Process Safety - Storage tanks

An EPA study covering a ten-year period (1990 - 2000)reveals that of the 312 accidents at tank farms examined in this period it was found that operator error accounted for 22%. Additionally, 55% were attributable to tank failure, 10% to valve failure, 4% to pump failure and 3% to bolted fitting failure. Human error also accounted for 100% of accidents that resulted in fatalities, 88% involving stock loss and 87% of property damage, with the root cause attributed to overfilling/over-pressurisation.
Storage tanks fail due to a number of reasons including collapse due to vacuum,human error, poor maintenance, vapour ignition, settlement, earthquake,lightening and over-pressurisation.
Make sure your operators are trained in the safe operation of storage tanks.

Process safety - learn from these incidents

The Karnataka Department of Factories, Boilers and Industrial safety and health has posted accidents that have occurred in their state.
Four incidents are posted:
1. Confined space incident
2. Incompatible material incident
3. Accident in Urea plant
4. Toxic gas release in bulk drug manufacturing.
The details are available in this link. Please circulate to all your colleagues as the incidents can happen anywhere.
Some more accidents are given in a pdf file (large file) in this link

Process Safety and Emergency Preparedness

I was reading about the two recent incidents of fires in high rise buildings in Bangalore and Kolkata and the high number of fatalities involved. In both cases, emergency escape paths were either blocked or locked. In a chemical plant emergency, things are much worse - domino effects can have catastrophic effects.Events will snowball quickly and unless you are well prepared, it will be difficult to handle a major emergency. All plant personnel should understand that mock drills are conducted when there is no emergency.In an actual emergency, Murphy's law will apply: "Anything that can go wrong will go wrong". A mock drill mentally prepares you for the do's and dont's.
Plant operating and maintenance personnel, especially those on shift duty must always keep themselves familiar about emergency alarm activation, escape paths, emergency breathing air escape packs and self contained breathing apparatus, crash shutdown procedures,emergency communication systems, what to do in total power failure and other possible emergencies.Most of the emergencies uncannily happen in the early morning hours when all shift people are sleepy and the general shift people are sleeping!
In some of the chemical units that I visit, the people assume that emergency preparedness is the job of the safety officer!If you want to survive in an emergency, YOU have to take responsibility and be prepared. Do not think it will not happen to you.You will not have a second chance.

Process safety - 5 Years after the BP incident

On March 23rd, 2005, the worst industrial accident in the US for more than a decade occurred at the BP Texas refinery. 5 years after the incident a news article mentions the following:
“Since the disaster, the company has spent more than $1 billion on improvements at the refinery, and continues to invest more. It's spent another $1 billion or so settling about 1,000 civil lawsuits filed by the more than 170 workers injured in the blast and by families of the dead.
“Those systems require constant vigilance. You start to think you've got it fixed, and eventually you start to focus on other things. If you let your focus wander too far, you're system starts to slip without your realizing it.”
“The U.S. Chemical Safety and Hazard Investigation Board found in 2007 that the explosion resulted from a lethal combination of cost-cutting, a lack of investment in training and mechanical systems and a lack of vigilance in maintaining safety procedures. The company has implemented sweeping changes in process safety procedures and revamped how it operates refineries. Many of those changes have been adopted by BP's rivals as well.”
“The question that continues to dog BP and the refining industry: Has it done enough?It has rejected, for example, a Chemical Safety board recommendation that it add a process safety expert to its board of directors.”
“It took the explosion,” said Gary Beevers, international vice president for the United Steelworkers union, which represents more than 1,000 workers at the refinery. “As this industry has shown, it takes something terrible for changes to happen.”
My own observation of any big incident like this is that immediately after the incident there are a lot of things done. But the question is the sustainability of these actions. Time and again I have seen that unfortunately history tends to repeat itself unless top leadership are really and continuously committed to process safety.More and more boards of Chemical and refining companies are filled up with non technical persons, with the result that there is no one at the board level to explain to the board the repercussions of cost cutting without a proper assessment.
Read the whole article in this link

Boiler burst - cause of incident at NFL?

Please see news item from Tribune, Chandigarh:
NFL tragedy
Ropar admn not informed in time
Megha Mann
Tribune News Service
Nangal, March 20
While the boiler at ammonia plant burst at around 11:40 am today, district administration Ropar was informed after 40 to 50 minutes of the incidence.
Confirming this, deputy commissioner Priyank Bharti said that even area SDM Lakhmir Singh was not informed immediately after the incidence.
“As per the protocol, the NFL authorities should have informed us within minutes after the incidence. But it took at least 40 to 50 minutes for the news to reach us. Fortunately, there was no ammonia leakage. Had it been a gas leakage, more damage could have been caused and informing us untimely could have added to chaos,” he observed.
However, official spokesperson NFL Naya Nangal claimed that the SDM and DSP were informed within 15 minutes of tragedy.Sources said that injured Umesh Kumar’s timely action of switching off main gas connection helped in saving many lives. Had the ammonia spread around, more losses of life and property would have happened.
The plant, where tragedy struck, was to be closed on Monday for 25 days maintenance practice. Annual target of NFL for urea production was 4. 78 lac tonnes and NFL had already attained 4.73 lac tonnes production.Daily production of ammonia at the plant is 900 tonnes, while that of urea is 1450 tonnes. NFL spokesperson said that company would meet its target with the help of other units. The unit has been shut down three days before the scheduled time due to accident.
Nangal MLA Rana KP Singh too reached the spot. He held the NFL management responsible for this tragedy and demanded a high level probe. He said that the fire fighting equipments at factory were not up-to-date. SSP L K Yadav asked people not to panic as the accident was result of some technical failure.

Process Safety - Blast in ammonia plant

On Saturday, a blast was reported in the ammonia plant of the Nangal fertiliser plant.
It is reported that the saturator tower fell down as a result of the blast. