Speech by Jordan Barab of OSHA on Process Safety Management

At a speech by an OSHA official Jordan Barab,the following have been highlighted by the speaker:
"First: Effective process safety programs and strong workplace health and safety culture are critical for success in preventing catastrophic events.
Second: Industries need to learn from their mistakes. We know the major causes and we know the remedies. Yet lessons learned are not applied and the same problems surface to threaten workers again and again.
Third -- and I'm not telling you anything you don't already know: Numbers don't tell the whole story. Focusing on low DART rates alone won't protect you from disaster. New metrics are needed.
Now, let's explore these ideas a bit more.
Let's look at Concept number one: Effective process safety management systems and workplace safety culture are critical for success in preventing catastrophic events.
In the Baker Panel Report, issued after the BP Texas City explosion, the panel devoted considerable space to the importance of effective process safety systems and the need to build a strong corporate safety culture.
Process safety failures are typically low-frequency but high-consequence events. Our PSM systems have to be strong, and we cannot wait until we have an incident to discover that they were not.
What it comes down to is organizational culture. To paraphrase Professor Andrew Hopkins (whose work I'm sure you are all aware of): Workplace culture is not just an educational program that gets everyone to be more risk-aware and think "safety first." It's deeper and more ingrained than this. Hopkins and the Center for Chemical Process Safety have defined culture as "the way we do things around here."
What I'm talking about is a set of practices that define the organization and influence the individuals who make up the organization. This kind of pervasive, systemic organizational safety culture must come from the top -- and it must be expressed with transformative action, not just simple slogans.
Next: Concept Number Two: Industry must learn from its mistakes.
For three years now, OSHA has had in place a Refinery Process Safety Management National Emphasis Program. We are deeply troubled by the significant lack of compliance we are finding in our inspections, and with the number of serious refinery problems that continue to occur.
Time and again, our inspectors are finding the same violations in multiple refineries, including those with common ownership -- a clear indication that concerns and findings are not being communicated across corporations or throughout the industry or even within different units in the same refinery.
Consistently throughout the course of the Refinery NEP, we have found that over 70 percent of the citations fall into the top four PSM elements:
• Mechanical Integrity
• Process Safety Information
• Operating Procedures
• Process Hazard Analysis
Let's talk about these top four elements:
1. In MECHANICAL INTEGRITY, problems include failure to perform inspections and tests, and failure to correct deficiencies in a timely manner. This is a particular concern given the aging of refineries in the United States.
2. PROCESS SAFETY INFORMATION, including failure to document compliance with Recognized and Generally Accepted Good Engineering Practices to keep process safety information up to date, and to document the design of emergency pressure relief systems.
3. OPERATING PROCEDURES: failure to establish and follow procedures for key operating phases, such as emergency shutdowns, and using inaccurate or out-of-date procedures.
4. PROCESS HAZARDS ANALYSIS, including lack of attention to human factors and facility siting, and failing to address PHA findings and recommendations in a timely manner -- or, all too often, failing to address them at all.
More than a year ago, OSHA sent a letter to every petroleum plant manager in the country, informing them of these frequently cited hazards. Yet, a year after this letter went out, our inspectors continued to find the same problems in many facilities.
And, finally: Concept Number Three: The problem with numbers.
In any business or organization, one of the problems we find when trying to measure performance is determining how and what we measure.
Unfortunately, as we've discovered, having good numbers on your OSHA 300 logs doesn't correlate with having an effective process safety program.
The classic example of this is BP-Texas City, which had very good injury and illness numbers prior to the 2005 explosion that killed 15 workers and injured 170 others. This tragedy, of course, revealed serious process safety and workplace culture problems at the facility despite the good numbers the company had on paper.
It was noted in press reports that many of the workers killed at BP Texas City had just finished a meeting that touted their safety record. More recently, it was noted in the press that BP executives were on the Deepwater Horizon drill in platform in the Gulf of Mexico, celebrating their excellent safety record shortly before the explosion and fire that led to the deaths of 11 workers. In the days following that catastrophe, company officials continued to wave their low injury and fatality rates as a defense while workers widows planned funerals.
There's a message here: Boasting about favorable safety rates while workers are dying doesn't make a company look like a serious employer; and trade organizations that give awards to their members based solely on a lack of slips, trips and falls doesn't make them look like they are seriously addressing serious problems.
Don't misunderstand me: We need to keep reporting and tracking the numbers -- DART rates are useful -- but employers must not let those numbers lull them into a false sense of security. Looking only at these numbers doesn't warn us about pending doom from cutting corners on process safety
To ensure strong PSM systems, we need to do a better job of identifying useful leading indicators. We all recognize the stock market's investment warning that "past performance is no guarantee of future success." This also applied to the low-frequency, high-consequence events that process safety programs guard against.
The chemical and petrochemical industries must continue to develop and track leading indicators to measure the performance and continuously improve process safety management systems".
In my experience, the points that have been highlighted by the speaker are time and again found lacking in many industries.
Read the full speech in this link

