INCORRECTLY CONNECTED HOSE CAUSES INCIDENT

 On February 21, 2023, at 10:15 p.m., an unknown amount of propane was accidentally released, seriously injuring a temporary employee at a facility in California.
A temporary employee had moved a propane-fueled forklift to the facility’s filling station to refuel its tank. He connected the filling station’s hose to the forklift’s tank and opened the valve to start the propane flow. The hose connection was not secure, and propane immediately discharged into the atmosphere. The employee tried to either tighten or remove the hose during the release. As a result, the cold propane sprayed and cryogenically burned him. The temporary employee was not wearing personal protective equipment (PPE) that could have protected the employee from being exposed to cold propane.

There was no documentation that the temporary employee had been trained on safely filling propane tanks, although another employee stated that the temporary employee had been trained. The company's investigation found that site training on refilling propane fuel tanks did not include information on items to inspect before beginning the filling operation.
Probable Cause
Based on the company's investigation, the CSB determined that the probable cause of the accidental release of propane was not securing the hose connection before starting the filling operation. Not using personal protective equipment that could protect the employee from being exposed to cold propane contributed to the severity of the incident.

Source:CSB.gov

A LOOSE BEARING LOCKNUT CAUSES AN INCIDENT

On February 11, 2023, shortly before 1:00 p.m., a pump failure released hydrocarbons (primarily crude oil) and nitrogen oxide at a crude oil production facility in Texas. The crude oil released from the failed pump ignited, causing a fire that damaged nearby equipment and led to additional material releases The company estimated the property damage from the incident to be about $1.5 million.

The company's investigation found excessive wear and tear on the pump, which led to its failure. The company also found that the pump’s bearing lock nut, which holds the bearings in place, was loose. It concluded that this loose lock nut allowed the pump shaft to move and contact pump components, which caused pump damage that resulted in crude oil being released from the pump into the atmosphere. The company also concluded that heat from metal-to-metal contact in the pump seal area may have provided the ignition source.
During the incident, over 1,500 barrels of hydrocarbons (primarily crude oil) and over 1,200 pounds of nitrogen oxide were released.

Probable Cause
Based on the company's investigation, the CSB determined that the probable cause of the accidental crude oil release and fire was the failure of a crude oil pump. The released crude oil was likely ignited from heat from metal-to-metal contact in the worn pump.

DISTILLATION TOWER COLLAPSE DUE TO INTERNAL FIRE

On September 5, 2023, at 11:50 a.m., a distillation tower (“Tower”) collapsed (Figure 1) at a Petrochemical in Texas. The collapse was the result of a fire inside the distillation tower. The incident resulted in approximately $194 million in property damage.

A few weeks before the incident, the company shut down its Pyrolysis Gasoline unit, including its extractive Tower. The company followed its procedure to remove solvent and hydrocarbons from within the Tower to prepare for maintenance work. On the day of the incident, a maintenance crew began opening manways to prepare the Tower for entry. At 9:30 a.m., temperatures with the Tower’s stainless steel structured packing beds began to rise. The company sounded an emergency alarm at 10:44 a.m. after smoke and flames showed a fire within the Tower. Personnel were evacuated after adding nitrogen and trying to stop air from entering the Tower. At 11:53 a.m., the Tower folded over (collapsed).
The company investigation found that the Tower fire resulted from a chain of undesired reactions. About a month before the unit shut down, equipment leaks in another area of the process allowed water to enter the extractive distillation unit, leading to internal corrosion that removed iron from the metal walls. This iron formed iron sulfide (a pyrophoric material) from hydrogen sulfide that is usually present in the process equipment. When the Tower’s manways were opened, oxygen (air) entered the Tower, starting an exothermic iron sulfide oxidation reaction. The company concluded that the heat from this iron sulfide oxidation reaction resulted in localized heating (1,300 to 1,800 degrees Fahrenheit) within the structured packing that weakened the Tower’s walls and ultimately caused the Tower to collapse.
In addition, The company’s investigation found that a 2016 incident had revealed the potential for iron sulfide to accumulate within the Tower. The investigation team determined that this knowledge had not been effectively transferred to the existing site personnel. Had the site’s operations team known about the potential for iron sulfide within the Tower, changes to the procedure to remove solvent and hydrocarbon could have been made to mitigate the heating from the iron sulfide oxidation.
During the incident, approximately 160 pounds of sulfur dioxide and an unknown amount of other reaction and combustion products were accidentally released.
Probable Cause
Based on The company’s investigation, the CSB determined that the probable cause of the fire was smoldering iron sulfide oxidation within the structured packing of the Tower. Contributing to the incident was that the company did not effectively maintain its knowledge from its 2016 incident finding that iron sulfide could accumulate within the Tower.

