I really lament the lack of sharing of information and investigations of process incidents in India. The US Chemical Safety Board is doing excellent work by posting videos of incidents for the whole world to see! I can get more information about the BP Texas incident from the internet than I can get about the reasons for the Jaipur Oil depot fire! I was browsing around for details about incident reporting system in India and I chanced upon this website www.cairs.nic.in
I hope the site is kept updated and the information shared.
I am in the process of collecting incidents from friends and colleagues to share with all, without mentioning the organization's name. Unless we learn from past mistakes, the same incident will keep repeating. If any one of you feel like sharing some process incidents without mentioning the name of your organization, please send the details to me. I will put it up on the blog.
January 31, 2010
Off site chemical disaster management in India
My opinion about off site disaster management in India for chemical disasters is that a lot needs to be done. When I worked in Saudi Arabia, I volunteered to be part of the on site emergency team.The training I underwent for 5 years for just being a member of the on site emergency team was stupendous! We had not only to undergo 4 hours of practical training every month, but weekly refresher trainings also. I was also sent to a 5 day course on advanced emergency response course for hazardous materials and rescue where we learnt to deal with actual emergencies with live fires, gas leaks and personnel rescue techniques from top of distillation columns!!
In India, the off site response to a chemical accident is governed by the Chemical Accidents (emergency planning, preparedness and response) rules 1996.
However, I have seen videos of off site mock drills conducted in India and there is a lot of scope for improvement. I hope the NDMA (National Disaster Management Authority) will soon improve the situation.
In India, the off site response to a chemical accident is governed by the Chemical Accidents (emergency planning, preparedness and response) rules 1996.
However, I have seen videos of off site mock drills conducted in India and there is a lot of scope for improvement. I hope the NDMA (National Disaster Management Authority) will soon improve the situation.
MSDS availability and hamonisation
Today in the process safety seminar, a participant asked about the plethora of MSDS available on the net and which one to follow. There is work going on to standardize the MSDS internationally. Please visit this link for further details.
There is also an ISO standard ISO 11014:2009 available for MSDS.
But how many of your personnel know how to interpret the MSDS terms from a view of process safety? My book deals with such practical issues.
There is also an ISO standard ISO 11014:2009 available for MSDS.
But how many of your personnel know how to interpret the MSDS terms from a view of process safety? My book deals with such practical issues.
January 29, 2010
Learnings from Process Safety Seminar
Today I attended the Process Safety Seminar conducted by ICC at Chennai, where I had presented a paper on "Management of Change". The learning's from the seminar are as follows:
1. In an incident involving a blast wave, a magnetic hatch on the top of an ethylene tank flew open due to the blast wave as the hatch cover was facing the blast wave and the hinge was on the other side. This allowed ethylene to come out and add to the fire. One of the lessons learnt is - during a HAZOP study look at these issues. It may be a simple issue but an important one.
2. In another incident, a fired heater was supported on fireproofed support legs. During an incident of a coil rupture and a fire, the fire proofed support legs withstood the fire but the vertical metallic stack which was about 20 m in height could not and toppled on other equipment.
3. In a runaway reaction incident where the reactor exploded, the investigator was trying to determine the thermo chemistry of the reaction in a experimental set up. Unfortunately, the reaction temperature increased so rapidly that it destroyed the equipment in the lab! Luckily no one was injured.
4. IS14489:98 (Bureau of Indian Standards - Code of practice on Occupational health and safety audit)- this focuses mainly on OHS issues. However, a committee has updated it with process safety elements also, but the updated code of practice is yet to be released.
5. There was also talk about behaviour based safety, but I am not a fan of BBS. There is a good article from a union's perspective. See the pdf file "the steelworker perspective on behavioral safety"in this link
1. In an incident involving a blast wave, a magnetic hatch on the top of an ethylene tank flew open due to the blast wave as the hatch cover was facing the blast wave and the hinge was on the other side. This allowed ethylene to come out and add to the fire. One of the lessons learnt is - during a HAZOP study look at these issues. It may be a simple issue but an important one.
2. In another incident, a fired heater was supported on fireproofed support legs. During an incident of a coil rupture and a fire, the fire proofed support legs withstood the fire but the vertical metallic stack which was about 20 m in height could not and toppled on other equipment.
3. In a runaway reaction incident where the reactor exploded, the investigator was trying to determine the thermo chemistry of the reaction in a experimental set up. Unfortunately, the reaction temperature increased so rapidly that it destroyed the equipment in the lab! Luckily no one was injured.
4. IS14489:98 (Bureau of Indian Standards - Code of practice on Occupational health and safety audit)- this focuses mainly on OHS issues. However, a committee has updated it with process safety elements also, but the updated code of practice is yet to be released.
