Lessons from Deepwater Horzon incident investigation by USCG

The US Coast Guard has released its investigation report on the Deepwater Horizon disaster. There are lessons to be learnt for us in the chemical processing industry. The key findings from the report are given below:
"Failure to Use the Diverter Line: When the drilling crew directed the uncontrolled well flow through the Mud Gas Separator (MGS), the high pressure exceeded the system’s capabilities and caused gas to discharge on the Main Deck. Alternatively, the crew could have directed the well flow through a “diverter line” designed to send the flow over the side of the MODU (Mobile Offshore Drilling Unit). Although the diverter line also may have failed under the pressure, had it been used to direct the flow overboard, the majority of the flammable gas cloud may have formed away from the Drill Floor and the MODU, reducing the risk of an onboard explosion.
Hazardous Electrical Equipment: At the time of the explosions, the electrical equipment installed in the “hazardous” areas of the MODU (where flammable gases may be present) may not have been capable of preventing the ignition of flammable gas. Although DEEPWATER HORIZON was built to comply with IMO MODU Code standards under which such electrical equipment is required to have safeguards against possible ignition, an April 2010 audit found that DEEPWATER HORIZON lacked systems to properly track its hazardous electrical equipment, that some such equipment on board was in “bad condition” and “severely corroded,” and that a subcontractor’s equipment that was in “poor condition” had been left in hazardous areas. Because of these deficiencies, there is no assurance that the electrical equipment was safe and could not have caused the explosions.
Gas Detectors: Although gas detectors installed in the ventilation inlets and other critical locations were set to activate alarms on the bridge, they were not set to automatically activate the emergency shutdown (ESD) system for the engines or to stop the flow of outside air into the engine rooms. The bridge crew was not provided training or procedures on when conditions warranted activation of the ESD systems. Thus, when multiple gas alarms were received on the bridge, no one manually activated the ESD system to shut down the main engines. Had it been activated immediately upon the detection of gas, it is possible that the explosions in the engine room area could have been avoided or delayed.
Bypassed Systems: A number of gas detectors were bypassed or inoperable at the time of the explosions. According to the chief electronics technician, it was standard practice to set certain gas detectors in “inhibited” mode, such that gas detection would be reported to the control panel but no alarm would sound, to prevent false alarms from awakening sleeping crew members. Similarly, the crew bypassed an automatic shutdown system designed to cut off electrical power when ventilation system safety features failed, possibly allowing flammable gas to enter an enclosed area and reach an ignition source. The chief electrician had been told that it had “been in bypass for five years” and that “the entire fleet runs them in bypass.”
Design of the Main and Emergency Power Sources: Although the arrangement of main and emergency generators on DEEPWATER HORIZON met IMO MODU Code requirements to have completely independent engine-generator rooms along with independent power distribution and control systems, it did not prevent a total failure of the main electrical power system, when the explosions and fire damaged multiple generators and their related power distribution and control equipment. The design did not adequately take into account that the proximity of the air inlets to each other created a risk that flammable gases could impact all six generators at once.
Crew Blast Protection: DEEPWATER HORIZON did not have barriers sufficient to provide effective blast protection for the crew. Although the barriers separating the Drill Floor from adjacent crew quarters met the standards of the IMO MODU Code, those specifications are only designed to slow the spread of fire, not to resist an explosion. They did not prevent personnel in the crew accommodations area from sustaining injuries.
Command and Control: Because of a “clerical error,” by the Republic of the Marshall Islands, DEEPWATER HORIZON was classified in a manner that permitted it to have a dual-command organizational structure under which the OIM was in charge when the vessel was latched on to the well, but the master was in charge when the MODU was underway between locations or in an emergency situation. When the explosions began, however, there was no immediate transfer of authority from the OIM (Offshore Installation Manager) to the master, and the master asked permission from the OIM to activate the vessel’s EDS. This command confusion at a critical point in the emergency may have impacted the decision to activate the EDS".

The full report is available in this link.