Fire in oil tank

A fire that reportedly started in an oil tank in China that was earlier involved in a fire and had remnants of oil left in it has been reported. It is reported that workers were dismantling the affected tank when it caught fire. Do your job hazard analysis well before any hot work. Its these small things that count.Read the article in this link.

An appeal to readers - Share an incident!

I appeal to readers of this blog to share at least one process incident a month for the benefit of all. You need not mention the company's name. I have been receiving contributions regularly only from a few readers. Even if you write a brief few lines of the incident, it would be enough. Thanks in advance!

Do not forget Bhopal!

Tasleen, 26, who was poisoned by the Bhopal gas leak, cares for her disabled daughter. Photograph by Alex Masi
Every day, the people working in the chemical industry must realise that process safety is for the good of people - people inside the plant and people outside the plant. The horrors of the Bhopal Gas Disaster continue even today. We should not forget Bhopal. I think it will be a good practice for every chemical plant to organise a"Don't Forget Bhopal" day on December 2nd or 3rd every year and remind all managers of the things that went wrong at Bhopal and the lessons learnt from Bhopal..
See the human impact of Bhopal in pictures in this link.

Critical utilities are important for process safety

A news article reports that a refinery in the US has been flaring gas after loosing a big transformer which shut down the grid. I have been observing cases of transformer failures causing plants to either run on reduced capacity or shut down. Electrical systems are key for process safety. They are silent and appear docile but when they fail, they can cause a process upset that may lead to a catastrophe. Maintain you key utility systems with the same fervor as you would maintain your plant!
Read the news article in this link.
The EPA has reported an accident in 1999 involving a plant converting bauxite to alumina in a series of steam-heated pressure vessels. A loss of power stopped all pumps including those that circulated process material through heat exchangers for cooling. However, steam injection stayed on causing temperatures and pressures to increase. Pressure relief valves and piping were blocked or choked with solid deposits hindering their ability to relieve the increasing pressure. Several vessels over-pressured and exploded. The force of the explosion and release of highly corrosive caustic material injured 29 employees and extensively damaged the plant.

A third eye for process safety

After the BP oil rig disaster, authorities in the US are now planning to monitor the critical parameters of all oil rigs from land. An article mentions that the system will "put real-time data from offshore wells in front of government-employed petroleum engineers, who could keep a close watch during vital drilling operations or whenever anomalies are detected.Many drilling contractors and oil companies already use high-tech monitoring systems to keep track of what's happening offshore -- even from computer centers hundreds of miles inland".
Now while this is a good idea, it throws up another window regarding security of such networks. Just imagine if someone was able to unauthorizedly break into these networks!
I personally feel that while technology can be an enabler,it cannot solve all problems. Read the full article in this link.

