December 29, 2014

Quality of HAZOP studies

I had raised a question to a PSM group in LinkedIn about the deteriorating quality of HAZOP studies.
David Graham, a Process Safety Professional wrote this interesting and humorous comment
Slightly off-topic, but: Quite a few years ago I led a HAZOP on a new build unit for a refinery in the Middle East, on behalf of a large consultancy. One of the consultancy staff led a similar HAZOP on revamp of an existing unit. The staff employee took output from both studies and wrote the Management Report, major findings, etc. 
He included the following phrase in the report:
"It has to be understood that HAZOP will not reveal all the hazards to a project in operations and maintenance activities. It is therefore anticipated that any remaining hazards will be found during operations."
Boom!


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December 24, 2014

December 21, 2014

4 killed in confined space accident

A Newspaper report mentions the deaths of 4 workers working inside a storage tank in Assam , most probably due to lack of oxygen.

Read the Times of India newspaper report in this link.

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EDITORIAL: The chemistry we never want to think about needs thought

EDITORIAL: The chemistry we never want to think about needs thought

Thought provoking editorial!


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December 20, 2014

Lithium ion battery runaway reactions

 After the completion of investigation of the battery fires incidents in the 787 aircraft, the NTSB has concluded the following in its report available at http://www.ntsb.gov/doclib/reports/2014/AIR1401.pdf:
 
"The NTSB identified the following safety issues as a result of this incident investigation:
Cell internal short circuiting and the potential for thermal runaway of one or more battery cells, fire, explosion, and flammable electrolyte release.
This incident involved an uncontrollable increase in temperature and pressure (thermal  runaway) of a single APU battery cell as a result of an internal short circuit and the cascading thermal runaway of the other seven cells within the battery. This type of  failure was not expected based on the testing and analysis of the main and APU battery that Boeing performed as part of the 787 certification program.
However, GS Yuasa did not test the battery under the most severe conditions possible in service, and the test battery was different than the final battery design certified for installation on the airplane. Also, Boeing’s analysis of the main and APU battery did not consider the possibility that cascading thermal runaway of the battery could occur
as a result of a cell internal short circuit.

Cell manufacturing defects and oversight of cell manufacturing processes.
After the incident, the NTSB visited GS Yuasa’s production facility to observe the cell manufacturing process. During the visit, the NTSB identified several concerns, including foreign object debris (FOD) generation during cell welding operations
and a postassembly inspection process that could not reliably detect manufacturing defects, such as FOD and perturbations (wrinkles) in the cell windings, which could lead to internal short circuiting. In addition, the FAA’s oversight of Boeing,
Boeing’s oversight of Thales, and Thales’ oversight of GS Yuasa did not ensure that the cell manufacturing process was consistent with established industry practices

Thermal management of large format lithium ion batteries
Testing performed during the investigation showed that localized heat generated inside a 787 main and APU battery during maximum current discharging exposed a cell to high temperature conditions. Such conditions could lead to an internal short circuit and cell thermal runaway. As a result, thermal protections incorporated in large format lithium ion battery designs need to account for all sources of heating in the battery during the most extreme charge and discharge current conditions. Thermal protections include (1)recording and monitoring cell level temperatures and voltages to ensure that exceedances resulting from localized or other sources of heating can be detected and addressed before cell damage occurs and (2) establishing thermal safety limits for cells to ensure that self heating does not occur at a temperature that is less than the battery’s maximum operating temperature.

Insufficient guidance for manufacturers to use in determining and justifying key assumptions in safety assessments.
Boeing’s EPS safety assessment for the 787 main and APU battery included an underlying assumption that the effect of an internal short circuit within a cell would be limited to venting of only that cell without fire. However, the assessment did not explicitly discuss this key assumption or provide the engineering rationale and justifications to support the assumption. Also,as demonstrated by the circumstances of this incident, Boeing’s assumption was incorrect, and Boeing’s assessment did not consider the consequences if the assumption were incorrect or incorporate design mitigations to limit the safety effects that could result in such a case. Boeing indicated in certification documents that it used a version of FAA Advisory Circular (AC) 25.1309, “System Design and Analysis” (referred to as the Arsenal draft), as guidance during the 787certification program. However, the analysis that Boeing presented in its EPS safety assessment did not appear to be consistent with the guidance in the AC. In addition, Boeing and FAA reviews of the EPS safety assessment did not reveal that the assessment had not (1) considered the most severe effects of a cell internal short circuit and (2) included requirements to mitigate related risks.

