25 Years after the Bhopal Gas Disaster

The bhopal gas disaster on the night of December 2nd/3rd, 1984 led to a number of changes in legislation regarding the management of chemical process safety.
The recent massive blaze at the petroleum storage facility at Jaipur indicates the need for improvement in managing chemical process safety in India.
A comparison of the changes in legislation made in the USA after the Bhopal Gas Disaster with the changes made in India is given below:
Changes made in USA:
1.After the Bhopal Gas Disaster and other accidents in the 1980’s amendments were made to the Clean Air Act (1991). OSHA (Occupational Safety and Health Administration) was authorized to develop its 29 CFR 1910.119 rule of 1992, Process Safety Management. This system is mandatory in the USA since 1992 for chemical industries, storing or processing highly hazardous chemicals, above a threshold quantity. After the implementation of this rule, there was a major incident at the BP Texas refinery in 2005. A thorough investigation about the reasons for the incident and follow up actions are clearly visible to the public. The investigation reports of the incident are made available to the public on the web.
2.The US Environmental Protection Agency also implemented the Risk Management Program in 1996 to prevent an off –site disaster (An off-site disaster is an event that has repercussions outside the boundary walls of the chemical industry in which the incident took place).
3.The US Chemical Safety Board was set up in January 1998 by an amendment of the Clean Air act. It is authorized to investigate chemical accidents in the USA and publish its investigation reports on its website www.csb.gov. The board cannot impose fines or promulgate regulations. It creates public awareness by publishing its investigation reports on the web.
Changes Made in India:
1.After the Bhopal gas disaster, the Factories Act was amended to assign the responsibility of the “occupier”, who is legally responsible for the safety of the workplace and workers, to the highest level of management in an organization. For a public limited company, one of the directors on the board had to be designated as “occupier”. The Environmental legislation also underwent changes, with the Environment Protection Act introduced in 1986. Under this act, a number of new legislations were framed. The Manufacture, Storage and Import of Hazardous Chemical rules, 1989 required safety audits to be carried out in hazardous chemical factories, storing more than a threshold limit of hazardous chemicals.
2.The Chemical Accidents (Emergency Planning, Preparedness and Response) Rules, 1996 was also introduced. Preparation of on-site Emergency Plan by the Industry and Off-site Plan by the District Collector and the constitution of four-tier Crisis Groups at the Centre, State, District and Local level for management of chemical accidents are mandatory under these Rules.
Recommendations to improve chemical process safety management in India:
1.The enforcement of existing legislation regarding chemical process safety by the Indian authorities must be made effective by training the law enforcers in the latest developments in prevention of chemical accidents, inspection and management system audit techniques.
2.While statutory safety audits continue to be performed in the chemical industries, the public should also be informed about the status of implementation of the recommendations of the safety audit.
3.The investigation of Chemical Process Incidents in India should be carried out by an independent body similar to the Chemical Safety Board of USA and their investigation reports must be made public.

PS: Regarding Sriram's comment below, there is a requirement in Factories rules Sec 41 C for hazardous operations that "the occupier must appoint persons who possess qualifications and experience in handling hazardous substances and are competent to supervise such handling within factory..."

Vacuum - the frequent killer!

During the last one year I came across 4 cases of tanks/pressure vessels collapsing/buckling due to vacuum developing inside. Why do we forget so easily that tanks/vessels that are not designed for vacuum will fail if vacuum develops inside? Time and again operating personnel make the mistake of either draining the tank/vessel, with the vent valve or vacuum breaker blocked in, or allow the tank/vessel to cool without ensuring the vent valve or vacuum breaker is lined up. The reason for this, I think, is due to human psychology. When we look a a large tank/vessel, we tend to believe it is very strong! If the tank/vessel is not designed for vacuum, this is a dangerous thought! It is a matter of education and all organizations must train their personnel on the hazards of vacuum. Why must be keep repeating the same mistakes?
Watch a beautiful youtube video about a rail tank car implosion due to vacuum at
http://www.youtube.com/watch?v=E_hci9vrvfw

Process Safety Management Vs Experience

There is a school of thought that systems corrupt the people's ability to think. Recently I was in a debate with one of my friends in the Chemical Industry who was arguing that his organization has people with tremendous experience and there is no necessity for him to implement any system.
Trevor Kletz has said it very beautifully "Organizations do not have memory". What happens when these people leave or retire? Having spent my whole career in the chemical industry, I am convinced that the phrase "History repeats itself" can be adpated to "Incidents repeat themselves". I keep investigating incidents of tank ruptures,fires and explosions, runaway reactions that uncannily had happened either to me or my friends decades ago.Having a robust process safety management system that captures organizational memory and integrates it with day to day decision making is what is needed to prevent these incidents from recurring.

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.

Process Safety and Behaviour Based Safety

There's a lot of buzz to day in behavior based safety. My experience indicates that as far as any safety is concerned, the behavior of top management is what dictates the behavior of the entire workforce.If top management keeps on talking about cost cutting and not talking about safety, that's what they will get - cost cutting measures getting implemented without analyzing the effect of the change on process safety! The BP Texas refinery incident is an example of this. The behavior of top management towards process safety does not involve rocket science. However, presently, a dangerous trend is taking place in the Industry. The board of directors in many of the chemical facilities do not have a technical person. My problem is not with the board of directors but with the information that reaches them. The president and other members of the top management who report to the board sometimes do not clearly communicate the risks involved in the implementation of certain decisions.This is a recipe for disaster.
I'm happy that the Baker Panel report has recommended that a person with adequate process safety experience must be on the board to explain to top management the effects of certain decisions on process safety.