The importance of corrosion monitoring and control in Process safety

What you do not see is most dangerous in Process Safety. Corrosion is a major problem in the chemical process industry and I am observing a disturbing trend. Regular painting and maintaining of metallic structures and equipment is often delayed when budget pressures dominate. Corrosion is insidious. It slowly and surely kills. If you do not have a good corrosion monitoring and control system, you will one day run out of luck, with disastrous consequences. An article by Dr A K Samant of ONGC mentions the following:"Corrosion control is an important consideration. The periodic monitoring techniques and analytical assessment of corrosion severity is very important and critical since it provides the direction to ensure proper utilisation of materials and corrosion control methodologies. Therefore, correct and appropriate condition assessment techniques should be used to avoid premature failure and ensure maximum safety".
Read the full article in this link

A missing word causes an accident!

Mr Yigal Riezel, Process Safety Management Consultant mentions about an explosion in a gas oil tank that was attributed to the use of nylon rope for taking a sample of tank contents.The operator lowered a nylon rope attached to the sampling device through the sampling hatch on top of the tank. This caused a static electricity spark. After the explosion, in which the operator was killed, the investigation determined that the special precautions mentioned in the tank sampling procedure of tank sampling included the following remark: “In order to reduce the potential for static charge, nylon or polyester rope, cords or clothing should be used”. The committee immediately sent the finding to the originators of the standard and got a fast reaction apologizing for a typing mistake by missing the word NOT before “be used”.

Disposal of old ammonia gas cylinders

I am really not sure whether the guys in this video really know what they are doing. They are reportedly disposing old ammonia cylinders.. watch this video and comment....

LPG tanker accidents

Thanks to Abhay Gujar for sending information about these LPG road tanker accident.
You can view them in this Link

The importance of P & ID's in process safety

The Piping and Instrumentation Drawing (P & ID) is the heart of any plant. There is always a debate about whether your P & ID's reflect the current as built status. With newer people joining the organisation, it is important that your P & ID indicates all the relevant information. Jeff Ratush has made a good presentation which I have attached in this link

No Safety, No Moolah!

A news article mentions that safety will be the sole criterion for judging employee performance in the fourth quarter for BP, as per an internal memo from BP CEO.
"The memo, written by new chief executive Bob Dudley, was sent to employees on Monday, the story said.
The sole criterion for judging performance in the 2010 fourth quarter would be "each business's progress in reducing operational risks and achieving excellent safety and compliance standards," said the memo.
The change was designed to ensure an incident such as the "Deepwater Horizon tragedy" never happens again, the story said".
Read the full article in this link. and in this link too

Knocked off valve causes ammonia leak

An ammonia leak has been reported in China, causing 3000 people to be evacuated.It reportedly began when a valve was "knocked off". Further details are not available.
Do you have proper controls inside your factory to prevent unwanted vehicle movement?
Read the news articles in Link 1
Link 2

Confined spaces are deadly!

The Ministry of Manpower of the Singapore Government has published a good flyer on hazards of confined space, with case studies of fatalities inside confined spaces covering ISO tanks, sewers, excessive inhalation of solvent vapours inside a confined space and CO poisoning.
See the flyer in this link and please share it with all your employees. It may save a life!

Lessons from the Tesoro Refinery Blast Investigation

The Washington State Department of Labour and Industries have investigated the above incident and issued citations totaling USD 2.39 Million. I have summarized the investigation findings and citations as follows:

•On April 2nd,2010 early morning, a blast at the Tesoro refinery in Anacortes, USA, occurred killing 7 personnel. The blast occurred due to the catastrophic failure of a feed effluent exchanger in the naphtha hydrotreating unit during start up. The exchanger was about 40 years old. The original refinery was started in 1950’s by Shell. Shell sold the refinery to Tesoro in 1998. The failed heat exchanger was not tested for last 10 years. Tesoro had planned an inspection in 2008 but did not carry it out.

•6 out of 7 personnel who died were not trained in the start up procedure.

•The frequency of Tesoro Refinery's inspection of the feed effluent exchanger was not consistent with applicable manufacture's recommendations, good engineering practices, and or prior operating experience.

