Emergency situations and tiredness

An article in the Times Of India mentions that Air India cabin crew have started a campaign protesting the extra hours they were forced to work.The article mentions that the cabin crews alertness is most important in emergency situation and evacuations where time is of the essence. In a chemical plant, during emergencies, it is very similar to emergency situations in planes and the operating crew needs to be alert. When I was shift in charge and had operators continuing on overtime, (especially from evening to night shift), I have seen the errors committed by these operators during emergencies. It is a human need for rest and you cannot fight it. Look at your staffing requirements properly and ensure that competent people are available in adequate numbers.

Read the article in this link.


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Process safety and competency

In the next decade, the key process safety issue for India is going to be process safety competency. The average age of the Indian Workforce is today reported to be about 27 to 30 years and as experienced personnel leave the organisation, a huge process safety knowledge deficit is arising. The process safety competency gap is observed right at the top in some organizations to the bottom of the pyramid. Only those companies in the CPI who recognize that process safety competency is a a huge business risk will be able to safely manage their processes.
Read what one global organisation is doing about competency in this link.

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

Plane accidents and process safety

"06/23/1967 Mohawk Airlines
BAC-111-204AF Blossburg, Pennsylvania The airplane crashed after an in-flight fire destroyed the pitch control systems. All 34 people aboard were killed. A malfunctioning nonreturn valve allowed hot engine bleed air to flow back through an open air delivery valve, through the APU and into an acoustic blanket lined section of the fuselage. This caused flexible hoses with hydraulic fluid to ignite and lead to an uncontrollable fire". Beware of check valves!!

"09/06/1971 Pan International
BAC-111 Hasloh, Germany The aircraft collided with a bridge, shearing off both wings, after a double engine failure occurred during takeoff. The water-injection system to cool the engines during takeoff was inadvertently filled with kerosene instead of water".

30 years ago, an operator in the plant I worked filled up antifoam liquid from a drum similar to an oil drum into the hydraulic governor of a large steam turbine. We found out when the governor started misbehaving!!

Source of plane accidents : http://planecrashinfo.com/unusual.htm

"Automation Addiction" in flying and its relation to process safety

Joan Lowy of AP has written an article mentioning the following:
'Pilots' "automation addiction" has eroded their flying skills to the point that they sometimes don't know how to recover from stalls and other mid-flight problems, say pilots and safety officials. The weakened skills have contributed to hundreds of deaths in airline crashes in the last five years.
Some 51 loss of control" accidents occurred in which planes stalled in flight or got into unusual positions from which pilots were unable to recover, making it the most common type of airline accident, according to the International Air Transport Association.
"We're seeing a new breed of accident with these state-of-the art planes," said Rory Kay, an airline captain and co-chair of a Federal Aviation Administration advisory committee on pilot training. "We're forgetting how to fly."
Read the article in this link.

This has direct relations to the Chemical Process Industry. With so much automation in our idndustry, I am sure that operators are really forgetting their troubleshooting skills in the event of an emergency. Dr Trevor Kletz has always propounded that things must be kept simple and the way process control manufacturers are developing and implementing "solutions" for process safety, it leaves me dumbstruck. In another post, I had written that today I see operators who are becoming "procedural robots" during emergencies and plant upsets. This is a dangerous situation. Simulators do help in keeping operators skills up to date but management often thinks that it is a waste of money. Cluster simulation training ( for processes that have the same licensor) could be started, with companies pooling in for a common simulator training facility.

How do we make PSM work in India?

PSM is an administrative control over process safety. The elements may vary from 14 to 30 and above but finally it is an administrative control. Human beings take decisions that can have an effect on PSM. For example, the CSB has released the safety video of the Bayer Crop science explosion where it mentions an interlock was bypassed by operators with the knowledge of the manager. Whatever systems you have, there will be a time, when under pressure for production, mistakes can happen and the administrative control fails. Behaviour based safety, developing process safety culture, operational discipline all are dependent on the Human Being. Especially the ones at the top…

Why do the same mistakes keep happening over and over again? It’s because of a basic human trait ….. if   nothing has happened for so many years, one does not expect to see anything bad in the future, too.

What you do not see may cost you terribly!! Whose job is it to see that the human being at the operational level does not deviate from set procedures? It’s the job of the top management. But it’s a chicken and egg situation. Today’s top management in Chemical Plants are under severe pressure themselves and often loose sight of what is going on at the ground level. Whenever a new system that brings in top management involvement is implemented, I often see, that initially, everything is working all right and top management are focused on process safety. As time gets by, and people (including top management) and priorities change, the effectiveness of PSM changes, too. I feel that the only way to make PSM work is through effective legal enforcement. In this connection, I am happy to see in the CSB video that the Costa County officials have been able to bring down incidents by effective auditing of PSM systems.

I do not see this happening in India where PSM is not even Mandatory! Let’s not wait for another Bhopal to occur. Do write in your comments.

Iphone app manages fatigue

An Iphone app has been developed that manages fatigue of flight crew. "The predictions are based on the Boeing Alertness Model developed jointly by Boeing and Jeppesen, which is based on a modified version of the long-validated Three Process Model of Alertness. This contains circadian and homeostatic components to yield predicted alertness.
The modular design of the fatigue risk management solution, however, allows operators to make use of alternative alertness models if desired.An iPhone application based on the Boeing Alertness Model called CrewAlert has also been released by Jeppesen. Available in the Apple App Store for $19.99, CrewAlert is billed as "the first app designed specifically to help airlines and their crews manage alertness and fatigue".This is an interesting development and maybe we in the chemical industry can use a similar type of app for managing worker fatigue!
Read the article in this link.