Source: CSB.gov

Virtual training enhances process safety

 http://tradearabia.com/news/EDU_322350.html

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Excellent video on engulfment by MSHA

For personnel handling solid raw matarials, this is an excellent video by MSHA in this link.

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

Training tackles memory distortion to improve process safety

 Training tackles memory distortion to improve process safety


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

PROCESS SAFETY TRAINING SERVICES BROCHURE

To all my readers, please find the process safety training brochure listing out the various topics I provide training in this link. 

 
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3D virtual simulator for chemical plants

Now this is one technology driven change that sure is going to benefit process safety! The Department of Energy is running a program with West Virginia University to test 3D virtual simulators for training process plant simulators. Read an article about this in this link.

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

Distilleries are Dangerous!

I have visited many distilleries in sugar plants. When compared to chemical plants, the operators knowledge of process safety is limited. In one of the distilleries, the operators were not aware of the reason why the water level was being maintained at the bottom of a flare tower. As experienced people leave the organization, it becomes all the more important for management to implement a process safety management system in distilleries. An incident in a distillery which experienced a nitric acid spill and was subsequently closed is given in this link.

Avoid making your operators into procedural robots

I was reading an incident report of a ammonia pipeline rupture in the USA. The pipeline ruptured and released a large amount of ammonia. The case study report available in NTSB website indicates that even though the operator was receiving a large amount of alarms indicating a pipeline rupture, he attributed the drop in line pressure to less supply and more delivery. This skewed his troubleshooting abilities. How many of you are ensuring that your plant operators are trained to analyze data from DCS and troubleshoot the problem? There is no better defense than a trained and informed operator and your plant training programs should ensure this. During an emergency an operator cannot refer to procedures and all his training and knowledge will come to the forefront in troubleshooting the problem correctly.

Process Safety -Fatigue and training

Between 2007 and 2009, at least 6 commercial aircraft in India landed on the wrong runway. Fatigued crew and lack of training are supposed to be the reasons. Just ponder for a moment - if incidents like these can happen in the aviation industry, can we in the Chemical Industry ignore these issues? Fatigue and training are issues which are relevant to process safety and a lot of work has been done on shift schedules and circadian rhythms.Overtime in a process plant brings about its own problems. My own experience is that a number of incidents happen when the operator is on overtime. We cannot blame the operator. The bigger issue is whether the organisation has a training program that always has manpower in the pipeline - to replace sudden resignations. Just like the software industry, the chemical process industry in India needs to have trained people "on the bench". But this always has its costs. It finally depends on how much risk the organization is prepared to take.

Training in the Aviation and Chemical Process Industry - why different approaches?

With the advancement of instrumentation in the chemical industry,today plants are operated by DCS systems. These systems are excellent from a data collection and control point of view. The more I look at it, it appears that plant control rooms are now beginning to look like a plane's cockpit! While a pilot (similar to a control room operator) is put through mandatory rigorous training before he commands a plane, there are no mandatory requirements for the qualification of a control room operator. I was earlier a simulator trainer in a methanol plant in Saudi Arabia and I realized the enormous benefits of the benefits of investing in a chemical plant simulator. We could study and give feedback on the trainees response to various artificially created abnormal scenarios. In India, the concept of simulator training is yet to catch on. With the software experts available in India cannot we provide simulators that are cost effective?
I believe the simulator training is mandatory in the Indian Nuclear Industry but not in the chemical industry. Comments are welcome.