•The Tesoro Refinery did not correct deficiencies associated with effluent exchanger shell and tube side warm up lines before further use or in a safe and timely manner

•Tesoro Refinery did not correct deficiencies associated with effluent exchanger companion flanges and temporary clamps before further use or in a safe and timely manner when the necessary means are taken to assure safe operation. (flanges were leaking during start up and steam lances held by personnel were used to dilute the leaks)

•Tesoro Refinery did not develop and implement written procedures for startup following turnaround, or after an emergency shutdown of exchangers that provided clear instructions for safely conducting activities involved in the process consistent with the process safety information that addressed steps for each operating phase.

•Tesoro Refinery did not establish and implement written procedures to manage the change made to the warm up steps during the March 2009 start up and those conducted in February and March of 2008 on the E6600 effluent exchangers.

•Tesoro Refinery did not establish and implement written procedures to manage the changes made to the operating limit minimum hydrogen oil ratio feed to Naphtha Hydrotreater.

•Tesoro Refinery did not establish and implement written procedures to manage the change made by placing mechanical clamps on the companion flanges between effluent exchangers E-6600 A/B and D/E on or about March 2009.

•Tesoro Refinery did not establish and implement written procedures to manage the change made by placing the Anacortes Corrosion Awareness and Management Program (ACAMP) on hold indefinitely beginning the third quarter of 2004.

•Tesoro Refinery did not establish and implement written procedures to manage the change made by discontinuing the process hazard analysis revalidation system that included mechanical integrity and corrosion control review in 2006.

•Tesoro Refinery did not establish and implement written procedures to manage the changes made by temporarily or permanently suspending inspection procedure I-08.07 on or about September 2009

•The Tesoro Refinery did not ensure that the 2006 Process Hazard Analysis Revalidation was consistent with the current process.

•The Tesoro Refinery did not update process safety information following changes made to the effluent exchangers on or about December 2005.

•The Tesoro Refinery did not investigate each incident which resulted in, or could reasonably have resulted in, a catastrophic release of highly hazardous chemicals in the workplace. Failure to investigate incidents could result in their recurrence and cause serious injury or death.

•Tesoro Refinery did not ensure that appropriate checks and inspections were performed to assure that equipment, such as the warm up lines and replacement tube bundle, were installed properly and consistent with the design specifications. Lack of quality assurance inspections and checks could lead to improper installations of process equipment and result in serious injury or death.

•Tesoro Refinery did not ensure that maintenance materials, spare parts and equipment were suitable for the process application for which they will be used, such as the bellows assemblies.

•Tesoro refinery did not ensure that all emergency responders and their communications were coordinated and controlled by the Incident Commander (IC).

•Tesoro Refinery did not assure that all Fire Brigade members were fully trained prior to the incident response on the morning of April 2nd, 2010.

Read the full citation in this link.

Process safety and the Stuxnet worm

A news article mentions the following: "A sophisticated worm designed to steal industrial secrets and disrupt operations has infected at least 14 plants, according to Siemens.Called Stuxnet, the worm was discovered in July when researchers at VirusBlokAda found it on computers in Iran. It is one of the most sophisticated and unusual pieces of malicious software ever created -- the worm leveraged a previously unknown Windows vulnerability (now patched) that allowed it to spread from computer to computer, typically via USB sticks.
The worm, designed to attack Siemens industrial control systems, has not spread widely. However, it has affected a number of Siemens plants, according to company spokesman Simon Wieland. "We detected the virus in the SCADA [supervisory control and data acquisition] systems of 14 plants in operation but without any malfunction of process and production and without any damage," he said in an e-mail message".
As technologies become more and more complicated, chemical plants are also becoming susceptible to attack through the software and other technologies they use. Do not be complacent about your plant software security systems. Many chemical companies ban USB sticks inside their premises.
Read more of the article in this link.