Facility siting - fiberglass tanks and radiated heat

An incident in the US highlights the need for a careful evaluation of siting (location) of fiberglass tanks. In the incident, a fire from a hydrocarbon relaease due to an equipment failure led to the melting of a fiberglass tank containing hydrochloric acid. The HCl spilled into a dyke area. If you are using fiberglass tanks for storing hazardous chemicals, take into consideration the heat radiated from nearby potential sources of fires.
Read about the incident in this link.

Mumbai Port Chlorine gas leak - recommendations

The PIB has published the recommendations of the expert committee set up to probe the chlorine gas leak from old cylinders I had mentioned in my earlier post. One of the recommendations states "The Head of Civil and Mechanical Engineering Department of MbPT should take immediate action to repair the fire hydrant system and ensure that the fire hydrant system is in working condition. This activity shall be completed by 31^st, December, 2010".
Maintain your fire water systems. You never know when they will be needed.
Read the PIB press release in this link.

Behind every major incident is one or more near misses!

An article in the Wall Street Journal mentions that "BP PLC narrowly averted potential disaster after a 2008 natural gas leak at a field it operates in Azerbaijan, about 18 months before the deadly Deepwater Horizon explosion in the Gulf of Mexico triggered the worst offshore oil spill in U.S. history". "The gas leak, which was disclosed in BP's 2008 annual report and was widely covered by news agencies at the time, occurred in the offshore Azeri-Chirag-Guneshli (ACG) field, Azerbaijan's largest, in September 2008. As a precaution, BP evacuated 211 workers from the site of the leak and partially shut down production from the field.Details that emerge from cables—written by unnamed diplomats in the U.S. embassy in the Azeri capital of Baku and posted on the WikiLeaks website—show how dramatic and potentially dangerous the gas release was. One cable said that BP was "fortunate" to have been able to evacuate all the workers safely and prevent the gas from igniting, given the "explosive potential" of the leak".

Behind every major incidents there are a number of warnings! Read the full article in this link.

Plant explosion kills two - pay heed to your process near misses and incidents

A news article mentions that two workers were killed and two others were seriously injured in an explosion and fire at a West Virginia chemical plant on Thursday afternoon. The explosion occurred at a plant that reprocesses highly flammable potassium titanium fluoride salts, zirconium, and other chemicals for use in the aluminum industry. The article mentions that "It is the fourth fire in the last five years and the second fatal fire since 2006. The AL Solutions plant has been the site of multiple fires since it opened in 1991, then under Jamegy Inc. In 1995, a propane tank exploded, killing one worker and injuring another. Another fire broke out in 1997. On July 18, 2006, a worker was killed when a similar explosion and fire ripped through the foundry of the facility. On December 21, 2006, another blaze broke out after a forklift malfunctioned, setting ablaze a tank filled with titanium. On August 2, 2009, yet another fire erupted as employees were shoveling zirconium into barrels".
Pay heed to your previous incidents and learn lessons from them. Even if you have excellent management systems for process safety, there is no use if the your organisation does not incorporate the learning's of past incidents in its DNA.
Read the article in this link.

Did inferior raw materials cause the cordite factory blast?

A newspaper article reports that insiders of the Cordite factory believe that supply of poor quality material could be to blame for the blast that killed 5 workers on November 25. I have observed that the trend in the industry is to go for the lowest cost (L1). While process safety does not prohibit you from going for the least cost supplier, ensure that you do not create process safety problems due to inferior quality. Read the article in this link.

Lessons from the Tesoro Refinery Blast Investigation

The Washington State Department of Labour and Industries have investigated the above incident and issued citations totaling USD 2.39 Million. I have summarized the investigation findings and citations as follows:

•On April 2nd,2010 early morning, a blast at the Tesoro refinery in Anacortes, USA, occurred killing 7 personnel. The blast occurred due to the catastrophic failure of a feed effluent exchanger in the naphtha hydrotreating unit during start up. The exchanger was about 40 years old. The original refinery was started in 1950’s by Shell. Shell sold the refinery to Tesoro in 1998. The failed heat exchanger was not tested for last 10 years. Tesoro had planned an inspection in 2008 but did not carry it out.

•6 out of 7 personnel who died were not trained in the start up procedure.

