December 31, 2015

Weak Sulphuric acid FRP tank collapse

In a factory, where 10 MT weak sulphuric acid was stored, suddenly the suction line valve tank nozzle assembly got broken and through this opening sulphuric acid drained out from the tank. This resulted in vacuum formation in the tank. This FRP tank hit against the supporting channel legs due to the formation of vacuum.
Causes :
1. The FRP tank was not maintained with a adequate strength and stability

2. The FRP tank was not tested and certified by the Competent person every year

 Source: DGFASLI

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Urea prill tower incident

In a Fertilizer manufacturing factory urea manufactured in prill tower passes through a grizzly (a stainless steel sieve) and falls on a conveyor. To facilitate repair works to be carried out to a grizzly bar, two metal rods were placed above the grizzly bar and this was covered by a tarpaulin sheet.Right below this arrangement welding of grizzly bar was carried out. When the welding process was being carried out heavy lumps of urea started falling down from the prill tower and fell on the iron plates placed over the grizzly bar. The iron plates along with heavy lumps of urea fell on the workers working right below the covered tarpaulin sheet and they sustained head Injuries and died.
Causes :
The temporary arrangements made above the grizzly bar to facilitate welding work was not of a strong and rigid construction to withstand falling of heavy lumps of urea from prill tower.

Ref:DGFASLI




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December 26, 2015

How the Apollo 1 Fire Changed Spaceship Design Forever

Interesting article on how designers learn from their mistakes.....after all they are also human.
How the Apollo 1 Fire Changed Spaceship Design Forever


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December 23, 2015

Accident and emergency | Chemistry World

Accident and emergency | Chemistry World

‘2015 should be remembered as a year when the chemical industry was sharply reminded of its social responsibility’



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December 22, 2015

Empty drums are deadly drums

Often empty drums are treated with much less safety precautions than filled drums. An empty drum that has not been purged free of residues chemicals is a potential bomb. Read about an incident from HSE UK, with a small film about the incident in this link.


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December 18, 2015

Management of Change or Change of Management?

In 1999, when I was carrying out a PSM audit, we were auditing a maintenance mechanic. I was asking whether he can explain what is the meaning of management of change. He replied that when his company was recently taken over by another company, that is management of change!
Are you carrying out MOC for change in Management?

 
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December 15, 2015

Whitepaper on dust explosions

Read a good white paper by Fike about Dust explosions in this link.

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December 11, 2015

Ammonia leak kills one

News reports coming in of an accident in an ammonia plant in Canada when a contractor employee who was doing weather proofing job on an ammonia storage tank was killed due to an ammonia release. Apparently, a piece of equipment struck a valve on the tank and caused the leak. This accident highlights the dangers of working with highly hazardous chemicals and the need for proper JSA's to be carried out.

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December 8, 2015

December 6, 2015

Lessons relearned - TCE - inadequate isolations

Read a TCE article on Lessons relearned - inadequate isolations in this link.

 
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December 2, 2015

The Ghosts of Bhopal

On the 31st anniversary of the Bhopal Gas Disaster, and with the post Bhopal generation of Chemical Engineers now managing Chemical plants, let us remind ourselves that the Ghosts of Bhopal are still around. We continue to see compromises in process safety management leading to catastrophic accidents.
  • For a new generation who have grown up with ISO and PSM systems, remind yourself that systems alone cannot prevent accidents. 
  • You must not be deaf and blind to what the systems are telling you. 
  • You must also speak up and not be mute when you observe process safety issues. 
  • Do not forget the lessons from the past. 
  • For people at the highest level in the organization, do not get lulled into a false sense of security just because nothing has happened. 
  • Actively seek out bad news...remember the ghosts of Bhopal are still around, waiting to give you a scare....
An example of the Ghosts of Bhopal is the recent CSB incident investigation report of the Caribbean Petroleum Tank terminal explosion and multiple fires released by CSb in October 2015.
CSB finds that systemic failures at CAPECO included: (The highlighted failures are the same failures that happened in Bhopal)
  1. A history of poorly maintaining terminal operations;
  2. An inherent financial pressure to fill the tanks within the Planning Department’s stipulated time, which was at odds with safety;
  3. A failure to learn from previous overfill incidents at the facility;
  4. A lack of preventative maintenance for the malfunctioning float and tape device, automatic tank gauge transmitters;
  5. An unreliable computer for calculating tank fill times;
  6. A lack of overfill prevention safeguards as an independent alarm;
  7. A lack of formal procedures for tank-filling operations for operators and managers;
  8. An insufficient mechanical integrity program for safety critical equipment;
  9. Poor adherence to human factors principles for safety critical equipment.



