Inadvertent mixing of chemicals

On May 23, 1998, Employee #1 mixed a cobalt solution and Methyl Ethyl Ketone Peroxide (MEKP) together when the solution exploded and fatally burned Employee #1. Employee #1 was believed to be in the process of pouring excess liquids, which accumulated in the top measuring cup, back into the original container. Employee #1 inadvertently poured the cobalt solution into the MEKP bottle. These chemicals are violently incompatible. The label on the cobalt solution was illegible.
Source: osha.gov

Be careful of peroxides!

On August 28, 1994, at 9:10 p.m., Employees #1 and #2 were adding hydrogen peroxide to a tank of wastewater containing a dilute solution of cyanide and caustics. The hydrogen peroxide was being added by gravity from the floor above. The hydrogen peroxide tank began to "bump" (bubble from escaping gas), so the employees opened the valve more fully to increase hydrogen peroxide addition speed when an explosion occurred which totally destroyed the peroxide tank. Employee #1 was treated for chemical and thermal burns on his hands and released. Employee #2 was admitted to Lawrence Memorial Hospital in New London, CT, with multiple burns and serious eye damage. On August 30, the employee's eye recovery prognosis was "good." A later prognosis was "excellent." The ophthalmologist expects 100 percent recovery in both eyes.

How well trained are your operators on emegrency reponse?

Employees #1 and #5 through #7 were near the chlorine unloading area at a bleach plant when the gasket of a recently-installed vaporizer failed, releasing between 500 and 700 gallons of liquid chlorine. When Employees #1 and #7 went to investigate the extent and location of the leak, they found an overwhelming concentration of the chemical. They were not using SCBAs, nor was Employee #6, who used the wrong escape route. Employee #5, the bleach plant operator, attempted to find and assist Employee #6. Employees #2 through #4 attempted to shut down the vaporizer system but they did not know the location of the one critical shut-off valve, and the key person was not immediately available to help. Employees #1 through #7 suffered chemical burns from inhaling the chlorine fumes; all were hospitalized except for Employee #2.
Source:osha.gov

Mechanical seal failure incident

On April 6, 1994, a unit operator was conducting rounds of the coker unit when he observed a leak coming from the mechanical seal of the heavy gas oil pump of coker unit #1. The operator decided to seek assistance; the head unit operator and six or seven unit operators responded. The operators placed water and steam on the leak to suppress the vapor from the seal. The head unit operator decided to shut down the pump and transfer the product to the secondary pump. As the operator shut down the primary pump, the mechanical seal blew, causing a vapor cloud to generate from the seal. The operators continued to put steam and water on the seal and isolated the pump from the pipe line. The remaining product in the pipe line leading to the primary heavy gas oil pump vaporized, leading to the dispersion of the vapor cloud. The operators who responded were wearing bunker gear and several wore emergency respirators. Those with respirators isolated the pump from the pipe line by closing the suction and discharge valves. The operators who were not wearing emergency respirators stationed themselves upwind of the vapor cloud and put water on the cloud; however, the wind changed direction several times, exposing unprotected operators to vapors. Employees #1 and #2, two unprotected operators who responded to incident, were brought to Long Beach Memorial Hospital to be treated for inhalation of hydrocarbons. Employee #1 was hospitalized.
Source: osha.gov

35 years after Bhopal- lessons still being learnt!

35 years ago, on the night of December 2nd/3rd 1984, the Worlds worst industrial disaster took place.

In India and elsewhere around the World, catastrophic chemical plant incidents continue to occur. Memory is short. In the numerous incidents since Bhopal, many of the reasons are similar to those of the Bhopal disaster:

• cost cutting without properly analysing the effects on process safety
• poor competency
• poor asset integrity
• high attrition rate
• inadequate emergency response and planning
• inadequate facility siting
• not paying heed to audit reports and past incidents etc.

What has changed between 1984 and 2019? It is technology. But can technology change behavior of people? In 2010, two fatal accidents occurred at two different sites of one of the World's best process safety managed organization. Why? Think about it!

Even if you have a 40 element PSM system, there is no guarantee that a catastrophic accident will not occur.  Is there a solution to this? One of the possible solutions is accountability at the highest level. By this I mean legal requirements that will make the entire board of chemical organizations accountable for a process incident that kills or maims people. The Sword of Damocles should surely work.
We still do not have any PSM rule in India apart from the OISD guidelines for the oil sector. We still do not have an independent incident investigating authority. The status of the chemical safety and security rating system whose draft was published few years ago is not known.

My thoughts are with the victims of Bhopal - dead and surviving...and I pray that another Bhopal does not occur.

Read my earlier posts on Bhopal:

http://indiaprocesssafety.blogspot.in/2011/01/bhopal-pictures-speak-thousand-words.html

http://indiaprocesssafety.blogspot.in/2012/12/national-process-safety-week-on.html

See a presentation on the Bhopal Gas Tragedy by Vijita S Aggarwal, Associate Professor, University School of Management Studies,GGS Indraprastha University,Delhi, India in this link.

Read my older post comparing the Bhopal and the BP incident of 2005 in this link

Read the then Police Chief’s account of the tragedy in this link.