news article in the Wall street journal mentions the following: "OSHA administrator David Michaels, in a news briefing Thursday, said his agency is putting the power industry "on notice that it is inherently dangerous" to conduct gas blows and he said the industry "must assure worker safety," if it persists.
But he said he wouldn't put an emergency order in place that would prohibit gas blows until the agency studies it further. "We would love to be able to ban it, but we can't," he said.
The chairman of the Chemical Safety Board, which investigated the incident, said Thursday that OSHA's response to the Kleen Energy explosion was insufficient despite it being even though it is the third-largest recommended fine in a single accident in agency history.
"I believe there should be an emergency response to an emergency situation," said Rafael Moure-Eraso, the board's chairman, a former academic.
After the board's probe, big equipment makers including General Electric Co. and Siemens AG said they would tell their customers to substitute compressed air or nitrogen for natural gas. Utility American Electric Power also said it would avoid the procedure based on the board's findings and its own analysis".
Read the full article in this link.

Fire in chemical godown at Bangalore

Thanks to Mr Sritharan for sending the following information:
Please find the news on the fire which broke out in a chemical (solvents and thinners) storage godown in Shivajinagar, Bangalore. The godown was located in a densly populated commercial and residential area. As usual the fire dept says that the godown did not have the necessary license only after the incident and do not have proper procedures to check out these violators.
Also the news reports that the local people started pouring water as soon as they saw the fire without knowing that some water sensitive chemicals can indeed aggrevate the situation. Only the trained fire fighters should handle these types of chemical fires.
Read the news article in this link.

Where does the buck stop in Process Safety Management?

I have been viewing the numerous developments in process safety in India with great interest. The Indian Chemical Council has taken a big interest in Process Safety and is collaborating with the Center for Chemical Process Safety of the US. While it is good that a great awareness of Process Safety Management is being created in India, where does the buck stop as far as Process Safety Management goes? The composition board of directors of many chemical organisations in India are changing with fewer and fewer companies having technically qualified people at the helm.With due respect to the immense experience that other directors bring, I see an erosion in technical competence at the board level. While risk based process safety does bring in process safety metrics to the board's attention, it needs technical competence to analyse these metrics. Ultimately, the culture of the organisation trickles down from the decisions that the board takes. What is the long term solution to this issue? No amount of management systems is going to avoid a catastrophic incident. They will warn you adequately before a big incident happens, but unless someone at the board level is competent to analyse these warnings, you cannot prevent the incident. It boils down to basic human behaviour. Is a director on the board going to pay more attention to what another technically competent director is saying, or to the various process safety metrics he sees displayed but may not fully understand? I leave it to you to decide...
Meanwhile read an interesting article in the Fortune magazine in this link.

Drum bursting hazard - readers innovation

In my earlier post , I had mentioned an incident on the dangers of pesticide technical drums bursting when placed in a hot box or steam heated bath. A couple of readers Mr P.Kadhiravan and Mr P.Thulasiraman of Coromandel International Limited have devised a simple pressure relief system for the technical drums which they place in a steam bath for melting. Their pressure relief device is screwed on to the drum in the bung area after removing the drum cap. A photo of their innovation is shown. Kudos to them! And thanks to them for sharing this information.

Share your incidents!

I thank readers of this blog for their continued support. I request readers to send in short descriptions of process incidents they know, to me at bkprism@gmail.com for publication in the blog. I will give the reader credit for the input. The company's name need not be mentioned.Thanks in advance!

Enforcing Process Safety Management

I always wonder that even in the US where PSM is mandatory and companies face stiff fines, there are always violations taking place. Recently OSHA has proposed to fine a seafood company a total of $279,000, for deficiencies in its process safety management program. "The inspection identified other PSM hazards that resulted in 12 serious citations, with $84,000 in proposed fines. These conditions included failing to update process safety information, conduct an incident investigation of a January 2001 ammonia leak, certify or evaluate the PSM program every three years as required, establish and implement procedures to maintain changes in the process, and provide and document employee training".
Read the full article in this link

Engineering control to avoid deaths

The recent train accident at Sainthia station when a speeding train rammed into a stationary one,has raised many questions.An excellent article in Forbes India magazine describes the various engineering controls that are available to prevent such accidents. The article mentions that "There is a range of technological solutions that can remove the scope for human error and make the system fool-proof. The Indian Railways have experimented with a range of solutions to improve its safety record, but none of them has been scaled up nationwide either due to the lack of budget or simply because the powers-that-be had other priorities. When asked, a senior executive in the Indian railways, in charge of technology implementation, prefers to maintain a stoic silence on the issue. Former railway officials, however, are far less sanguine. “The job must be ruthlessly done and the management must not shy away from shedding blood,” says a former Chairman Railway Board who did not wish to be quoted".
In the chemical process industry also, I observe many cost cutting initiatives affecting engineering controls. As long as nothing happens, nobody dies!
Read the full article in this link.

Gas leak from storage tank

Thanks to Abhay Gujar for sending this news. The Hindustan Times has reported a gas leak from a chemical company in Kalyan. Another article reports that the gas that leaked was Hydrochloric acid.
Read more about the incident in this link
The MSDS of Para Toluene Sulfonyl Chloride which was reportedly stored in the tank, indicates that it is water reactive. Read the MSDS in this link.

Safety valves and runaway reactions

I was participating in a HAZOP study of a reactor where a runaway reaction was possible.There was a serious discussion about the reaction kill system, when one of the participants asked what the operators will do if a runaway reaction occurs. The operations chief who was participating immediately answered - run away!He had witnessed an actual runaway reaction in which the reactor started rumbling, gaskets blew, safety valve lifted,and the operators ran away. Know the design basis of your safety valves. This is important for management of change and for writing operating procedures.