Confined space fatality

Two cylindrical foam sponge pads had been inserted in a riser guide tube to form a plug. Argon gas had been pumped into the 60 cm space between the two sponges as shielding gas for welding on the exterior of the riser guide tube. After completion of the welding, a worker descended into the riser guide tube by rope access to remove the upper sponge. While inside, communication with the worker ceased. A confined space attendant entered the riser guide tube to investigate. Finding his colleague unconscious, he called for rescue and then he too lost consciousness. On being brought to the surface, the first worker received CPR; was taken to hospital; but died of suspected cardio-respiratory failure after 2 hours of descent into the space. The co-worker recovered.
Source:IGOP

Councillors across party lines ‘file’ out of MMC after ammonia file goes missing

Councillors across party lines ‘file’ out of MMC after ammonia file goes missing: File finally traced after noisy scenes in council; Council presses for resolution to shift hazardous ammonia tanks outside the city’; Sealing of ammonia tank demanded

Ammonia leak in Kochi

http://www.newindianexpress.com/cities/kochi/2018/jan/29/ammonia-leakage-at-fact-plant-kochi-city-police-books-tanker-driver-1764808.html

Fatigue and an incident

A worker on a pipe laying barge suffered a blackout without warning and fell. The worker had no previous medical condition and had passed a pre-employment medical the day before the event. He was medivaced for treatment of cuts and bruises and underwent further extensive medical examination. The examination did not find any medical condition that could explain the blackout.
The worker had been working for at least 22 hours, including travelling. After arrival on the facility and induction he went straight into night shift. He suffered the blackout in the first shift. Had he been operating heavy equipment or machinery, the consequence of the blackout could have been far more significant.
A significant contributing factor for the above case is fatigue. The effects of fatigue vary from individual to individual. They can include impaired decision making, delayed response time, inability to concentrate, reduced alertness, and blackout. In the cases above, the site management team failed to manage the risk associated with fatigue. There was a perceived need to carry on with the job.
Key Lessons
Recognise fatigue as a serious safety risk that requires appropriate risk management. Fatigue can cause impaired decision marking, delayed response time, inability to concentrate, and reduced alertness.
Set a clear policy relating to hours of work and communicate it to management and employees. Include travel time as working hours.
Courtesy: NOSPA

Tank Hazard Alert

Tank hazard alert

Fire extinguisher incident

Fire extinguisher incident

Floating roof drain incident

In a hydrocarbon storage tank, the floating roof drain valve was kept open during rainy season. One night, operators smelt hydrocarbon vapours in the dyke area and found hydrocarbon liquid coming out of the open floating roof drain. The connection of the floating roof drain to the roof had failed due to corrosion. Are you checking them for internal corrosion?

Hazardous Energy source kills engineer

An analyser engineer was killed when the engineer removed the cover on an explosion-
proof  enclosure during preventive maintenance. As the engineer loosened the cover, it came out with force and hit him on the head. The force was caused by pressure inside the enclosure from leaking sample gas or instrument air components. It was not equipped with an external indicator to determine the pressure inside the enclosure nor did it have any pressure relief device.
When you hand over equipment for maintenance, make sure all sources of energy are locked out, tagged out and tried.

Is your organization pulling people out of safety training or safety meetings?

In my long process safety consulting journey, I have seen really committed organizations who demonstrate their commitment to safety as well as those who don't really walk the talk. In one of the plants where I was implementing PSM, the Vice President of manufacturing came to the each of my training sessions 10 minutes before the sessions were starting even though he was not required to be part of that training session. He would stay for the first 15 minutes of every session and then leave. Initially, there were latecomers to the meeting, but when word went around that the Vice President himself is attending the start of each session, people started coming on time. In over 20 training sessions I had conducted, he never missed one. This was his way of demonstrating his commitment and operational discipline.
In a diametrically opposite example, I had started implementing PSM in a medium scale organization that was very hierarchical in nature and was run by the top boss ("Owner"). In the first session with top management, the top boss thought that it was not important for him to demonstrate his commitment because he had other "important" things to do, I tried explaining to him the importance of his commitment and involvement, but when things did not improve, I stopped the project.
In another organization, the bosses of the Vice President who was attending my sessions kept on sending messages to him to contact them to discuss some organizational issue, while the planned session was on, even though they knew he was in a process safety session. I tell such organizations.....get your act together or do not implement PSM at all. It will be a guaranteed failure!

Leadership and Process Safety Management

Every now and then we read about incidents of loss of containment even in reputed companies. Why do these incidents happen?
The incidents that I have investigated brings out two categories of leadership - one who think that once a PSM system is implemented, their role is over and the system should prevent incidents. The other is "We did not know this was happening or this risk was being taken at the plant".
Both are leadership issues that form the crux of why incidents continue to occur.
A PSM system is not like a light bulb....switch it on and no incidents occur! It requires top leadership on a daily basis to send the right signals to ensure the PSM system works as intended.
The leadership should also be competent in understanding the process safety risks and should spend quality time to seek and ensure that these risks are controlled on a day to day basis. PSM dashboards are good but can be more useful if leadership does a deep dive into the indicators. The dashboards can also lull you into a sense of complacency if the right indicators are not chosen.
Last, but not the least....Leaders should not review the PSM  system AFTER an incident occurs but must proactively understand whether process safety risks are controlled on a day to day basis.

Good pragmatic article on BBS

BBS is not a panacea for everything. This article is a pragmatic view of the BBS process
Read it in this link

Happy New Year!

Another dawn of a New Year! Wish you and your family a very Happy, Healthy and Safe New Year!