Cost Vs Process Safety - the perennial question

An article mentions that in the recent BP Deep Horizon oil spill, "Cementing contractor Halliburton had warned the well needed 21 so-called centralizers, devices used to reduce the risk of gas leaking into the well. But Mr. Walz testified that he felt a safe cement seal could be obtained by simply spreading out six centralizers BP already had. He said he and colleague John Guide thought that would "honor the modeling" from Halliburton.
That's as wishful -- and seemingly irresponsible -- as the response another BP engineer had given Halliburton before the disaster, saying that "hopefully the pipe stays centralized due to gravity."
BP engineers knew they were dealing with a difficult well and that more than 120 workers were at the Deepwater Horizon rig. Why, then, would BP personnel be so seemingly cavalier about a crucial part of the process? Mr. Walz and Mr. Guide may have provided the answer when they said BP employees are graded every year based on how much money they save the company".
Read the full artcile in this link.

Stronger Safety after an incident!

A news article mentions the following:
"Incoming BP boss Bob Dudley has announced the creation of a new safety division along with a management reshuffle that includes the departure of Andy Inglis, the head of the oil firm's key exploration and production division.
The group said the safety division would have "sweeping powers" to oversee and audit the company's operations around the world with the safety and operational risk department having authority to intervene in all aspects of its technical activities.
The powerful organisation is designed to strengthen safety and risk management across the group, following the Gulf of Mexico disaster that caused the biggest oil spill in US history. It will be headed by Mark Bly and report directly to incoming chief executive Dudley, who replaces Tony Hayward on Friday.
Dudley said: "These are the first and most urgent steps in a programme I am putting in place to rebuild trust in BP – the trust of our customers, of governments, of our employees and of the world at large. That trust is vital to the restoration of shareholder value which has been so adversely affected by recent events.
"Our response to the incident needs to go beyond deepwater drilling. There are lessons for us relating to the way we operate, the way we organise our company and the way we manage risk."
It is good that BP is reorganizing its safety functions. But in many companies, I keep hearing from the existing safety department that line managers do not pay heed to what they say! Look inwards into your organization and see if you are listening to you existing safety managers! They will have a lot to tell you. In fact prior to the BP Texas refinery disaster, it is reported that the safety manager had put up a slide on the key risks in which he mentioned "BP Texas refinery kills someone in the next few months"!
Read the news article in this link

H2S leak at Refinery

A news article has reported a H2S leak at a refinery in USA. A contractor is reported to have died, though it is not clearly known whether it was because of the leak.The leak is reported from a clamp that was installed to arrest a previous leak. Read the full article in this link.
Read another article about the leak in this link.

Toxic sludge flood disaster in Hungary

BBC has reported a flood of toxic hazardous waste which escaped from a reservoir in an alumina plant in Hungary.Four people have reported to have died.It is estimated that about 600,000 to 700,000 m3 of sludge escaped. If you are storing hazardous waste in your facility, ensure the storage meets all local regulations. Generally, it is human tendency to focus less on a waste storage facility when compared to a process plant. But your hazardous waste storage must be treated as an important part of your process safety program.
Read more in these links:BBC1 , BBC2
Deadly chemical reactions

Process Safety - Old is Gold If.....

A news report about an accident at a refinery in USA mentions that the cause of the incident was lack of inspection and maintenance of decaying 40 year old equipment. How are your maintaining your "old" equipment? Are your inspection philosophies revisited based on operating and maintenance experience? Personally, I have seen huge water pumps that are over 40 years old and are still supplying water to a large chemical manufacturing unit in India. The pumps are well maintained and look good enough to run for another 10 years!
The article mentions the following:
"On Monday, Silverstein said his inspectors determined the Anacortes accident was caused when a 40-year-old steel heat exchanger ruptured and spewed vapor and liquid that immediately exploded. Tests showed welds in the exchanger had developed cracks over the years. The rupture occurred along those weak points as the equipment was coming back online after maintenance.
Tesoro hadn't properly inspected the exchangers since 1998, and even then didn't test the most vulnerable areas, Silverstein said. Tesoro had planned to test them in 2008, but never did.
"If they had, we believe, they would have found the cracks that caused this explosion," Silverstein said. "They would have prevented this horrible incident from ever happening."
All seven workers who died had been standing near the exchangers. They were there in part, Silverstein said, because Tesoro had been unable in recent years to stop the equipment from leaking volatile, flammable gases.
So employees were positioned around the machinery in hard hats, gloves and goggles with "steam lances" — long tubes — they used to disperse the vapors. They also had to manually adjust valves during startup to make sure leaks didn't get out of control.
Read the full article in this link