Insufficient guidance for FAA certification engineers to use during the type certification process to ensure compliance with applicable requirements.
During the 787 certification process, the FAA did not recognize that cascading thermal runaway of the battery could occur as a result of a cell internal short circuit . As a result, FAA certification engineers did not require a thermal runaway test as part of the compliance demonstration (with applicable airworthiness regulations and lithium ion battery special conditions) for certification of the main and APU battery. Guidance to FAA certification staff at the time that Boeing submitted its application for the 787 type certificate, including FAA Order 8110.4, “Type Certification,”did not clearly indicate how individual special conditions should be traced to compliance deliverables (such as test procedures, test reports, and safety assessments) in a certification plan.

Stale flight data and poor quality audio recording of the 787 enhanced airborne flight recorder (EAFR).
The incident airplane was equipped with forward and aft EAFRs, which recorded cockpit audio data and flight parametric data. The EAFRs recorded stale flight data for some parameters (that is, data that appeared to be valid and continued to be recorded after a parameter source stopped providing valid data), which delayed the NTSB’s complete understanding of the recorded data. In addition, the audio recordings from both EAFRs during the airborne portion of the flight were poor quality. The signal levels of the three radio/hot microphone channels were very low, and the recording from the cockpit area microphone channel was completely obscured by the ambient cockpit noise. These issues did not impact the NTSB’s investigation because the conversations and sounds related to the circumstances of the incident occurred after the airplane arrived at the gate and the engines were shut down, at which point the quality of the audio recordings was excellent.

The NTSB determines that the probable cause of this incident was an internal short  circuit within a cell of the APU lithium ion battery, which led to thermal runaway that cascaded to adjacent cells, resulting in the release of smoke and fire.The incident resulted from Boeing’s failure to incorporate design requirements to mitigate the most severe effects of an internal short circuit within an APU battery cell and the FAA’s failure to identify this design deficiency during the type design certification processes."


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December 19, 2014

Repost - Process Safety in the 21st Century

I had originally posted this in 2010. Four years later, some of my predictions are coming true!!! Guess I should become an astrologer...

Process safety in the 21st Century(ORIGINALLY POSTED ON NOVEMBER 11th, 2010)

Having spent 30 years in the chemical industry, I am trying to hazard a guess on the direction of process safety in the 21st century:
1.The human being will become more and more the focus in process safety. Technical competency of individuals is fast decreasing and job hopping means that process safety knowledge is fragmented in an organisation.
2.Plants are becoming more and more hi tech with control systems and instruments with wireless technology and “smart” technology while the human being is becoming “unsmarter”.
3.As organisation become larger and larger, the management of process safety is getting lost somewhere in between the layers of communication. While leading process safety indicators are good in highlighting problem areas, the focus on these indicators is also human dependent and with directors on boards of companies changing, this focus gets shifted from time to time.
4.There will be Low frequency High Potential accidents happening in large organisations. The BP case is just a teaser. Even in organisations that manage their process safety closely, one slip is enough.Managing to avoid this “slip” will become tougher and tougher in this “flat world”.
5.Fortunately or unfortunately we are in an age of rapid technology change. Plant operators should be careful to select the technologies they need and more importantly to “deselect” the technologies they do not need. One mans bread may be the other man’s burnt toast!
6.To become more and more competitive, organizations are cutting costs. While there is nothing wrong in cutting costs, I see a drastic decrease in in-house competency to assess the technical issues while cutting costs.
7.There will be a number of security issues with chemical plants as control technologies change.
8.Competency of people is becoming a major issue. Simulator training of plant operators may become a legal requirement soon in many countries!

I do not want to bore you with this monologue, but how do we avoid this? Top management must continually have a feel of what is going on at the ground level. There is no better solution that the old fashioned way of walking the talk by periodically meeting people at ground zero and observing what their problems are! I’m signing off…..!