I also managed to locate a Dec 31, 1984 article on the Bhopal Gas Disaster written in India Today. Read it in this link.

Read an eyewitness account of a IIT professor who was travelling by train at Bhopal station when the disaster occurred in this link 

Remind your employees, including top management that the ghosts of Bhopal are still around by organizing a process safety week from December 2nd every year
 
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December 1, 2015

Beware of hose worm clamps!

 A chemical cleaning unit of a heat exchanger was rigged up with hoses, fixed with clamps. When the cleaning operation was going on, one of the workers accidentally stepped on the hose which was sending in pressurised chemical cleaning solution. The hose worm clamp gave way and the hose sprayed chemical cleaning solution into the eyes of the worker, causing permanent damage to his vision.

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November 25, 2015

A non profit organisations view about Process Safety in the USA

The Center for Effective Governance in the USA (a non profit organisation) has published a report called "Blowing smoke" where they say that " Voluntary standards don’t work, and existing regulations are not effectively enforced"
Read about the report in this link.
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November 19, 2015

November 16, 2015

Chlorine accidents

Chlorine accidents

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November 7, 2015

Incident due to nomalization of deviation

Operators used to routinely try to clear blockages in an asphalt line by heating the line externally with a propane torch. In this incident, this normalisation of deviation turned into an incident when it caused an explosion in the tank. Read about the incident in this link.

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October 29, 2015

When cranes collapse

See a video and photographs of crane accident that happened in Aug 15 in the Netherlands in this link
There are lessons to learn....

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October 26, 2015

Be careful when dealing with pressurised lines

A man was killed in an accident involving a high-pressure water line at a well site. The victim along with two other men
was trying to heat a frozen high-pressure water line when the line ruptured. The victim was hit by a stream of high pressure water  at a pressure of 3,500 to 4,500 psi.The victim died from the impact of the water.

Read another safety alert from HSE UK http://www.hse.gov.uk/safetybulletins/hydraulic-injection-injury.htm


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October 22, 2015

Sealant reinjection incident investigation

A paper presented in the Process safety congress at Dordrecht on June 4th, 2015 depicts the detailed incident investigation of the accident at a refinery in Antwerp in 2013 during sealant re injection. Read about it in this link.

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October 19, 2015

Readers response to post

Mr M.K.Rao, Executive Director of India Glycols responded to my post "Of Mimic panels and Video walls - back to the past?"
His reply is as follows:

"The subject Blog item is interesting and highly relevant too.

When I entered the DMT control room (IPCL, Baroda) in the year 1981, the scene was similar. The space above the pneumatic controllers had a mimic panel that depicted the complete PFD. In addition, we had a model of the entire plant on a large table in the same control room at a corner. It made learning faster and we used to have a better feel of the process. It was easier to know what was going on at a glance.
 

Going by the best of Past & Present, I feel a combination of
  1. DCS work stations
  2. Mimic panel representing the complete/ continuous PFD like in the past (Instead of Video panels – which may appear broken)
  3. A model (physical) of the plant right in the control room would help"

I agree with his valid suggestions and thank him for responding..
 

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October 17, 2015

Hydrogen explosion incident

 Read about a hydrogen explosion in a compressor in this link.


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October 13, 2015

Dead leg incident

 Read an incident involving a piping dead leg in this link.

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October 12, 2015

Of Mimic panels and Video walls - back to the past??