•The frequency of Tesoro Refinery's inspection of the feed effluent exchanger was not consistent with applicable manufacture's recommendations, good engineering practices, and or prior operating experience.

•The Tesoro Refinery did not correct deficiencies associated with effluent exchanger shell and tube side warm up lines before further use or in a safe and timely manner

•Tesoro Refinery did not correct deficiencies associated with effluent exchanger companion flanges and temporary clamps before further use or in a safe and timely manner when the necessary means are taken to assure safe operation. (flanges were leaking during start up and steam lances held by personnel were used to dilute the leaks)

•Tesoro Refinery did not develop and implement written procedures for startup following turnaround, or after an emergency shutdown of exchangers that provided clear instructions for safely conducting activities involved in the process consistent with the process safety information that addressed steps for each operating phase.

•Tesoro Refinery did not establish and implement written procedures to manage the change made to the warm up steps during the March 2009 start up and those conducted in February and March of 2008 on the E6600 effluent exchangers.

•Tesoro Refinery did not establish and implement written procedures to manage the changes made to the operating limit minimum hydrogen oil ratio feed to Naphtha Hydrotreater.

•Tesoro Refinery did not establish and implement written procedures to manage the change made by placing mechanical clamps on the companion flanges between effluent exchangers E-6600 A/B and D/E on or about March 2009.

•Tesoro Refinery did not establish and implement written procedures to manage the change made by placing the Anacortes Corrosion Awareness and Management Program (ACAMP) on hold indefinitely beginning the third quarter of 2004.

•Tesoro Refinery did not establish and implement written procedures to manage the change made by discontinuing the process hazard analysis revalidation system that included mechanical integrity and corrosion control review in 2006.

•Tesoro Refinery did not establish and implement written procedures to manage the changes made by temporarily or permanently suspending inspection procedure I-08.07 on or about September 2009

•The Tesoro Refinery did not ensure that the 2006 Process Hazard Analysis Revalidation was consistent with the current process.

•The Tesoro Refinery did not update process safety information following changes made to the effluent exchangers on or about December 2005.

•The Tesoro Refinery did not investigate each incident which resulted in, or could reasonably have resulted in, a catastrophic release of highly hazardous chemicals in the workplace. Failure to investigate incidents could result in their recurrence and cause serious injury or death.

•Tesoro Refinery did not ensure that appropriate checks and inspections were performed to assure that equipment, such as the warm up lines and replacement tube bundle, were installed properly and consistent with the design specifications. Lack of quality assurance inspections and checks could lead to improper installations of process equipment and result in serious injury or death.

•Tesoro Refinery did not ensure that maintenance materials, spare parts and equipment were suitable for the process application for which they will be used, such as the bellows assemblies.

•Tesoro refinery did not ensure that all emergency responders and their communications were coordinated and controlled by the Incident Commander (IC).

•Tesoro Refinery did not assure that all Fire Brigade members were fully trained prior to the incident response on the morning of April 2nd, 2010.

Read the full citation in this link.

Hazardous waste facility explosion report

"A U.S. Chemical Safety Board (CSB) case study released today on the 2009 explosion and fire at the Veolia ES Technical Solutions L.L.C. facility in West Carrollton, Ohio, calls on the industry to improve safety standards covering hazardous waste processing, handling, and storage facilities. The Board also recommended that fire protection codes be revised to require companies to determine safe distances between occupied buildings and potentially hazardous operating areas.
The accident occurred on May 4, 2009, when flammable vapor was released from a waste recycling process, ignited, and violently exploded. The blast seriously injured two workers and damaged 20 nearby residences and five businesses. CSB investigators found that the north wall of the lab and operations building – where the victims were injured –was less than 30 feet from the waste recycling processing area where the flammable vapor was released.
CSB Chairman Rafael Moure-Eraso said, “This accident should not have happened. Our report notes that OSHA cited the company for inadequate attention to process safety management practices in the handling of flammable liquids. But in case of an accident, I believe it is absolutely critical that buildings at chemical facilities be sited safe distances from process equipment to maximize the safety of workers. We are making recommendations that would help ensure that operating areas with occupied buildings such as control rooms be sufficiently separated from process areas containing flammable liquids and gases that have the potential to explode.”
Read the report in this link.