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December 12, 2014

Update on Dupont incident

Excerpt from Written Testimony Submitted by U.S. Chemical Safety Board Chairman Rafael Moure-Eraso to the Joint Committee: Senate Committee on Environment and Public Works and the Senate Committee on Health, Education, Labor, and Pensions hearing entitled, "Oversight of the Implementation of the President’s Executive Order on Improving Chemical Facility Safety and Security”:
 
"The most recent example is the tragic chemical accident at the major DuPont chemical plant in La Porte, Texas, just east of Houston.  On November 15, 2014, there was a release of methyl mercaptan, a highly toxic and volatile liquid, which DuPont itself has estimated at 23,000 pounds – a very significant quantity.  Odors of the chemical were reportedly discernible many miles from the plant.  Four workers – including operators and would-be rescuers – perished inside the methomyl-production building where the release originated.
DuPont is certainly no “outlier.”  In fact, DuPont has long been regarded as one of industry’s leading lights in safety, and it markets its safety programs to other companies.  What happened last month, however, was the fifth release incident at a DuPont facility that the CSB has investigated since 2010, and three of these had associated fatalities.  While the CSB investigation remains underway in La Porte, some preliminary facts are already emerging.
The incident occurred following an unplanned shutdown of the methomyl unit due to inadvertent water dilution of a chemical storage tank several days earlier.  Efforts were underway to restart the process, but problems occurred including plugged supply piping leading from the methyl mercaptan storage tank.  As efforts were underway to troubleshoot these problems, it is likely that methyl mercaptan (and possibly other toxic chemicals) inadvertently entered the interconnected process vent system inside the building.  The release occurred through a valve that was opened as part of a routine effort to drain liquid from the vent system in order to relieve pressure inside.  We found that this vent system had a history of periodic issues with unwanted liquid build-up, and the valve in question was typically drained directly into the work area inside the building, rather than into a closed system.  In addition, our investigators have found that the building’s ventilation fans were not in service, and that the company did not effectively implement good safety practices requiring personnel to wear appropriate personal protective equipment (PPE) that was present at the facility.  Appropriate PPE would include equipment, such as supplied air respirators, for workers performing potentially hazardous tasks inside the building.
In summary, this was a complex process-related accident with tragic results.  It gives rise to a number of design and organizational safety concerns.  Its occurrence – taken along with other major accidents afflicting large and small corporations – underscores the need for some systemic reforms.  It would be a serious and tragic mistake to consider each of these accidents as just another isolated event, reflecting only the limited practices of a small group of people operating outside regulatory scrutiny.  If it can happen at DuPont, I would submit it can happen anywhere."


Read the complete CSB written testimony to joint committee from which above excerpt was taken in this link

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December 11, 2014

December 6, 2014

Accident while working on control valve

OSHA has an incident about an employee loosing his end of a finger when performing calibration of a control valve. The incident teaches us the importance of hazard identification and risk assessment prior to performing a job.
Read about the incident in this link.

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December 3, 2014

30 years after Bhopal - lessons not learnt

30 years ago, on the night of December 2nd/3rd 1984, the Worlds worst industrial disaster took place.

In India and elsewhere around the World, catastrophic chemical plant incidents continue to occur. Memory is short. In the numerous incidents since Bhopal, many of the reasons are similar to those of the Bhopal disaster:
  • cost cutting without properly analysing the effects on process safety
  • poor competency
  • poor asset integrity
  • high attrition rate
  • inadequate emergency response and planning
  • inadequate implementation of facility siting
  • not paying heed to audit reports and past incidents etc.
What has changed between 1984 and 2014? It is technology. But can technology change behavior of people? In 2010, two fatal accidents occurred at two different sites of one of the World's best process safety managed organization. Why? Think about it!

Even if you have a 40 element PSM system, there is no guarantee that a catastrophic accident will not occur.  Is there a solution to this? One of the possible solutions is accountability at the highest level. By this I mean legal requirements that will make the entire board of chemical organizations accountable for a process incident that kills or maims people. This includes the Director, Finance and Director, HR too. The Sword of Damocles should surely work.

Our Prime Minister is doing a great job in encouraging "Make in India". I wish the slogan was "Make Safely in India" . We still do not have any PSM rule. We still do not have an independent incident investigating authority. The status of the chemical safety and security rating system whose draft was published last year is not known.

My thoughts are with the victims of Bhopal - dead and surviving...and I pray that another Bhopal does not occur.

Read my earlier posts on Bhopal:



See a presentation on the Bhopal Gas Tragedy by Vijita S Aggarwal, Associate Professor, University School of Management Studies,GGS Indraprastha University,Delhi, India in this link.
Read my older post comparing the Bhopal and the BP incident of 2005 in this link
Read the then Police Chief’s account of the tragedy in this link.