 I just returned from a large modern refinery. When I visited the control room, with large video walls, my thoughts went back to 1979 when I was operating an ammonia plant with pneumatic controllers and no DCS. The wall above the controllers had a mimic panel that depicted the complete process flow diagrammatically. This depiction covered the whole control room wall between the controllers and the ceiling, so it was large and easy to see.  The motors and pumps had running lamp indications in the panel. For 300 control loops, we had about 200 hard wired alarms located between the controllers in sets of 20.

See a concocted image of a mimic panel located above pneumatic controllers similar to the one I had used below:





















The modern control room I visited looked similar to the one below, with large video walls:









I was recollecting the progress in instrumentation - from pneumatic control systems to electronic to DCS without video walls and now DCS with video walls. - back to the past!!!!
Technology can and will always be an enabler only and as long as human beings exist, human errors will continue...take for instance the modern day DCS. We have so many alarms that inundate the operator during plant upsets, that vendors now sell alarm suppression software! Why do we need that many alarms in the first place???

One important philosophy in Process Safety - KEEP IT SIMPLE AND DON'T FORGET THE PAST!!

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Fire in a laboratory of an industrial gas facility

Reports coming in of a fire in the laboratory of an industrial gas facility in Singapore. Reportedly one person was killed. Read about the incident and see the photos  in this link.

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October 10, 2015

A temporary change causes a fatality

Temporary changes are dangerous if not managed properly. Read about an incident involving a temporary change that causes a fatality. This incident highlights what Dr trevor Kletz used to say "We do not know what we do not know"
Read the incident in this link.

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October 7, 2015

Overheated air compressor causes fatality

 Read about an incident involving an overheated air compressor that caused a fatality in this link

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October 3, 2015

4 workers hurt in explosion at SunEdison's Texas plant : Business

 New coming in about a fire in a polysilicon plant in USA involving Silane. Read about it in this link:
  4 workers hurt in explosion at SunEdison's Texas plant : Business


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CO2 Gas Hazards in the Brewing Industry

Don't take CO2 for granted thinking it will not harm you. Read this article:
CO2 Gas Hazards in the Brewing Industry

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October 1, 2015

2 workers killed in Vizag pharma city unit blast | Business Line

2 workers killed in Vizag pharma city unit blast | Business Line



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Du Pont incident recommendations by CSB

The CSB has approved the draft recommendations in the DuPont incident last year at LaPorte, Texas that killed 4 employees. I observe many similar instances in batch processes in various manufacturing units in the pesticide industry during PSM audits. The CSB recommendations are given below:

