Not learning from process safety incidents

An article in the Houston Chronicle mentions that "After the lethal explosion at BP's Texas City refinery that killed 15 workers in 2005, the oil industry boosted safety at industrial operations on land but never made the same improvements offshore, according to federal investigators meeting in Houston this week.
The Chemical Safety Board is set to conclude that the offshore drilling sector's focus on monitoring individual worker injuries - while ignoring bigger warning signs of "process safety" problems that could lead to emergencies - set the stage for the Deepwater Horizon disaster."
Read the article in this link. 
I have seen this phenomenon occurring in large chemical manufacturing groups. The lessons from a process safety incident in one unit in a large group was not learnt in another unit of the group. I was heartened to read an article in the newspaper today where a large pharma manufacturer is planning to appoint a technical head to streamline operations to a consistent level. The article mentions that "Underlining the importance of technical expertise, Mr Shanghvi said, historically, for example, senior people with a marketing background handled businesses and also manufacturing. But they would have limited technical expertise, and so the company is looking to separate the two and create a separate set of systems for manufacturing, he said".
I wish all chemical manufacturing companies give the same importance to technical competence as process safety does require a lot of technical competence to understand and follow. Read the article in this link. 
 
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Safety valves and vibration

A news article mentions that there is a dispute between BP and OSHA over spring loaded safety valves. the article mentions that "OSHA is concerned because improperly set valves can result in too much shaking, said Jordan Barab, deputy assistant secretary of labor for OSHA. That vibration could cause the valves -which regulate the opening and closing of pressure vessels - to break.BP believes the valves "comply with industry standards and do not constitute a safety hazard," said spokesman"
The article also mentions that the total cost of the 2005 BP Texas city refinery explosion is 3.5 billion dollars.
Read the article in this link.

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Another manlift accident

After replacing a cone roof on a tank, the contractor crew was removing unwanted material from the work site using a manlift. The incident report mentions that "One item to be moved was a steel box full of metal parts, weighing a total of approximately 900 pounds. Rather than split the load into smaller lots, the Tank Service Supervisor decided to remove the loaded box from the roof using the manlift, so the box was rigged to the underside of the operator’s basket on the lift.
As he began moving the boom over, the manlift suddenly tipped over because the combined weight of the contractor and equipment in the lift basket greatly exceeded the machine’s posted capacity limits. The box hit the ground first. The basket the Tank Services Supervisor was in immediately landed on the box; the force of impact loosened the slings, detaching the box from the basket. With the weight of the box off the basket, the counterweight righted the lift, causing the basket to quickly rebound to about 15’ above grade.
The sudden, forceful, upward movement of the boom catapulted the Tank Services Supervisor out of the basket to the ground. He was wearing a harness and lanyard at the time, but had failed to “tie off” to the anchor point in the basket before he moved the lift. He was hospitalized and is recovering"
Read the incident report in this link.


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Process Safety and Road Safety

Everyday, a large number of tankers carrying hazardous chemicals traverse across India's roads. Chemical manufacturers and suppliers do take all required precautions during the transportation. GPS systems are used for tracking vehicles from a central control room. But the safety sense of other road users need to improve a lot. An article in Livemint mentions the abysmal  state of road safety in India. The article mentions that "The number of deaths (in road accidents) is equal to three jets crashing every day (410 human beings), but since aircraft aren’t involved, they don’t make headlines. Annually about 150,000 people die every year due to road accidents, and about 400,000 people get maimed, the cost of which is about Rs. 1 trillion".

Read the article in this link.
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Thermal imaging to detect gas leaks

A thermal imaging camera manufacturer reports that process operators at a high-pressure, low-density polyethylene (LDPE) plant in Stenungsund, Sweden are using a optical gas imaging camera to detect potentially dangerous gas leaks. The article mentions the following:
"In the LDPE production process - ethylene, a highly flammable hydrocarbon, is converted into polyethylene in a high-pressure polymerisation reaction.
Before the purchase of a FLIR GF306 optical gas imaging camera - Borealis used gas 'sniffers' - devices which measure the concentration of a certain gas in one single location and generate a concentration reading in parts per million (ppm). An operator of the FLIR GF306 stated "The main advantage of the optical gas imaging camera is that it provides you with the possibility to detect gases in real-time visually. Whereas sniffers just give you a number, an optical gas imaging camera allows you to detect gas leakage anywhere within the field of view of the camera."
Now that Borealis have a FLIR GF306 optical gas imaging camera they are able to do a quick scan at every start-up. With a quick scan - process operators are able to scan approximately 80% of the entire plant in about thirty minutes. To do the same task with gas sniffers would need a team of ten people working for two full days".

Read the article in this link
PS: I am not endorsing the product. This is for information only.


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Hot material spill kills two

A newspaper article reports that two people were killed when a hot material at 300 deg C fell on them when they were cleaning a boiler. When issuing confined space entry permits ensure that you conduct all proper checks for any residual energy that may be trapped inside. Read the article in this link.
 
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A day in the life of a Plant manager

I have been harping on the less amount of time plant managers are spending today visiting the plant and talking to the operators. Today Process Safety is being devoured by technology that is being pushed by vendors - including advanced process control, high funda instruments, SIL rated loops, software that promises just about to do anything including HAZOP studies, RCA's etc.., dashboards for monitoring process safety performance etc... While technology can be an enabler, ultimately, we need to realize one thing - there is no substitute for a plant manager to do his daily rounds and talk to operators.Today's plant manager has become a technology slave - be it answering e-mails from his laptop to checking his blackberry for bad news!
I was happy to read that in one major multinational in UK, the plant managers are compulsorily made "free" for the first three hours of their day so that they visit the plant, do a plant round and talk to operators and engineers. If you practice this, most of the process safety issues will be resolved.