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December 1, 2014

DuPont Says Plant Leaked 23,000 Pounds of Toxic Gas by Jim Malewitz, The Texas Tribune November 29, 2014

DuPont Says Plant Leaked 23,000 Pounds of Toxic Gas
 by Jim Malewitz, The Texas Tribune
 November 29, 2014

About 23,000 pounds of a flammable, foul-smelling toxic gas leaked from the DuPont chemical plant in La Porte where four workers died earlier this month, the company said Saturday.

That’s significantly more than the 100 pounds of methyl mercaptan that DuPont estimated had escaped the plant in its initial report, and was enough to asphyxiate the four workers and hospitalize another.

Companies are required to report all releases of at least 100 pounds of the gas to the Texas Commission on Environmental Quality. DuPont said it revised its initial estimate after determining how much gas was in the plant’s pipes and vessels before and after the tragedy.

“The release occurred inside a process building at the site’s Crop Protection unit and dissipated from openings in that structure over time,” the company said in a statement.

The U.S. Chemical Safety and Hazard Investigation Board is still investigating the incident.

Methyl mercaptan can cause nausea, vomiting and fluid buildup in the lungs. Its rotten-egg smell wafted over La Porte for at least 24 hours after the accident, but county health officials said the leak posed little risk to the community because the gas rapidly degrades once released into the air. Even trace amounts carry the smell.

The plant, about 30 miles southeast of Houston, makes products like alcohol resins and a popular insecticide called Lannate.

In the past five years, the TCEQ has cited it at least two dozen times for violating state law. The plant has failed to perform routine safety inspections, keep equipment in proper working order and prevent unauthorized pollution leaks, according to violation notices issued by the agency. In a few instances, the agency demanded fines of a few thousand dollars from DuPont for more serious lapses.

But the unauthorized leaks of toxic chemicals are common in Texas. Thousands — and even millions — of pounds of toxic chemicals beyond what permits allow have spewed from the state's facilities, as The Texas Tribune has reported. Though many of those events were close calls that prompted evacuations at worst, some triggered deadly explosions that, in turn, caused even more gas to be released.

Since 2009, Texas chemical manufacturers have reported at least 19 other unauthorized releases of methyl mercaptan, according to state data. DuPont’s was the only methyl mercaptan release that killed or injured workers during that period.

This article originally appeared in The Texas Tribune at http://www.texastribune.org/2014/11/29/dupont-says-plant-leaked-23000-pounds-toxic-gas/.

November 28, 2014

USB sticks and security issues

In 2012, two power plants in the USA were affected by malware attacks, brought in by USB sticks. Read the article in this link.
Have you banned USB sticks in your plant?
 
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November 18, 2014

Snake in the control room

 In 1984, when I was shift in charge in an ammonia plant, the control room was ordinary building with three aluminium doors. Two doors were in front of the building and one at the back. The door at the back was near to a locker room. One day as an operator was changing his dress, he spotted a snake in the room. Immediately he raised an alarm (Basically he screamed his lungs out!!) and we managed to isolate the snake inside the room till help came and the snake was taken out. Imagine the plight if the snake had entered the main control room which was just a few feet away. Are you prepared for "snakes" in your control room? By this I mean are you ready with a plan in case the control room becomes uninhabitable due to some emergency? The emergency could be a fire, toxic gas ingress or anything else. Don't think it will not happen. Instead, be prepared.


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November 15, 2014

Planning for mock drills


Mayday! Mayday! The distress calls from Mukesh Ambani's plane that shook ATC - Times of India

The above article from Times of India shows how preparation for mock drills could cause an incident.
  
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November 13, 2014

News article from BBC

 Thanks to Sanjeevi for sending this news article from BBC http://www.bbc.com/news/business-29997074


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El Al crew briefly 'lost control' of plane in August incident, investigation shows - National Israel News | Haaretz

El Al crew briefly 'lost control' of plane in August incident, investigation shows - National Israel News | Haaretz

The incident highlights the need for a human being to take control during emergencies. Automation will not solve all problems.

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November 12, 2014

Fire in turbine in power plant

A leak in an oil pipeline of a steam turbine has caused a fire which has stopped power production in a Chennai power plant. Though no persons were injured, it highlights the dangers of lube oil leaks.
Read an article on Controlling the risks of lubrication oil fires - from Machinery Lubrication.