"Pursuant to its authority under 42 U.S.C. §7412(r)(6)(C)(i) and (ii), and in the interest of promoting safer operations at US facilities handling chemicals and protecting workers and communities from hazards, the Board makes the following interim safety recommendations to the DuPont chemical manufacturing facility in La Porte, Texas and the International Chemical Workers Union Council of the United Food and Commercial Workers:
Inherently Safer Design Review
Prior to resuming Insecticide Business Unit (IBU) manufacturing operations, conduct a comprehensive engineering analysis of the manufacturing building and the discharge of pressure relief systems with toxic chemical scenarios to assess potential inherently safer design options. At a minimum, evaluate the use of an open building structure, and the direction of toxic chemical leaks and the discharge of pressure relief systems with toxic chemical scenarios to a destruction system. Implement inherently safer design principles to the greatest extent feasible and effectively apply the hierarchy of controls such that neither workers nor the public are harmed from potential highly toxic chemical releases. Detail the analysis, findings, and corrective actions in a written report and make this report available to DuPont La Porte employees, their representatives, and the CSB.
Ensure Manufacturing Building is Safe for Workers
Prior to resuming Insecticide Business Unit (IBU) manufacturing operations, conduct a robust engineering evaluation of the manufacturing building and the dilution air ventilation system that includes the implementation of corrective action(s) to the greatest extent feasible in order to ensure a safe environment for all workers. Develop a documented design basis for the manufacturing building and the air dilution ventilation system that identifies effective controls for highly toxic, asphyxiation, and flammability hazards and implement these controls to the greatest extent feasible. Address non routine operations and emergency response activities in the design basis. The design basis for the manufacturing building and the dilution air ventilation system must use the hierarchy of controls and inherently safer design principles to the greatest extent feasible.
Ensure Relief System Design is Safe for Workers and the Public
Prior to resuming manufacturing operations, ensure all Insecticides Business Unit (IBU) pressure relief systems are routed to a safe location and effectively apply the hierarchy of controls to protect workers and the public. Commission a pressure relief device analysis, consistent with API Standard 521 and the ASME Code, including a field review. Include an evaluation of relief system discharge location to ensure that relief systems are discharged to a safe location that will prevent toxic exposure, flammability, or asphyxiation hazards in order to ensure public and worker health and safety to the greatest extent feasible. Include an evaluation of relief scenarios consistent with API Standard 521.
Perform More Robust Process Hazard Analyses
Develop and implement an expedited schedule to perform more robust process hazard analyses (PHAs) consistent with R1, R2, and R3 for all units within the Insecticides Business Unit (IBU). At a minimum, the PHAs must effectively identify and control the hazards referenced in this document utilizing the hierarchy of controls. The PHA schedule must be prioritized based on anticipated risks to the public and workers in order to ensure that the highest risk areas receive priority consideration. At a minimum, the more robust PHAs must be consistent with the approach applied to post-incident reviews described above in paragraph 10.
Ensure Active Workforce Participation
Work together with the International Chemical Workers Union Council of the United Food and commercial Workers (ICWUC/UFCW) Local 900C and the ICWUC/UFCW staff (at the request of the local) to develop and implement a plan to ensure active participation of the workforce and their representatives in the implementation of Recommendations R1 through R4. In addition, provide a copy of DuPont’s integrated plan for restart to La Porte workers and their local union representatives.
Public Transparency and Accountability
Make publicly available (on a website) a summary of the DuPont November 15, 2014 incident investigation report, the integrated plan for restart, and actions to be taken for the implementation of Recommendations R1 through R5. This website must be periodically updated to accurately reflect the integrated plan for restart and implementation of Recommendations R1 through R5."




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Safe in India - a new initiative

I came across the website www.safeinindia.org run by three IIM graduates. SafeInIndia is an initiative to address the issue of crush injuries in the Automotive Sector and work on win-win sustainable solutions.
Glad to see such initiatives springing up. Their report on the automobile sector is available for download from their website which can be accessed here www.safeinindia.org.
 
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September 30, 2015

Two dead in mishap at Birla copper plant in Gujarat | Business Standard News

More details in this article:

Two dead in mishap at Birla copper plant in Gujarat | Business Standard News

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2 killed in accident at Birla Copper unit in Dahej | Business Line

 Thanks to Mr M.S.Srinivasan for sending this

2 killed in accident at Birla Copper unit in Dahej | Business Line


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The Volkswagen emission issue and risk management

I had posted this question to a group in Linkedin: "The ongoing Volkswagen emission issue raises a bigger issue of corporate risk management. From a reading of its annual report, the company did have in place all risk management controls, yet the issue took place. While only a deeper investigation will reveal the details, what is your take on improving risk management? We in the chemical Industry deal with process safety risks among other things and the incident does raise an alarm bell about corporate risk management and its effectiveness". 

Nigel Cann (Process Safety and Dangerous Goods Risk Specialist, Australia) responded with this very good reply:
"Karthikeyan - this is a good topic for this group. I wonder how many people in the PSM field have seen this incident playing out in the news and thought it doesn't apply to them. High profile cases like this need to be taken as the warning for the rest of us that they are. So like every incident that makes the headline, have you (and everyone else) thought about how things could go wrong in the plants and processes that I am responsible for.

Some thought provoking questions for people:

* Where have we met the letter of the law, rather than addressing the spirit of it?

* Have we had a problem that was causing issues at high level that seemed to magically disappear? Do we understand why?

* Do we have people checking the checkers?

And one that I had a concern for when a GM at an operating plant:
* Are the regulators technically competent to give me a critical assessment of my PSM system? (or in some cases...)

