ARE DOLLARS TAKING PRECEDENCE OVER OVER PROCESS SAFETY?

Shortly after midnight, a highly flammable gas leaked in an ammonia manufacturing unit of a chemical plant producing nitrogenous fertilizers. The gas, mainly comprising hydrogen, leaked from a valve at a pressure of 220 bar and a temperature of 120°C. It spontaneously ignited forming a fiery stream directed towards the pipeline carrying the gas. Due to the heat, the pressure in the pipeline increased; the top portion of the pipe ruptured releasing the gas that exploded. The alert was sounded and the police implemented an emergency plan: traffic was stopped in the roads in the vicinity of the plant and resident were asked to stay indoors. The rest of the gas burnt at the rupture point for 2 hours. The leak was plugged and the fire brought under control at 2.45 am. Human casualties included 2 employees who suffered mild concussions and sustained cuts. They were treated onsite. The plant operations were stopped during the enquiry. 

The accident occurred due to a gas leak at the joint of a valve (in open position and at maximum flow). There was no leakproof joint between the two metal parts in contact. The internal metal surface of the valve was not compliant with the specifications in terms of quality. The valve, replaced in 2002, was not considered to be an element critical to the safety even though the process was classified in the high-risk category. Only price was taken into consideration while selecting the maintenance supplier. There was no exchange of information between the operator and the subcontractor during the operation and no acceptance of work was done (especially inspection of the valve bolting). The operator revised procedures, optimised management of maintenance and subcontractors (qualification, information, follow-up, etc.). The emergency operation conditions were also reviewed (appropriate number of trained staff even during low activity periods).

Source:Aria database

COMPETENCE AND CULTURE - GO HAND IN HAND

During a maintenance operation in a refinery, two operators opened the wrong purge. Four hundred litres of naphtha spilled out and caught fire. The operators were not qualified to perform this task and, like 10% of their colleagues, did not follow the operating procedure. The authorities noted persistent shortcomings in the facility operator's safety culture.

Source:Aria database  

ARE YOUR CRITICAL ALARMS SET CORRECTLY?

On March 14, 2023, at 11:40 a.m., approximately 1,000 pounds of flammable hydrocarbons were accidentally released from a pump seal and ignited (autoignition) at a Refinery in Texas, causing a fire.      The company estimated the property damage from the incident to be over $1 million.                        

During the unit startup approximately five days before the incident, the pump (a centrifugal pump) had operated with low suction (inlet) pressure for nearly two hours due to a low liquid level in the upstream equipment. The low suction pressure caused the pump to cavitate, which vibrated the pump and damaged the pump’s bearings. Five days later, on March 14, the damaged bearings and the resulting stress on the pump’s mechanical seal caused the seal to fail. The hot hydrocarbons within the pump were released into the atmosphere and ignited, causing a fire. The material was released at 590 degrees Fahrenheit (°F) and had an autoignition temperature of 484 °F.
 In addition, on March 11, two days after the unit startup, vibration from the damaged pump triggered a “High Priority Alarm.” The refinery’s usual responsive action to high-priority vibration alarms was to switch pumps. However, the company did not have another pump available and continued to operate the installed pump, as refinery employees believed the pump was still safe to operate. Employees anticipated that a replacement pump would be available on March 13, but the pump was not replaced before the incident on March 14.
Although the pump vibrations continued and worsened, they never triggered the “Critical High High” vibration alarm threshold because the alarm was programmed incorrectly. Had the vibration alarm been programmed correctly, the “Critical High High” alarm should have activated on March 12, two days before the incident.
The company's investigation found that the refinery operators mistrusted the pump vibration alarms due to past nuisance alarms, causing employees to normalize these alarms.

Probable Cause
Based on the company's investigation, the CSB determined that the probable cause of the incident was the release and ignition of hydrocarbons from a failed pump that had been damaged after it cavitated during a unit startup. Contributing to the incident were unit startup conditions that damaged the pump, incorrectly programmed alarms, and employee mistrust of alarms.

Source: CSB.gov

Cultivating a Safety Culture Amid Constant Change

Cultivating a Safety Culture Amid Constant Change: Developing a power plant safety culture takes time and constant effort, but the payoff is priceless, safety leaders at three major power companies said

Principles-Based Operations: A Military-Proven Method Part II

Principles-Based Operations: A Military-Proven Method Part II: Part II of Principles-Based Operations focuses on level of knowledge, forceful backup, questioning attitude, procedural compliance, and formality.