Two people die in fertiliser plant fire

There are news reports that two people died and two were injured in a fertilizer plant fire in Libya on 11.7.10 when maintenance work was on. Work permit systems are enforced to prevent such loss of lives and I will post more details if I get it.

Missing incident investigation deadlines

In many process safety audits , I keep observing that detailed investigation of incidents keep missing their deadlines. This speaks of the culture of the organization. When we don't learn from incidents, we will repeat them. I was reading a news item in Times of India which mentions about the investigation of the Mangalore air crash. I quote from the article " What happens when Directorate General of Civil Aviation (DGCA) officials violate their own rules? Nothing. It's been over a month and a half after Mangalore air crash and no preliminary investigation report has been released yet, though the country has a rule that puts a 10-day deadline for filing one. Little wonder, then that the rule concerning accident/incident investigation is hardly known in the aviation industry as it has almost always been violated.
If this can happen in the Indian aviation industry, I am worried!!!
Read the full article in this link.

Texas City to the Gulf

An article "Blast at BP Texas refinery in 2005 foreshadowed Gulf disaster" by Propublica mentions the following about the BP Texas city refinery incident:
Soon after the merger, BP demanded a 25 percent budget cut across all its U.S. operations.
Among the reductions at Texas City:
* Cut inspectors and maintenance workers by the dozens to save just over $1 Million.
* Eliminate safety calendars: $40,000 in savings.
* Reduce purchases of safety shoes for employees: $50,000 in savings.
* Eliminate safety awards: $75,000 in savings.
An outside auditor that Parus had hired, produced what was probably the most damning internal report [2] ever to emerge from the Texas City refinery. After surveying more than 1,000 workers and interviewing hundreds, the auditors concluded that the plant's employees had an "exceptional degree of fear" of a catastrophe, and that "blindness" across the entire corporation prevented critical safety information from reaching the top levels of BP management. It also said that poor conditions at the plant created hazards "you would never encounter at Shell, Chevron, Exxon, etc."
The 62-page report included direct quotes from some of the workers:
"The heroes around here are the ones working to the production goals and who complete them early. 80 to 90 per cent of what gets recognized is doing it fast counts."
"Telling the manager what they want to hear, that gets rewarded. For example, one person who had cut costs, done a lot of Band-Aids with maintenance and had a quit-your-bellyaching, quit-your-complaining attitude was rewarded in the last reorganization. When his replacement was brought into his previous maintenance position, his replacement found that not a single pump was fit for service; air compressors, not one spare was fit for service."
"Units are 90% of the time run to failure, due to postponing turnarounds [maintenance]. So making money or saving money for that particular year looks good on the books. This is a serious safety concern to operating personnel. We do not walk the talk all the time. Costs and budgets are preached to reduce costs."
Read the full article in this link.

Gas blowing of pipelines - CSB's recommendations

In my earlier post, I was dead against the blowing of new pipelines with natural gas to clear debris as there is a potential for an explosion or fire to take place where the gas is vented. The CSB, after investigating the explosion in the Kleen energy power plant has made similar recommendations to OSHA and others. I am quoting from their report:
Promulgate regulations that address fuel gas safety for both construction and general industry. At a minimum:
a. Prohibit the release of flammable gas to the atmosphere for the purpose of cleaning fuel gas piping.
b. Prohibit flammable gas venting or purging indoors. Prohibit venting or purging outdoors where fuel gas may form a flammable atmosphere in the vicinity of workers and/or ignition sources.
c. Prohibit any work activity in areas where the concentration of flammable gas exceeds a fixed low percentage of the lower explosive limit (LEL) determined by appropriate combustible gas monitoring.
d. Require that companies develop flammable gas safety procedures and training that involves contractors, workers, and their representatives in decision-making.

Read the full report and recommendations in this link.

Heed the warnings!

