RISK BASED PSM PROCESS SAFETY MANAGEMENT INDIA CONSULTANT INCIDENT INVESTIGATION HAZOP TRAINING ROOT CAUSE ANALYSIS AND LESSONS FROM INCIDENTS
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December 27, 2010
Defense Less? The story of Deepwater Horizons last moments
An investigation by the New York Times graphically depicts the last moments of the Deepwater Horizon oil rig.The article mentions the following:
"What emerges is a stark and singular fact: crew members died and suffered terrible injuries because every one of the Horizon’s defenses failed on April 20. Some were deployed but did not work. Some were activated too late, after they had almost certainly been damaged by fire or explosions. Some were never deployed at all.At critical moments that night, members of the crew hesitated and did not take the decisive steps needed. Communications fell apart, warning signs were missed and crew members in critical areas failed to coordinate a response.The result, the interviews and records show, was paralysis. For nine long minutes, as the drilling crew battled the blowout and gas alarms eventually sounded on the bridge, no warning was given to the rest of the crew. For many, the first hint of crisis came in the form of a blast wave.
The paralysis had two main sources, the examination by The Times shows. The first was a failure to train for the worst. The Horizon was like a Gulf Coast town that regularly rehearsed for Category 1 hurricanes but never contemplated the hundred-year storm. The crew members, though expert in responding to the usual range of well problems, were unprepared for a major blowout followed by explosions, fires and a total loss of power.They were also frozen by the sheer complexity of the Horizon’s defenses, and by the policies that explained when they were to be deployed. One emergency system alone was controlled by 30 buttons".
"The industry has long depicted blowout preventers as “the ultimate fail-safe.” But Transocean says the Horizon’s blowout preventer was simply incapable of preventing this blowout. Evidence is mounting, however, that the blowout preventer may have been crippled by poor maintenance. Investigators have found a host of problems — dead batteries, bad solenoid valves, leaking hydraulic lines — that were overlooked or ignored. Transocean had also never performed an expensive 90-day maintenance inspection that the manufacturer said should be done every three to five years. Industry standards and federal regulations said the same thing. BP and a Transocean safety consultant had pointed out that the Horizon’s blowout preventer, a decade old, was past due for the inspection.
Transocean decided that its regular maintenance program was adequate for the time being."
Read the full article in this link.
December 24, 2010
Static charge + Flammable dust = EXPLOSION
Mumbai Port Chlorine gas leak - recommendations
Maintain your fire water systems. You never know when they will be needed.
Read the PIB press release in this link.
December 23, 2010
US Unions view of oil industry safety
"After the 2005 Texas City blast" which killed at least 15 people at BP's USW-represented Texas City, Texas refinery, "We got a federal grant to develop a process safety curriculum," he explained. "It was approved by OSHA and we offered it, for free, to the companies," where USW would train workers in safety, "if they would just pay the salaries of workers to come to it" for 3-day sessions, he added. They turned it down.
The industry's attitude extends down to the local level, the two Alaskans said. At Prudhoe Bay, until local management changed last year, bonuses depended on how few accidents managers reported. Health and safety data was "manipulated" and workers did not report accidents "for fear of being disciplined," Trimmer, Local 4959's secretary-treasurer, said. BP has "a safety matrix" for each pipeline work area, with standards set for how few accidents are allowed. Report more, the 30-year veteran said, and supervisors lose bonuses.
"One guy had a bad vehicle accident. He had a broken leg and didn't report if for three hours. When he finally had to and we asked him why he delayed, he responded that he feared being fired," Trimmer said. Overtime and fatigue are also problems: 18-hour days for 2-week stretches are technically banned, so workers toil 16 hours. Guenther, a 25-year chief steward at Prudhoe, said that from 1979 to 1994, management emphasized preventive maintenance on the pipeline, but things have gone downhill since. Workers left and were not replaced, while the oil field he worked at doubled in size. Only recently has new hiring exceeded retirements, Guenther added.
"We went from preventive maintenance to running around fixing problems at all hours of the day and night," even in Alaska's sub-zero cold, Guenther said. Problems pile up and are shoved into "a backlog." Structures at the pipeline are reaching the end of their useful working lives, 15-25 years old, developing cracks that are patched. And BP rejected the local's contract proposal for a full-time health and safety specialist.
"We have to fundamentally change how we regulate this industry - and there's an even wider gap between regulation and the industry" than elsewhere, Wright told the CSB. "What we need are effective management programs, with strong regulation, backed by strong unionization and strong worker involvement" in safety"
Read the article in this link
December 22, 2010
Two killed after inhaling nitrogen gas
Read more about the incident in this link.
Read an updated news article in this link
December 21, 2010
Pipeline explosion -"Rivers of Fire"
Read the news article about the incident with video in this link.
For an article about India's petroleum and gas pipeline network, read it in this link.
December 20, 2010
Safety valves and their importance
Read about the incident in this link.
December 17, 2010
Behind every major incident is one or more near misses!
Behind every major incidents there are a number of warnings! Read the full article in this link.
Dust explosions
"1.Properly assess your dust's fire and explosion characteristics so adequate measures can be taken for the prevention and mitigation of hazards in your own facilities and, if you are shipping the dust to some other facilities, at those locations.
2. Understand your own powder handling and processing operations. You should be able to identify likely ignition sources during both normal and abnormal operating conditions. Also pinpoint location(s) where combustible dust clouds could exist during normal and abnormal operating conditions.
3. Take effective measures to avoid or control ignition sources and formation of combustible dust clouds. Also consider explosion protection (such as venting and suppression) and isolation to lower the risk to a tolerable level.
4. Maintain dust explosion prevention and mitigation measures".
Read the full article in this link.
Another article about the ongoing investigation on the explosion in the AL solutions plant in by the CSB mentions that the CSB is also looking at the possibility of explosion of zirconium dust......read the article in this link.
December 15, 2010
Welding procedures and pipelines
Read the full article in this link.
December 14, 2010
Facility siting - different countries, different approaches
Now, In India, the main problem is lack of will in enforcing the existing laws. Many chemical plants come up in isolated areas but after some years, residences spring up around the plant, with the authorities knowing about it. The IOC Jaipur oil depot where a major fire occurred, is an example.
When will we ever learn? Read the article in this link.
December 13, 2010
Emergency management - the human factor
The dynamic positioning operator’s (DPO) testimony to the enquiry committee of the Deepwater Horizon oil rig disaster reveals the following: The operator had to deal with a large number of combustible gas alarms getting activated when the blow out occurred. The general alarm system was on “MANUAL” (in other words, even though a lot of combustible gas alarms were going on, the general alarm could get sounded only if the operator manually activated it). (Shades of Piper Alpha??) The operator was not trained on a situation where multiple gas alarms went off.
Reading the testimony of the DPO, the one thought that struck me was the chaotic situation she was dealing with. Every Human being reacts differently to emergency situations. When I was an asst. Shift in charge in an ammonia plant, we had a newly transferred shift in charge who had earlier worked most of his career in the utility plant. His way of dealing with any emergency situation in the ammonia plant was to run to the utility plant ( he was more comfortable there!). Are you training your operators for the worst case scenario? Here simulators play an important role and you should make the training scenario as realistic as possible.
Read the DPO’s enquiry transcript in this link.