* Do they even turn up to review our operation?"

 
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The Chemical Engineer | News | Employee killed at Nufarm site in Austria

Thanks to Mr M.K.Rao for sending this link:
The Chemical Engineer | News | Employee killed at Nufarm site in Austria


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September 28, 2015

Corrosion at pipe supports - causes and failures

 Read this good article Corrosion at pipe supports - causes and failures

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September 27, 2015

Hydrogen explosion incident due to a change

A company, which produces metal catalysts had made a modification to one of its reactors.
An explosion occurred on the first day of production following the modification and blew the lid through the roof of the factory.


Read about the incident in this link


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September 16, 2015

Severe acid burns to foot as drain collapses

This safety alert highlights the importance of integrity of drain covers:
 Severe acid burns to foot as drain collapses


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September 13, 2015

September 7, 2015

Fatality during pneumatic test

Read an OSHA accident report of a fatality during pneumatic test in this link. 

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September 6, 2015

The evolution of aviation safety

The evolution of aviation safety
Interesting take on statistics and safety!


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September 2, 2015

MOVING PROCESS SAFETY INTO THE BOARD ROOM - ARTICLE IN CHEMICAL ENGINEERING PROGRESS

To all my readers,
My article "Moving process safety into the board room" has been published in the September 2015 issue of Chemical Engineering Progress of American Institute of Chemical Engineers.

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August 25, 2015

Nitrogen pipeline rupture incident

 Read the lessons learnt from a nitrogen pipeline rupture incident in this link.
 
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August 22, 2015

Sealant injection accident

An accident involving a fatality during a leak sealant injection job in a piping highlights the dangers. Read about the incident in this link.

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August 18, 2015

Lessons from confined space fatalities

 In 2010, two welders died in a confined space accident.

The two welders were welding the 36'' final tie from piping system to exchanger. After completion of root welding, one welder made an unauthorized confined space entry into the exchanger to check welding root pass. He was thought that the argon purge was off but one valve was not completely closed and one purge line remained on. This resulted in the argon atmosphere being sustained within the exchanger. In addition, the purge plug ( which is put in place to reduce argon consumption during welding) was in place, which increased the concentration of argon in the vessel. So the first welder collapsed and the second entered for rescue without PPE. Both welders were overcome and died.

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August 12, 2015

Best practices to avoid glass lining damage

Often, we do not treat glass lined equipment with care. Read a good blog post on best practices for avoiding damage to glass lined vessels (two parts) in this link 

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August 9, 2015

Piping incidents

 Read about piping misalignment / vibration related incidents in this link.

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August 6, 2015

Inspecting pressure vessels


 Good practical article on best practices in inspecting pressure vessels in this link.

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August 5, 2015

Global Energy Firm fined £1.4m after worker killed in refinery fire - HSE UK

Read about an incident where a maintenance job caused a fatality. Highlights the importance of doing proper risk assessments.
Global Energy Firm fined £1.4m after worker killed in refinery fire - HSE UK

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Govt moots single entity for oil sector safety, installations | Business Standard News

Govt moots single entity for oil sector safety, installations | Business Standard News

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August 3, 2015

Controlling Legionella in cooling towers

See a write up by the Cooling Tower Institute on the best practices of controlling Legionella bacteria in cooling towers in this link


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August 1, 2015

DGCA orders removal of AI flight safety chief - The Hindu

DGCA orders removal of AI flight safety chief - The Hindu

Interesting article....especially the reasons mentioned



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July 27, 2015

How speaking up can save lives - BBC UK

Excellent article from BBC UK How speaking up can save lives

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July 18, 2015

July 12, 2015

Cracking issues

Cracking issues

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July 8, 2015

Six killed in tank explosion

News reports from South Korea indicate a waste water tank explosion when hot work was going on. It is suspected that a welding spark ignited methane, a biochemical gas. It appears that workers conducted a safety check and measured gas concentrations around the tank but not in the interior of the tank, which was sealed. It indicates the importance of analysing atmospheres inside tanks when hot work takes place outside.
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July 5, 2015

Pilots' brains can shut down during crisis | Business Standard News

This article has learnings for designers of plant control systems!