An article in CBS News website indicates that the BP Gulf of Mexico incident was not a one off incident. There was another incident in another BP oil rig in 2003 where a similar incident occurred but the gas did not ignite!
"Shortly after lunch on November 27, 2003, Oberon Houston was in his office beneath the helideck of BP’s Forties Alpha oil platform in the North Sea, off the coast of Scotland. One of a select group (1 percent of BP’s staff) of young engineers and managers targeted by the company for rapid advancement, Houston, 34, was working out maintenance plans for the coming week when he heard what he thought was a deafening explosion.Only it wasn’t an explosion. A gas line had ruptured-allowing thousands of pounds of pressurized gas to escape at supersonic velocity. That caused a thunderous sonic boom. Debris from the burst pipe and its cladding rained down, adding to the impression that “an artillery shell had just hit the platform.” The escaping gas quickly formed a huge and potentially lethal cloud around the rig. Now the threat of an actual explosion was very real. The smallest spark would detonate more than a ton of methane gas.
No one died or was even hurt that day on Forties Alpha, thanks in part to high winds that helped to disperse the gas after about 20 minutes of extreme danger to the platform and its crew of 180 people. But Houston, the number two in command aboard Forties Alpha, knew full well what could have happened. “Unlike a similar incident on the ill-fated Piper Alpha platform,” he observes, referring to an earlier accident in the North Sea, “the gas did not ignite, so what could have been a major disaster for myself and everyone else on board was averted by sheer luck.”
Though Forties Alpha could have produced a similar conflagration, it was nothing more than a near miss which was soon forgotten. BP admitted breaking health and safety laws by failing to guard against corrosion on the ruptured pipe that allowed the gas to escape. It was fined $290,000. The bigger loss came in early 2004. Houston resigned, and BP lost one of its best young engineers."
Read the full article in this link

Oleum release incident - CSB findings

The CSB has released its final report on the uncontrolled oleum release from INDSPEC Chemical Corporation in Petrolia, Pennsylvania, which forced the evacuation of three surrounding towns in October 2008.Oleum was released when a tank transfer operation was left unattended during weekend operations and an oleum storage tank overflowed.
The CSB investigation has determined that the normal power supply for the three oleum transfer pumps was equipped with a safety interlock, which would automatically shut off the flow of oleum when the receiving tank was full, thus preventing a dangerous overflow. However, the oleum storage building also had an auxiliary or 'emergency' power supply that had been installed in the late 1970s. It was originally intended as a temporary measure to keep the pumps functioning during interruptions of the normal power supply but eventually the emergency power supply became a permanent fixture. Facility management never installed interlocks for the emergency power and written operating procedures did not address how or when the emergency power supply should be used.
The CSB case study report identifies four key safety lessons for companies:
- In the 1980s, the facility changed the structure of the emergency power supply from temporary wiring to permanent conduit. The facility did not evaluate the significance of this change.
- The facility installed the emergency power supply without the engineering controls that already existed on the normal power supply.
-The facility's storage system design required operators to transfer oleum on the weekend to ensure operations were unaffected during the week. Operators used a work practice developed years earlier to transfer oleum using two pumps concurrently. This work practice was never recorded in written operating procedures.Management must remain vigilant in evaluating how work is actually performed.
- The facility never included information on the emergency power supply in piping and instrumentation diagrams and written operating procedures. Personnel hazard assessment (PHA) teams were therefore unable to evaluate the consequences of emergency power supply use.
Read the report in this link

Importance of Near misses in process safety

A newspaper report (Hindu dated 14.5.10) indicates the following points about the oil spil in the Gulf of Mexico:"Oil executives ignored warning signs in the hours before the Deepwater rig explosion in the Gulf of Mexico last month, a congressional hearing heard on Wednesday.
In a second day of hearings, the U.S. House of Representatives' energy and commerce committee said documents and briefings suggested that BP, which owned the well; Transocean, which owned the rig; and Halliburton, which made the cement casing for the well, ignored tests in the hours before the 20 April explosion that indicated faulty safety equipment".
No major incident occurs without warning. Do not ignore your near misses!Read more of the article in this link

Process Safety - Fire at Ankleshwar plant

A fire occurred at a pharma company in Ankleshwar. "The blaze at pharmaceutical major Wockhardt Ltd’s factory in Ankleshwar on Saturday was brought under control today. Additional fire tenders had to be called in from Vadodara, Ahmedabad and Surat and kept on standby.
“The fire was almost brought under control last night, but due to leakage of certain chemicals, there was re-ignition in some parts of the factory. The fire was completely extinguished by Sunday evening,” said Manoj Kutariya, Manager, Fire Safety, Disaster Prevention and Management Centre. . Read more in this link.

