RISK BASED PSM PROCESS SAFETY MANAGEMENT INDIA CONSULTANT INCIDENT INVESTIGATION HAZOP TRAINING ROOT CAUSE ANALYSIS AND LESSONS FROM INCIDENTS
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Employee #1 and several coworkers were working at a chemical plant that deals with nitric oxide. On the day of the accident, a major leak occurred in a stainless steel distillation column. The nitric oxide leaked into the facilities surrounding vacuum jacket and into the atmosphere through a pump, which controls a high quality vacuum inside the jacket to minimize transmission of heat toward the cryogenic distillation columns. A brown cloud quickly formed and the temperature and the pressure inside the distillation column and its surrounding vacuum jacket began to rise. The leak was detected and the vacuum pump was turned off to halt the leakage of nitric oxide into the atmosphere, allowing the pressure inside the column and vacuum jacket to stabilize around 130 psi. Although stabilized, the pressure was far above the normal pressure of less than or equal to atmospheric pressure (14.7 psi). Approximately 3 hours later, an explosion occurred. The operation and process were destroyed, and debris flew through the plant. Employee #1 suffered lacerations due to flying glass and was treated at a local hospital, where he received stitches and then released. A detailed investigation determined that the cause of the explosion was most likely due to something inside the vacuum jacket initiated the dissociation of nitric oxide, a reaction that is very rapid, exothermic, and self-propagating once started.
Source:OSHA.gov
Reactor #1, part of the ABS polymerization process began to overheat as the viscosity increased and threatened to stop agitation. This would cause a runaway reaction and ultimately result in an explosion. A small leak had developed in the lower bushing of the agitator and the employer instructed an employee to tighten it with a wrench. The employer replaced the normal feed (a mixture of styrene monomer, ground rubber, and acrylonitrile) with pure styrene monomer, which has a much lower viscosity, to "flush" the process in the hope that this would stop the leak. The mixture began to spill through the lower agitator packing and at approximately 2:30 p.m., there occurred a major spill of styrene monomer (flammable) and acrylonitrile (flammable and carcinogenic). They evacuated the plant and called for outside assistance to stop the spill and initiate clean-up.
Source: OSHA.gov
At approximately 9:30 a.m. on October 3, 2002, an employee who worked for a company that provided vehicle maintenance such as car washes, detailing, fueling, and lube and oil servicing, inadvertently drank acid from a plastic spray bottle while he was on a rest break. The employee, feeling very ill after ingesting the contents of the quart bottle, asked his coworkers to transport him to the hospital. He was taken to San Antonio Community Hospital where he was pronounced dead at 11:49 a.m. from internal injuries. Laboratory analysis indicated that the acid solution in the plastic bottle contained hydrofluoric acid and phosphoric acid with a pH of less than one.
Source:osha.gov
At 12:00 p.m. on November 5, 2019, Employee #1 was making a small spot weld on a piece of metal. He was performing the weld on a drum of that contained flammable windshield washer fluid. There was an explosive reaction, and the cover of drum hit the employee's face. Liquid splashed on the employee and was ignited by the explosion. Employee #1's clothes caught on fire. He sustained body burns and was killed.
Source:osha.gov