5. There was also talk about behaviour based safety, but I am not a fan of BBS. There is a good article from a union's perspective. See the pdf file "the steelworker perspective on behavioral safety"in this link
January 26, 2010
Hoses and Process Safety
The US Chemical safety board has reported an accident at a DuPont facility at Belle, West Virginia on Saturday. Apparently a braided hose connected to a one tonne phosgene tank ruptured. An operator who was exposed to the gas died the next day. For details see http://www.csb.gov/newsroom/detail.aspx?nid=302.
I am always wary of hoses in a chemical plant. They are silent killers. They may look good on the outside but may have been damaged inside. A facility that wants to ensure process safety must make a list of such hoses, their service and plan a program for replacement. Visual inspection of hoses may offer tell tale signs of hose damage. However, it is best that these hoses are replaced at a certain frequency even if they do not leak. Another option is to consider getting rid of the hoses altogether by replacing with properly designed piping.
I have witnessed a large fire due to a oil hose rupture in a gas compressor which happened in my shift about 25 years ago!The consequences were terrible.The whiplash effect of the ruptured hose sprayed oil over a wide area, contributing to the spread of the fire.
I am always wary of hoses in a chemical plant. They are silent killers. They may look good on the outside but may have been damaged inside. A facility that wants to ensure process safety must make a list of such hoses, their service and plan a program for replacement. Visual inspection of hoses may offer tell tale signs of hose damage. However, it is best that these hoses are replaced at a certain frequency even if they do not leak. Another option is to consider getting rid of the hoses altogether by replacing with properly designed piping.
I have witnessed a large fire due to a oil hose rupture in a gas compressor which happened in my shift about 25 years ago!The consequences were terrible.The whiplash effect of the ruptured hose sprayed oil over a wide area, contributing to the spread of the fire.
January 23, 2010
Pilot Error and Process Safety Management - The human connection
Today's paper indicates that Pilot's error caused the helicopter carrying Chief Minister Y.S.R to crash.The investigation report indicates "The cockpit voice recorder showed that there was poor crew resource management among them at any given stage of flying". They noticed a snag in transmission pressure on the instrument displays but failed to co-relate it with other indications associated with the snag. Both of them were busy trying to find out the cause of the snag, with the result that they were not aware that they were veering off course. Crew Resource Management (CRM) is a big issue in the cockpit of a plane or a helicopter. In simple terms, it is how jobs are shared during an emergency.
CRM is very relevant in chemical plant control rooms also. I have witnessed incidents due to wrong actions taken by control room personnel as there was no clear direction who would do what. Having said that, it becomes very difficult to compartmentalize actions during an emergency in a chemical plant. The practical solution to this is to have a senior control room operator monitoring the actions of the DCS operators and guiding them. The senior control room operator's job is like a conductor in an orchestra. Control Room Resource Management is one area where plant simulators can be used to train the personnel.
Another point which is in my mind is the provision of a voice recorder similar to that of a cockpit voice recorder and a CCTV camera in the control room monitoring the actions of the personnel during an emergency. Now I know this is going to get a lot of brickbats thrown at me but the purpose is not to spy on them. It is to make improvements in Control Room Resource Management after emergencies.
CRM is very relevant in chemical plant control rooms also. I have witnessed incidents due to wrong actions taken by control room personnel as there was no clear direction who would do what. Having said that, it becomes very difficult to compartmentalize actions during an emergency in a chemical plant. The practical solution to this is to have a senior control room operator monitoring the actions of the DCS operators and guiding them. The senior control room operator's job is like a conductor in an orchestra. Control Room Resource Management is one area where plant simulators can be used to train the personnel.
Another point which is in my mind is the provision of a voice recorder similar to that of a cockpit voice recorder and a CCTV camera in the control room monitoring the actions of the personnel during an emergency. Now I know this is going to get a lot of brickbats thrown at me but the purpose is not to spy on them. It is to make improvements in Control Room Resource Management after emergencies.
Emergency response to terror threats
Terrorism has brought about an added dimension to Process Safety Management. Recently an article mentioned that terrorists may target Indian refineries. Is your organization prepared to handle terror threats? The starting point for determining weak links in your security is by conducting a security vulnerability assessment. Do not assume your current security framework can take care of such threats. Also, prepare an emergency response plan in case the worst takes place. How are you maintaining your emergency isolation valves to shut off feed to the plant and to isolate affected sections? How good are your flare and venting systems protected against collapse during a major fire? How quickly can you safely shut off your plant and evacuate personnel? These are some of the questions that need to be answered.
January 17, 2010
Are you thinking about implementing PSM?