Pilots' brains can shut down during crisis | Business Standard News


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July 1, 2015

Testing of valves in cryogenic service (LNG etc)

When isolation valves in cryogenic service like LNG need to be tested after maintenance, the test should be carried out at the temperature at which the valve operates. Read an explanation of the test bench in this brochure.
Note: This is only for information.


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Hicks on biz: Human error is inevitable | Columnists | Opinion | Edmonton Sun

Hicks on biz: Human error is inevitable | Columnists | Opinion | Edmonton Sun

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June 30, 2015

Chemical Safety Alert: Safer Technology and Alternatives.by EPA

EPA has brought out a Chemical Safety Alert: Safer Technology and Alternatives. As per them, "This alert is intended to introduce safer technology concepts and general approaches, explains the concepts and principles, and gives brief examples of the integration of safer technologies into facility risk management activities."
Read the alert in this link.

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June 17, 2015

Fire in confined space incident

An interesting incident of a fire in a confined space in a ship has lessons for us in the Chemical industry. In this incident a technician was trying to use a cleaner spray to remove moisture from a junction box in a confined space. To speed up the process of drying, he then decided to use a heat gum. The moment the gun was switched on, the flammable vapours of the cleaner caught fire. Dont take anything for granted.
Read and see pictures of the incident in this link.


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June 13, 2015

Ammonia leak from road tanker kills 6

An ammonia road tanker apparently hit a low bridge in Ludhiana, causing damage to the tanker valves and subsequent release of ammonia gas that reportedly killed 6 people and sending 100 to hospital. Read about the accident in this link


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Advances in control systems

This 15 minute video from ABB is worth seeing to see clever uses of technology to make the operators job easier.  I would like your views on alarm shelving that is mentioned in the video. You can see the video in this link:
System 800xA with extended operator workplace

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June 11, 2015

Selection of Gaskets are important

During a process upset in a plant, a pressure transient took place. This led to two gaskets leaking in a pipeline carrying hazardous gases. Luckily the plant was shutdown and no untoward incident occurred. The investigation determined that improper gaskets were used.
1. Gasket failure
– A process shutdown lead to a transient pressure surge in the pipework which resulted in the failure of two gaskets, and a subsequent leak of hydrocarbons. The release activated the facility fire and gas
system, resulting in an emergency shutdown. Deluge was manually activated until the system had bled down and the release was confirmed to have ceased. There was no resultant fire or injuries.
2. Fuel line failure
– A fuel leak from a generator fuel line resulted in fuel being sprayed onto the generator exhaust resulting in a small pool fire. A Maintenance Engineer, working in an adjacent workshop, smelt
fuel and entered the generator room to investigate. He found a fuel oil mist around the generator and call ed the control room and notified of the leak. He then called for a ships generator to be put on line and left the generator room and shutdown the generator remotely. On his return to inspect the
engine, a small pool fire had started on the hot exhaust manifold covers. The fire was extinguished with a hand held extinguisher and there were no injuries.

What went wrong?
The incorrect installation of parts was a contributing factor in both incidents. Investigation of incident 1 found that a large number of installed gaskets did not meet the pipe specification. Two gaskets failed when exposed to an elevated pressure. Likewise for incident 2, the investigation found that incorrect hoses had been installed in a fuel supply service on the generator, which consequently leaked, resulting in a fire.

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June 8, 2015

Leadership Lessons from Retired Air Force General Charles V. Ickes from Crane Institute Certification.

 There are excellent leadership lessons to be learnt (applicable for process safety, too) in the following link:
Leadership Lessons from a Top Gun: Retired Air Force General Charles V. Ickes from Crane Institute Certification.

 
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June 5, 2015

Pipelne that spilled oil was badly thinned

There are excellent lessons to be learnt fom this incident. It reinforces what I have always been saying : Smart technology needs Smart people! It cannot function alone...

http://news.yahoo.com/pipeline-spilled-oil-california-coast-badly-corroded-073802050.html?soc_src=copy


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