Principles-Based Operations: A Military-Proven Method Part I

Principles-Based Operations: A Military-Proven Method Part I: Many organizations have begun applying operational principles used with great success in the millitary. The foundation for postive outcomes is integrity.

Blog 50 – Be the Process Safety Change You Want to See - News - Process Safety Matters

Blog 50 – Be the Process Safety Change You Want to See - News - Process Safety Matters

Safety is not an accident

Safety is not an accident

Chronic unease article

Chronic unease article

Lessons From Deepwater Horizon are Particularly Relevant Today

Lessons From Deepwater Horizon are Particularly Relevant Today

Piper Alpha changed personnel safety issues forever | Engineer Live

Piper Alpha changed personnel safety issues forever | Engineer Live

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safetydifferently.com : Oil and gas safety in a post truth world

Excellent article!
http://www.safetydifferently.com/oil-and-gas-safety-in-a-post-truth-world/

No excuse for cutting corners on corrosion in downstream plants

No excuse for cutting corners on corrosion in downstream plants: The risks to safety and revenue associated with corrosion in refineries and petrochemical plants are too high to ignore. Phil Yule, Cosasco, explains.

Making Safety Decisions without a Blindfold

Making Safety Decisions without a Blindfold: Mike Neill of Petrotechnics discusses overcoming barriers to safety.

7-ways-to-improve-operations-without-sacrificing-worker-safety

https://hbr.org/2018/03/7-ways-to-improve-operations-without-sacrificing-worker-safety

Great article!

Ghosts of Bhopal?

In a CSB investigation report about a Nitrous oxide explosion in 2016 that killed an employee, the following causes were listed in the report. Many of the causes identified by the CSB are identical to the causes of the Bhopal gas disaster in 1984. Can you identify some of them?
 1.    XXXXXX did not evaluate inherently safer design options that could have eliminated the need for the pump;
 2.    XXXXXX never evaluated its process to identify and control process safety hazards;
3.    XXXXXX did not effectively apply the hierarchy of controls to the safeguards that the company used to prevent a possible nitrous oxide explosion;
4.    XXXXXX installed equipment that increased the likelihood of an explosion without performing a management of change safety review;
5.    XXXXXX did not apply an essential industry safety instrumentation standard, or key elements of a voluntary safe storage and handling standard, both of which are intended to prevent nitrous oxide explosions;
6.    XXXXXX safeguards that failed to prevent the explosion include an automatic shutdown safety control and an explosion prevention device;
 7.    The automatic shutdown safety control XXXXXX relied on required the XXXXXX worker to be physically present – and located immediately adjacent to the trailer truck – in order to bypass the shutdown at a time when an explosion was most likely to occur; and
8.    The XXXXXX explosion prevention device – a flame arrestor – was never tested or inspected to ensure it could protect workers from an explosion.
 9.    XXXXXX failed to apply lessons from previous nitrous oxide explosions; and
10. XXXXXX did not provide its Cantonment facility with an appropriate level of technical staffing support.

And then there is a fatality!

How many of you have experienced good safety records when suddenly a fatality occurs in a non process area? Well, you have? The management of Process Safety and Occupational Health and Safety in a chemical plant have a few common elements like incident investigation, work permits, training, emergency planning and response etc. However there is one most important underlying foundation for both- it is a good safety culture. Recently, a large chemical plant experienced two fatalities within a span of two months. Both the fatalities were not in a process area (covered process as defined in PSM) but were road accidents within the factory complex. One of them could have been prevented if the driver was wearing a seat belt. I had visited the plant a month before the fatal road accident (driver without seat belt) and had observed that in the township (where employees reside) of that plant, many of the staff were not wearing crash helmets when riding a two wheeler or were not buckling up when driving a car. This is the problem. You cannot throw away your rules just because you have come out of the factory and entered the township! Safety Culture should be developed assiduously by management both in and outside the plant. Breaking safety rules outside a plant will carry the same behavior inside the plant and other employees will start emulating this. After a fatality, there is always a lot of introspection, but don't forget the basics - Management staff must walk the talk both inside and outside the plant. Plain and simple.

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.