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.
Contribute to the surviving victims of Bhopal by buying my book "Practical Process Safety Management"
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.
Contribute to the surviving victims of Bhopal by buying my book "Practical Process Safety Management"
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