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Confined space incident

Thanks to Deivanayagam Sivasankaran for sending a video of a confined space incident. What is striking is the immediate response of the man watch who jumps in to rescue his colleague. An accident in a confined space always has the capability to kill more people as would be rescuers jump in without even realizing that they themselves may be in danger. Train your man watched on proper procedures and what to do in the event of an incident in a confined space. It may save his life!
See the video in this link. 

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Fire risks of IBC's

Intermediate Bulk Containers (IBC's)  are used to store and transport many chemicals. A technical advisory bulletin by Willis North America mentions the significantly greater fire hazard the IBC's pose than the classic 55-gallon drum or smaller containers.
They recommend the following:

1. "Protection alternatives should always be investigated (i.e., possible use of off-site IBC storage facilities, etc.).
   The indoor storage of flammable or combustible liquids in nonmetallic or composite IBCs in plant production or warehouse storage areas should be prohibited. 
2. Attempt to store IBCs at a supplier location and receive the materials on a just-in-time basis. 
3. Consider alternatives such as designing and installing a properly protected bulk storage and piping system.
   Consider the use of steel 55-gallon drums or steel IBCs.
   Determine if nonmetallic or composite IBCs are the only method for receiving and storing flammable and combustible liquids in your plant".

Read the advisory in this link. 

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H2S kills again

 The Times of India has reported that two people lost their lives after inhaling H2S gas at a sewage treatment plant. One of the persons who died was a rescuer. Apparently a job of cleaning a pump was in progress when the incident occurred. Six other people were hospitalized.Neither of the two men given the job of cleaning pumps had any safety equipment or gas mask.
Read the article in this link
See a video of H2S safety in this link.

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Fukushima and Process Safety

The Fukushima Nuclear Accident Independent commission has submitted its report. There are lessons to learn from the incident.One of the conclusions of the commission is " Replacing people or changing the names of institutions will not solve the problems.Unless the root causes are resolved, preventive measures against future similar accidents will never be complete. The Commission believes the root causes of this accident cannot be resolved and that the people’s confidence cannot be recovered as long as this “manmade disaster” is seen as the result of error by a specific individual. The underlying issue is the social structure that results in “regulatory capture,” and the organizational, institutional, and legal framework that allows individuals to justify their own actions, hide them when inconvenient, and leave no records in order to avoid responsibility. Across the board, the Commission found ignorance and arrogance unforgivable for anyone or any organization that deals with nuclear power. We found a disregard for global trends and a disregard for public safety. We found a habit of adherence to conditions based on conventional procedures and prior practices, with a priority on avoiding risk to the organization. We found an organization-driven mindset that prioritized benefits to the organization at the expense of the public".


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Runaway reaction incident

The EPA has shared details of a runaway chemical reaction involving phenol formaldehyde reaction. In the incident investigation report,the following recommendations are made:
1. Conduct a thorough hazard assessment
2. Complete identification of reaction chemistry and thermochemistry
3. Ensure human factors are considered in administrative controls
4. Facilities should evaluate capacity of cooling system with respect to controlling unexpected exotherms.
5. Facilities must pay attention to the order of ingredients, the addition rates, under- or over-charging, and loss of agitation.
6. Learn from accident history and near misses

Read the case study in this link.

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Update on reactor blast incident

Further to the reactor blast incident at a pesticide manufacturing facility in Andhra Pradesh, a Times of India newspaper report indicates the following:
"According to experts, there were no control valve and safety rupture disc in the reactor, which exploded following increased temperature. Sources said that employees were testing 'myclo vutanyl', which is used as a pesticide in the agricultural sector, when the blast occurred. Dimethyl sulfoxide (DMSO) and trizol mixture of 8,000 litres in the reactor was tested by night shift employees and the sample sent to the lab. The lab reportedly was not satisfied with the results and the morning batch employees were testing the compound again. During the process, temperature in the reactor shot up to more than 150 degrees centigrade. The block in-charge noticed it and tried to address the problem but it exploded before he could take any action. The fifth block has about 30 reactors and tanks, sources said. A majority of the workers were on tea break during the incident. "Had all the workers been present at the time of the blast, it could have led to fatalities. Eighteen workers got injured as splinters from glasspanes struck them," a worker said'.
 While the root causes of the above incident are under investigation, when operating batch processes, many incidents occur due to lack provision or sizing of  adequate pressure relief devices. This occurs many times due to scaling up of pilot plant trials to plant production without adequately assessing all the reaction data and associated hazards. Have a proper management of change process to address these gaps in a robust way. Read the article in this link.


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A new refinery shutdown by caustic corrosion

 Reuters report that a new refinery in the USA which was being commissioned had an inadvertent slippage of caustic into the system. Apparently the caustic caused severe corrosion of the major equipment in the refinery when the temperature of the unit was increased as part of the start up process. operators came to know of the problem when they started having leaks and fires. The damage apparently is huge and about 50 heat exchangers have to be cleaned. The process hazard analysis of the plant should have spotted the possibility of caustic leaking into the system. While I do not know the reason for the incident, today what I see in HAZOP studies is the competency of the team is coming down and the net result is a poor study output. The onus is more and more on the chair to guide the team properly, No PHA software can do this for you.
Read the Reuters article in this link.

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