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November 9, 2014

Firefighter killed in ammonia leak in Israel

On 6.11.14, according to news reports, a firefighter was killed and hundreds of people living around an industrial area in Israel were asked to take shelter in their homes after an ammonia leak from a pressurised 60 MT ammonia  vessel. As per news reports, an initial investigation found that maintenance workers at the factory accidentally hit a pipe from the vessel, causing a crack to develop.The firefighter who died was responding to the emergency and trying to locate the leak when he became separated from his team due to the heavy cloud of ammonia vapors, and eventually ran out of air.
He was found unconscious shortly before midnight, but despite the efforts of medical teams, was pronounced dead at the scene.






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November 4, 2014

Case study on unusual failures in hydrogen production

A good case study on unusual failures in hydrogen production can be read in this link


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November 2, 2014

Learn lessons from this confined space incident

 LINK HAS BEEN UPDATED

An investigation of the marine accident investigation board of a confined space incident involving three fatalities indicates how careful you must be.
In this incident, three people died when they entered a ships hold.  You can also read about the rescue attempt and how the rescue contributed to the number of fatalities.
Read the report in this link.


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November 1, 2014

Learn lessons from this confined space incident

An investigation of the marine accident investigation board of a confined space incident involving three fatalities indicates how careful you must be.
In this incident, three people died when they entered a ships hold.  You can also read about the rescue attempt and how the rescue contributed to the number of fatalities.
Read the report in this link.

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Pesticide reacts with moisture and overpressurises container

 An employee at a company was injured when the top of a seven gallon metal container top burst open and hit his arm.
The built up pressure was caused by a pesticide packet that due to a defect, was not entirely closed and activated with moisture from the air and began releasing the small amount of chemicals it held, pressurizing the container.

Read about the incident in this link
  

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October 29, 2014

Could Bhopal Happen in America?


 Read the Al Jazeera article in this link

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October 28, 2014

Technology in Aviation

Process safety and aviation are commonly linked through automation and not to mention, the human!.  A plane is a very interesting pressure vessel which is subject to cyclical pressures and rarefied atmospheres.Read an article on how cabins in planes are pressurised and provided oxygen so that we don't pass out at high altitudes in this link.


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October 27, 2014

Symposium on process safety

IIT Gandhinagar is conducting an International conference on Safety and Symposium on Process Safety on December 5th and 6th. More information can be obtained in this link.

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October 24, 2014

October 19, 2014

The importance of asset integrity

The importance of asset integrity is highlighted in this accident when an employee was opening a bypass of a control valve which was malfunctioning. Read about the incident in this link.

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October 16, 2014

Expansion joint failure causes fatality

OSHA has cited a chemical plant in the USA for an expansion joint failure that caused a fatality. Read about the incident in this link. 


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October 13, 2014

Cyclones and emergency preparedness

The ferocity of cyclone Hudhud makes me shiver. Wind speeds were reported to be 195 kmph. My thoughts go back to 1984 when a 120 kph wind speed cyclone hit the ammonia plant where I was shift in charge. The ammonia tank flare toppled and the safety valves of the tank were maintaining tank pressure as emergency power to the tank compressors was lost. Luckily for us, the area around the plant was sparsely populated and a disaster was averted.
A parallel ammonia tank flare was erected in record time and we managed to connect it to the existing line from the tank and control the situation.
Visak has many chemical industries and refineries and the cyclone would have badly hit them. I hope the situation is brought back under control quickly.

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October 12, 2014

Ex manager of chemical plant sentenced to 25 years for causing 7 fatalities

A Chinese ex Manager of a chemical plant was sentenced to 25 years in prison after he was found guilty of altering the thickness and height of a sulphuric acid tank that later ruptured killing 7 people. Read the news article in this link.

   
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October 9, 2014

The challenge of change in Engineering by Phil Hopkins

 Phil Hopkins of Penspen Integrity, UK, has written an incisive and humorous article on  "The challenge of change in Engineering". It is worth reading by all chemical engineers.

Read the full article in this link

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October 6, 2014

Emergency response for sulphuric acid

Please find a good presentation for emergency response by NorFalco, for sulphuric acid leak in this link.