LPG Tanker fire on NH47 - Lessons to be learnt

Yesterday a LPG tanker caught fire after colliding with a car on NH 47 near Kochi. The news article and pictures from the site indicate a total lack of disregard for safety by the public. The picture shows people milling around the tanker which is on fire and there is even a guy with a handycam, taking videos, standing barely 15 feet from the burning tanker. The fire department personnel are also not wearing any protective clothing. The only silver lining is that they were warned about the BLEVE phenomenon and were cooling the tanker. While India claims to be a superpower in software industry, why do we not imbibe the best practices in fire fighting and rescue? Its not that we cannot, but requires a change in mindset!
Lets hope for a safe New Year 2010!

Process safety and security

A couple of days back an ULFA activist was caught near a oil refinery in Assam with lots of explosives. This was reported in the newspapers. Process safety and security are interlinked. The US formed the department of homeland security after 9/11. They look also at security of vulnerable chemical sites in the USA. India too should look into the security of chemical plants. We should learn from the experiences of others.

Layers of protection - too much instrumentation?

I just returned from a state of the art refinery. My thoughts went back 30 years ago when I was shift in charge of an ammonia plant. There was no DCS system but pneumatic controllers mounted on a control room panel. The complete plant had a total of about 50 hard wired alarms mounted on the panel.We ran the plant safely and successfully! Today, we have the DCS system with numerous alarms and now there are alarm suppression software!Are we complicating things too much?

Do we need a Chemical safety board?

After the Bhopal gas disaster and other accidents, the US set up a chemical safety board that investigates chemical accidents and published its investigation reports on the web. (www.csb.gov). In India, it is very difficult to obtain information about the root causes of chemical plant accidents. The HPCL incident, the Jaipur Incident and many others are examples.Is it time that a Chemical Safety Board similar to that of the CSB is set up in India?

Jaipur oil depot fire and facility siting

The Jaipur oil depot fire emphasises the need to enforce strict land use policies that are on paper. 25 years ago, Bhopal, too had a similar issue when slums were allowed to come up around the factory, resulting in large number of deaths. At the rate at which India's population is expanding,many chemical factories are worried about rampant growth of residences and building near their factories. Today, in Chennai, in Manali, the population and buildings that have come up are phenomenal when compared to 30 years ago when I worked there.

25 Years after Bhopal -lessons still to be learnt in Process safety

On 23rd March, 2005, the worst industrial accident in a decade occurred at a BP refining facility at Texas in the USA. The accident killed 15 workers and injured 180 others. 
A description of the accident by the U.S. Chemical Safety and hazard investigation Board (www.csb.gov), which independently investigates chemical accidents, is given below:
“The accident occurred during the startup of the refinery’s isomerization unit, when a distillation tower and attached blowdown drum were overfilled with highly flammable liquid hydrocarbons. Because the blowdown drum vented directly to the atmosphere, there was a release of highly flammable liquid and vapor onto the grounds of the refinery, causing a series of explosions and fires. Alarms and gauges that should have warned of the overfilling equipment failed to operate properly on the day of the accident.”
A comparison of the preliminary findings of the accident at Texas by the CSB, with the reasons for the Bhopal accident, where the toxic Methly Iso Cyanate gas leaked on the night of December 2nd, 1984, killing thousands of people, is given below:
Economic pressures compromising safety:
“A 2003 external BP audit referred to the Texas City refinery’s infrastructure and assets as “poor” and found what it termed a “checkbook mentality.” Budgets were not large enough to manage all the risks, but rather than expanding the budget, expenditures were restricted to the money on hand, in the opinion of the BP auditors. Stringent budget cuts throughout the BP system caused a progressive deterioration of safety at the Texas City refinery”.
In the Bhopal accident, the plant was incurring losses due to overcapacity. Cost cutting measures included the shutdown of safety systems like the vent gas scrubber and the flare system which was provided to safely burn any escaping MIC. The refrigeration unit of the MIC storage tank was also switched off. This elevated the tank temperature and when water entered the tank, it aided a runaway reaction to occur, causing MIC to be released. Manpower was also reduced, leading to improperly trained staff manning key positions. Malfunctioning valves and faulty gauges were never replaced.
Ineffective follow up on Safety Audits:
In the BP accident, “Several years of audits and reports had identified serious safety system deficiencies. However, the safety initiatives that were undertaken focused largely on improving personnel safety, rather than management systems, equipment design, and preventative maintenance programs to help prevent the growing risk of major process accidents.”
In the Bhopal accident, two years prior to the accident, a safety team from Union Carbide, USA, visited the plant and raised many points, including the potential for release of toxic material in the MIC unit area, either due to equipment failure, operating problems or maintenance problems. However, these problems were never analysed for the root causes and preventive actions were not implemented.
Lack of training:
In the BP accident, “The central training staff was reduced from 30 staff in 1997 to eight in 2004, and the training department budget was cut in half from 1998 to 2004. Trainers were given other duties, so that some spent little time on actual training”.
In the Bhopal accident, the planned six months training program for operators was gradually reduced to five weeks. By 1983, the MIC unit had 6 operators manning the shift, compared to 13 operators in 1980. Workers were moved from their regular positions to fill in new positions, without proper training.
Lessons still to be learnt:
No major accident occurs without sufficient warning. In the current era of cost cutting and manpower rationalizing, decision makers in the chemical industry should not forget the safety of the plant. Management must ensure that the findings of safety audits are addressed immediately. Investment in safety should be treated as an opportunity cost – the cost of an accident is always greater than the cost of preventing it. The accident at the BP Texas refinery should be a wake up call to the captains of the chemical industry. The lessons from Bhopal must not be forgotten.