Just last month, there was a fire in another unit at Ankleshwar. I had visited the Disaster Prevention and Management Center about 6 months back and I was very impressed with the facilities and the team headed by Mr Manoj. Kudos to them.

Process Safety - Storage tanks

An EPA study covering a ten-year period (1990 - 2000)reveals that of the 312 accidents at tank farms examined in this period it was found that operator error accounted for 22%. Additionally, 55% were attributable to tank failure, 10% to valve failure, 4% to pump failure and 3% to bolted fitting failure. Human error also accounted for 100% of accidents that resulted in fatalities, 88% involving stock loss and 87% of property damage, with the root cause attributed to overfilling/over-pressurisation.
Storage tanks fail due to a number of reasons including collapse due to vacuum,human error, poor maintenance, vapour ignition, settlement, earthquake,lightening and over-pressurisation.
Make sure your operators are trained in the safe operation of storage tanks.

Process safety - learn from these incidents

The Karnataka Department of Factories, Boilers and Industrial safety and health has posted accidents that have occurred in their state.
Four incidents are posted:
1. Confined space incident
2. Incompatible material incident
3. Accident in Urea plant
4. Toxic gas release in bulk drug manufacturing.
The details are available in this link. Please circulate to all your colleagues as the incidents can happen anywhere.
Some more accidents are given in a pdf file (large file) in this link

Process safety - 5 Years after the BP incident

On March 23rd, 2005, the worst industrial accident in the US for more than a decade occurred at the BP Texas refinery. 5 years after the incident a news article mentions the following:
“Since the disaster, the company has spent more than $1 billion on improvements at the refinery, and continues to invest more. It's spent another $1 billion or so settling about 1,000 civil lawsuits filed by the more than 170 workers injured in the blast and by families of the dead.
“Those systems require constant vigilance. You start to think you've got it fixed, and eventually you start to focus on other things. If you let your focus wander too far, you're system starts to slip without your realizing it.”
“The U.S. Chemical Safety and Hazard Investigation Board found in 2007 that the explosion resulted from a lethal combination of cost-cutting, a lack of investment in training and mechanical systems and a lack of vigilance in maintaining safety procedures. The company has implemented sweeping changes in process safety procedures and revamped how it operates refineries. Many of those changes have been adopted by BP's rivals as well.”
“The question that continues to dog BP and the refining industry: Has it done enough?It has rejected, for example, a Chemical Safety board recommendation that it add a process safety expert to its board of directors.”
“It took the explosion,” said Gary Beevers, international vice president for the United Steelworkers union, which represents more than 1,000 workers at the refinery. “As this industry has shown, it takes something terrible for changes to happen.”
My own observation of any big incident like this is that immediately after the incident there are a lot of things done. But the question is the sustainability of these actions. Time and again I have seen that unfortunately history tends to repeat itself unless top leadership are really and continuously committed to process safety.More and more boards of Chemical and refining companies are filled up with non technical persons, with the result that there is no one at the board level to explain to the board the repercussions of cost cutting without a proper assessment.
Read the whole article in this link

Process Safety - Phosgene hose leak update

A news article on the EPA investigation of the phosgene hose leak at DuPont's Belle, US facility in January 2010,indicate the following:
1. "This type of hose should be replaced every two months "due to the extremely hazardous nature of phosgene," EPA said. At the time of the Belle plant leak, the hose had been in use for seven months.The hose was 5 months overdue for replacement"
2. "The flexible, braided-steel hose was also the wrong kind of equipment to use in the first place because of the extremely hazardous nature of phosgene"
3."EPA also said that this type of hose should be installed within six months of its fabrication. This particular hose was fabricated in May 2008, but was not installed by DuPont until June 2009".
DuPont is world renowned for their high safety standards and I wonder what went wrong.
Read the full article in this link