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October 2, 2014

Duty of care: Indian Express

Duty of care : Indian Express

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October 1, 2014

Oversight in inspection causes a pressure vessel lid to blow off

A pressure vessel exploded, sending the vessel’s 250 Kg lid six metres into the air. No one was injured in the incident.
The explosion was found to have been caused by a failure of the vessel’s regulator and pressure relief valve. The investigation determined that sufficient maintenance of the safety devices was not being carried out. Also, statutory inspections were not completed for three years.Read about the incident in this link.

 
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September 26, 2014

23 injured in flare-up at SAIL’s Burnpur plant | Business Line

23 injured in flare-up at SAIL’s Burnpur plant | Business Line


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Another pressure testing incident

A technician suffered serious injury during a pressure test when a thermowell failed and hit him in the leg. Read the incident in this link.

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September 21, 2014

Technology of the future today

World’s First Plant to Print Jet Engine Nozzles in Mass Production



What does the above link have with process safety? Technology is rapidly changing. Try to guess how 3D printing will influence process safety management.


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September 17, 2014

Interaction with chemical engineering students

Today I gave a presentation on "Bhopal and it's relevance today -what young chemical engineers should know" to a group of 60 smart final year chemical engineering students in a leading university. My learnings from the interaction:
This generation of post bhopal chemical engineers are very curious to know what exactly happened at Bhopal and how they can use the learnings in their career in industry. If we do not pass on the relevance of the Bhopal disaster (and the learnings from Bhopal will remain relevant as long as the human being exists) to the present and future generations, we will continue to have major disasters in the Chemical industry. It would be nice if, during the students summer training in Industries, a topic on process safety is also mandatorily included.
The Management of Process safety should be taught as part of the core curriculum of undergrad chemical engineers. They will be the future decision makers in the industry.

I request Associations like the ICC and other chemical associations to take up the points mentioned above.
Also, every Responsible Care certified company may teach the lessons from Bhopal to chemical engineering students in at least three universities every year.


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Deaths Involving the Inadvertent Connection of Air-line Respirators to Inert Gas Supplies

Safety and Health Information Bulletins | Deaths Involving the Inadvertent Connection of Air-line Respirators to Inert Gas Supplies


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September 15, 2014

PRESENTATION TO BOARD OF DIRECTORS ON BHOPALS 30TH ANNIVERSARY

As you are aware, this year marks the 30th Anniversary of the Bhopal Gas Disaster. To commemorate the event, I am offering a 1 hour free presentation to boards of directors (including the Occupier and Finance Director) of any chemical manufacturing company on the topic "Are you in control of Process Safety"?
I will discuss all the current issues facing process safety and risk management in a chemical manufacturing  company and how directors can ensure effective risk management of a hazardous chemical facility.


If you are interested, please contact me at bkprism@gmail.com

My CV is given below:
I am a Chemical Engineer with over 35 years experience in the Industry in Operations, Technical Services and Process Safety. Prior to starting my Process safety consultancy in 2001, I had worked in India and Saudi Arabia.I have implemented risk based Process Safety Management systems based on best practices of OSHA CFR 1910.119 and others, in many plants in India and overseas. I have carried out many process hazard analysis studies and process safety related assignments in India, Germany, Greece, South Africa and the Middle East. I have also conducted many process incident investigations involving toxic gas releases, fires and explosions, runaway reactions, equipment failures, flare system explosions etc. You can contact me at bkprism@gmail.com


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Hazard of Potential Sidewalk Grate System Failure

Safety and Health Information Bulletins | Hazard of Potential Sidewalk Grate System Failure


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September 11, 2014

22 wouldn’t have died in pipeline blast had GAIL installed safety features: Probe report :Indian Express

22 wouldn’t have died in pipeline blast had GAIL installed safety features: Probe report - See more in this link - Indian Express
Please also see comments by the papers readers, below the article.

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GAIL pipeline fire due to collective failure: Probe report | Business Line

GAIL pipeline fire due to collective failure: Probe report | Business Line

By the way, collective failure is not a term used in "root cause analysis".

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September 9, 2014

Ammonia leak in China plant sickens 33

An emission of unburnt ammonia from a flare due to a plant problem has led to ammonia release , causing 33 people to require treatment. Read about the incident in this link.


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September 5, 2014

The boy who beeps - from GE

GE has brought out an interesting video on a young boy who can talk to machines by a beep! What does this have to do with process safety? You figure it out in this video.