Twelve years ago, when I was a Dy. General Manager (PSM) in a large organization in India implementing PSM, there were hardly a few industries in India that had heard about PSM.Later, when I became a PSM consultant to the Industry in 2001, I had to struggle a lot to create awareness about PSM.Today the awareness about PSM has tremendously increased. But I am afraid that if organizations are not careful, PSM also will go the way of ISO 14001 and OHSAS 18001. In my opinion, the quality of certification audits for ISO 14001 and OHSAS 18001 has drastically reduced. PSM also should not go that way. To begin with, organizations must be careful when they get into PSM, because they need to know what they are getting into. Wherever I implement PSM, I first check whether the organization is ready - both from a cultural perspective and adequacy of technical competency for PSM. If these are lacking, the organization first needs to attack these issues. PSM is a never ending journey - the scope for continual improvement is immense. Technical competency is a big issue in PSM. Today I see some organizations that are operating hazardous plants who do not have the basic knowledge of chemical engineering principles and reaction chemistry! So, if you are thinking about implementing PSM in your organization, know what you are getting into!
January 16, 2010
Are your back up systems available?
On Thursday 14th January, it was reported that the entire radar systems at the Air Traffic Control (ATC) at the Indira Gandhi International airport at Delhi failed in the evening for about an hour. It was also reported that no takeoffs or landings could take place for more than two hours following the systems crash. The back up system also failed.The ATC system was finally restored at around 2030 hrs after reloading the system, with the entire procedure taking about three hours. The radar system collapse led to massive delays.
The above incident raises the importance of keeping back up systems always ready. A back up system is just that – it must back up when needed. Obviously something went wrong with the back up also. The only silver lining is that there must have been procedures for manual operation which was obviously put into place as there was no safety of flight issue. How good are your back ups for power supply for the DCS system? How often do you check them? Do not think that it will not happen. I had the personal experience of all 7 DCS screens of a methanol plant operating at full capacity, going blank all of a sudden! Develop procedures and train personnel for handling such situations.
The above incident raises the importance of keeping back up systems always ready. A back up system is just that – it must back up when needed. Obviously something went wrong with the back up also. The only silver lining is that there must have been procedures for manual operation which was obviously put into place as there was no safety of flight issue. How good are your back ups for power supply for the DCS system? How often do you check them? Do not think that it will not happen. I had the personal experience of all 7 DCS screens of a methanol plant operating at full capacity, going blank all of a sudden! Develop procedures and train personnel for handling such situations.
January 14, 2010
Fire near refinery destroys shanties
It was reported that about 100 shanties were gutted in a fire near the Guwahati refinery on 11.1.2010. Luckily there were no casualties. The cause of the fire is yet to be ascertained. Local residents allege that the effluents released from the refinery in a bypass drain caught fire. The incident raises the question of facility siting and how did the shanties come up near the refinery? The Bhopal disaster was an epitome in facility siting. Shanties were allowed to spring up near the plant leading to greater number of deaths when the gas leaked. In today's scenario, allowing dwellings to come up near hazardous installations poses two risks - one is the exposure of people living in the shanties to the hazards from the installation and the other is from the security and terrorism point of view. The Jaipur oil depot fire also pointed out the hazards of allowing development close to hazardous installations. When will we wake up?
Accidents during transportation of Hazardous Chemicals - learning from NTSB
On12.1.2010, a 55 year old woman died when a chlorine cylinder that was being transported in a mini lorry, reportedly "exploded" at Thirumullaivoyal, near Chennai.
The newspaper photo depicts a mangled mini lorry with remnants of the cylinder that "exploded". I am sure that the investigation will be carried out. But what about the disclosure of the results of the investigation? We must learn from the National Transportation Safety Board of the USA who investigate transportation incidents. They investigate incidents involving aviation, road transport, pipeline and hazardous materials,marine, rail transport etc.Their investigators are on call 24 hours a day, 365 days a year. The results of investigations are posted on their website www.ntsb.gov. Why don't we learn from them? Information shared about the lessons learnt help to prevent another similar incident from happening and lives can be saved.
Another aspect of process safety that has been brought out by the incident is that it was reported that the chlorine was being transported for usage as a disinfectant. Today there are less hazardous alternatives to chlorine for the purpose of disinfection of water. The concept of inherent safety proposed originally by Dr Trevor Kletz propounds exactly this.
The newspaper photo depicts a mangled mini lorry with remnants of the cylinder that "exploded". I am sure that the investigation will be carried out. But what about the disclosure of the results of the investigation? We must learn from the National Transportation Safety Board of the USA who investigate transportation incidents. They investigate incidents involving aviation, road transport, pipeline and hazardous materials,marine, rail transport etc.Their investigators are on call 24 hours a day, 365 days a year. The results of investigations are posted on their website www.ntsb.gov. Why don't we learn from them? Information shared about the lessons learnt help to prevent another similar incident from happening and lives can be saved.
Another aspect of process safety that has been brought out by the incident is that it was reported that the chlorine was being transported for usage as a disinfectant. Today there are less hazardous alternatives to chlorine for the purpose of disinfection of water. The concept of inherent safety proposed originally by Dr Trevor Kletz propounds exactly this.
January 10, 2010
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.
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