The Human and Process Safety

Why is that we do not seem to learn lessons from incidents? One of the root causes of the 2005 BP Texas refinery incident was attributed to operator fatigue and overload. In many cases lack of training and troubleshooting skills are also mentioned. Do not neglect such warnings. An article mentions the following about the San Bruno gas pipeline accident:
"The San Bruno natural gas explosion has underscored a growing concern about the capabilities of utility employees who watch over the nation's pipelines and whose errors have been linked to a number of mishaps, some of them catastrophic.
The National Transportation and Safety Board has said among the questions it is investigating is whether workers at a PG&E pipeline-monitoring terminal in Milpitas were fatigued or poorly trained. And just eight days after the Sept. 9 blast, the federal Pipeline and Hazardous Materials Safety Administration moved to speed up adoption of a rule to insure that workers doing similar jobs at companies across the country are well-trained and rested -- especially since many of those workers put in 12-hour shifts".
"A 2005 NTSB study that scrutinized 13 pipeline mishaps involving various liquids from 1992 to 2004 found that "in ten of these accidents, some aspect of the SCADA system contributed to the severity of the accident." In many cases, the problems were aggravated when workers monitoring the systems failed to quickly recognize and respond to leaks. Among the accidents cited:
# An April 7, 1992, fire in Brenham, Texas, that caused three deaths and 21 injuries after a poorly trained worker failed to notice the changing pressure in a pipe, in part because the system didn't display data in a way the worker could easily interpret.
# On June 10, 1999, a worker failed to realize that a gasoline pipeline had ruptured and burst into flames in Bellingham, Wash., because the malfunctioning control system was providing erroneous data. As a result, it took more than an hour to shut the pipe's valves. Three people died and eight were injured.
# On Oct. 27, 2004, after a pipeline containing the caustic and potentially deadly chemical anhydrous ammonia ruptured in Kingman, Kansas, a worker misinterpreted alarms generated by a control system and mistakenly increased the flow of ammonia into the line. No one was killed or injured, but 204,000 gallons of the liquid flowed into a creek, killing more than 25,000 fish, including some threatened species.
"From 1990 to 2009, gas-line operator errors caused a little more than 5 percent of all the significant accidents nationwide, resulting in 8 fatalities, 150 injuries and $16.2 million in property damage, according to data kept by the Pipeline and Hazardous Materials Safety Administration. During the same period, operator error caused 11.5 percent of "serious incidents," which involve a fatality or an injury requiring hospitalization".
Read more of the article in this link.

Flammable gas detectors - use them properly

Flammable gas detectors which are widely used in the chemical industry are often not properly maintained. The use of improperly or wrongly calibrated detectors will lead to a false sense of security and may cause an accident. Read the guidelines given by International safety equipment association in this link

Explosion in Fertiliser plant in USA

A news article has reported an explosion in a fertilizer plant in USA. It is reported to have occurred due to a rupture of a high pressure Urea Ammonium Nitrate vessel.The noise from the explosion was reported to be louder than a sonic boom. Read more of the article in this link.

Don't underestimate the power of water!

In 2009, a massive failure of the power generation turbine at a hydroelectric plant in Russia killed about 74 people. According to Wikepedia, the root cause was attributed to lack of complete bolting of the turbine casing cover. The consequences were horrendous.Do not underestimate the power of water in a process plant. Water hammer, flashing of water into steam are hazards that can cause severe damage to plant equipment. Train your operators on these hazards.
Read about the failure in this Wikepedia link.
See amazing photos of the disaster in this link.