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September 3, 2014

Root causes - Unveil them to prevent future incidents

Often, I see incident reports where it mentions the root causes of the incident, but actually they are not the root causes.
I am taking the example of a case study put up on the OISD website called Fire Incident in Process Cooling Tower
in which it mentions the following as "Root Causes" for the incident: My comments are given in brackets.


ROOT CAUSE

1. The reason for explosion and major fire is gushing out of entrapped hydrocarbon from the cooling water return header to new cell, which got ignited since hot jobs were being carried out in close vicinity. The ingress of hydrocarbon was from leakage of hydrocarbon in cooler/condenser in connected process units.
(This is the direct cause of the incident)


2. Not adhering to the practice of stopping all work (especially hot work) and prohibiting all unrelated contractor and company personnel at site, before commissioning a new system/ facility. Also, carrying out hazard analysis/ risk assessment would have probably indicated that there could be trapped HC gas, and prompted commissioning/ operation team to vent out entrapped gases.
(Why was the work not stopped before commissioning of a new facility? Why was hazard analysis/risk assessment not carried out?)

3. Failure to prevent commissioning activities, even though several jobs were unfinished:

· HC and H2S detectors were not installed.

· Instrument cabling, cooling fan jobs were still unfinished.

· Decision to go ahead with commissioning at fag end of the day.

· Improper coordination amongst Operation, Maintenance and Project  departments.

· Unable to ensure the gaps identified in internal safety audit & operation check-list are liquidated before commissioning


(Why was the commissioning done even though several jobs were unfinished?)


I am hoping the OISD will publish the detailed investigation report of the HPCL Visak cooling tower fire incident and the GAIL pipeline leak incident, just as they have put up the Mr MB Lall's committee report on the Jaipur oil depot fire on their website.

 
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August 28, 2014

Pneumatic test fatality

Read the case study about a fatality during a pneumatic test in this link.

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August 20, 2014

Automation and the human

An incident with a plane when it descended  5000 feet without the knowledge of the pilots is reported in newspapers. The commander of the aircraft was under "controlled rest" , (naps allowed by rules) while the co pilot was reported to be busy with the flight data on her ipad. The ATC in Ankara, over which the plane was flying,noticed the flight dropping from its assigned altitude and radioed an emergency alert to the co pilot. The flight was then brought back to its designated altitude.  This incident is being investigated and the results of the investigation will be interesting to see. With so much automation, how did the plane drop 5000 feet without the co pilot noticing it?
In chemical plants, also, an alert and trained operator is the best defence against an incident. Automation is only an enabler and cannot replace the human. Focus on competency development program for your operators and shift crew. Establish a fatigue management program for your shift crew. When I was working in shifts in the Middle East in 1990's the management gave a lot of importance to fatigue management. In fact a near miss incident was reported when a maintenance worker was working on overtime on a critical equipment.


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August 16, 2014

Design and robustness

 How GE designs its jet engines

The above link is worth watching and it is interesting to see how strict mandates for aviation design are!
Of late, in India, I see a deterioration in design aspects in chemical plants., mainly because of cost cutting pressures and severe competition in the EPC space. This leads to some dilution in design. Let me give you an example. There were two EPC contractors bidding to build a new ammonia storage tank. One of them who was the lowest bidder got the assignment. Tank was erected, commissioned and everything went off well. As time went by, corrosion started affecting the tanks and only then it was noticed that the designer had scrounged on the number of root isolation valves to cut costs. This meant that if there was a leak in an instrument manifold tapping coming from the top of the tank to the bottom, the leak could not be isolated. You might argue that a HAZOP study should have spotted this, but the quality of HAZOP studies has nosedived!

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August 14, 2014

Temporary change and asset integrity

This case study from OISD highlights the importance of asset integrity and managing temporary changes. Share it with all your operation and maintenance crew.

 

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August 10, 2014

Video of fire in service station

Leak + ignition source = fire. See the leak of a flammable fuel then catching fire from an ignition source (vehicle) in this link

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August 9, 2014

Fatality due to fall in molten iron bucket

News reports indicate that an employee of a major steel company has died after falling into a molten iron bucket which was at 1600 deg C. The investigation will reveal the cause of the tragic incident.

I want to share an incident in another company I heard about few years back, where an engineer fell into a shredding machine that was operating. The fall was due to an open manhole, left open by maintenance. The engineer did not see the open manhole and fell into it. The maintenance crew had taken a break and left without barricading or closing the manhole cover.

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