Emergency management - the human factor

The dynamic positioning operator’s (DPO) testimony to the enquiry committee of the Deepwater Horizon oil rig disaster reveals the following: The operator had to deal with a large number of combustible gas alarms getting activated when the blow out occurred. The general alarm system was on “MANUAL” (in other words, even though a lot of combustible gas alarms were going on, the general alarm could get sounded only if the operator manually activated it). (Shades of Piper Alpha??) The operator was not trained on a situation where multiple gas alarms went off.

Reading the testimony of the DPO, the one thought that struck me was the chaotic situation she was dealing with. Every Human being reacts differently to emergency situations. When I was an asst. Shift in charge in an ammonia plant, we had a newly transferred shift in charge who had earlier worked most of his career in the utility plant. His way of dealing with any emergency situation in the ammonia plant was to run to the utility plant ( he was more comfortable there!). Are you training your operators for the worst case scenario? Here simulators play an important role and you should make the training scenario as realistic as possible.

Read the DPO’s enquiry transcript in this link.

Human issues in the Deepwater Horizon blowout

An Interim Report on causes of the Deepwater Horizon oil rig blowout and ways to prevent such events by the committee for the analysis of causes of the Deepwater Horizon explosion, fire, and oil spill by the National Academy of Engineering; National Research Council mentions the following:
"1.The incident at the Macondo well and Deepwater Horizon MODU was precipitated by the decision to proceed to temporary abandonment of the exploratory well despite indications from several repeated tests of well integrity [the test type known as a negative (pressure) test] that the cementing processes following the installation of a long-string production casing failed to provide an effective barrier to hydrocarbon flow (Sections II and III).
2. The impact of the decision to proceed to temporary abandonment was compounded by delays in recognizing that hydrocarbons were flowing into the well and riser and by a failure to take timely and aggressive well-control actions. Furthermore, failures and/or limitations of the BOP, when it was actuated, inhibited its effectiveness in controlling the well (Sections III and IV).
3. The failures and missed indications of hazard were not isolated events during the preparation of the Macondo well for temporary abandonment. Numerous decisions to proceed toward abandonment despite indications of hazard, such as the results of repeated negative-pressure tests, suggest an insufficient consideration of risk and a lack of operating discipline. The decisions also raise questions about the adequacy of operating knowledge on the part of key personnel. The net effect of these decisions was to reduce the available margins of safety that take into account complexities of the hydrocarbon reservoirs and well geology discovered through drilling and the subsequent changes in the execution of the well plan (Section VI).
4. Other decisions noted by the committee that may have contributed to the Macondo well accident are as follows:
• Changing key supervisory personnel on the Deepwater Horizon MODU just prior to critical temporary abandonment procedures (Section VI);
• Attempting to cement the multiple hydrocarbon and brine zones encountered in the deepest part of the well in a single operational step, despite the fact that these zones had markedly different fluid pressures (because of the different fluid pressures, there was only a small difference between the cement density needed to prevent inflow into the well from the high-pressure formations and the cement density at which an undesirable hydraulic fracture might be created in a low pressure zone) (Section II);
• Choosing to use a long-string production casing in a deep, high-pressure well with multiple hydrocarbon zones instead of using a cement liner over the uncased section of the well (Section II);
• Deciding that only six centralizers would be needed to maintain an adequate annulus for cementing between the casing and the formation rock, even though modeling results suggested that many more centralizers would have been needed (Section II);
• Limiting bottoms-up circulation of drilling mud prior to cementing, which increased the possibility of cement contamination by debris in the well (Section II);
• Not running a bond log after cementing to assess cement integrity in the well, despite the anomalous results of repeated negative-pressure tests (Section II);
• Not incorporating a float shoe at the bottom of the casing as an additional barrier to hydrocarbon flow (Section II); and
• Proceeding with removal of drilling mud from the well without installing the lockdown sleeve on the production casing wellhead seals to ensure the seals could not be shifted by pressure buildup under the seals (Section II).
5. Available evidence suggests there were insufficient checks and balances for decisions involving both the schedule to complete well abandonment procedures and considerations for well safety (Section VI).
6. The decisions mentioned above were not identified or corrected by the operating management processes and procedures of BP or those of their contractors or by the oversight processes employed by the Minerals Management Service (MMS) or other regulators (Sections VI and VII).
7. Currently, there are conflicting views among experts familiar with the incident regarding the type and volume of cement used to prepare the well for abandonment.There are also conflicting views on the adequacy of the time provided for the cement to cure. These factors could have had a material impact on the integrity of the well (Section II).
8. The BOP did not control—or recapture control of—the well once it was realized that hydrocarbons were flowing into the well. Also, both the emergency disconnect system designed to separate the lower marine riser from the rest of the BOP and automatic sequencers controlling the shear ram and disconnect failed to operate (Section IV).
9. Given the large quantity of gas released onto the MODU and the limited wind conditions, ignition was most likely. However, the committee will be looking into reports (such as testimony provided at the MBI hearings) that various alarms and safety systems on the Deepwater Horizon MODU failed to operate as intended, potentially affecting the time available for personnel to evacuate (Section V).
10. The various failures mentioned in this report indicate the lack of a suitable approach for anticipating and managing the inherent risks, uncertainties, and dangers associated with deepwater drilling operations and a failure to learn from previous near misses(Section VI).
11. Of particular concern is an apparent lack of a systems approach that would integrate the multiplicity of factors potentially affecting the safety of the well, monitor the overall margins of safety, and assess the various decisions from perspectives of well integrity and safety. The “safety case” strategy required for drilling operations in the North Sea and elsewhere is one example of such a systems approach (Section VII)
Read the full report in this link.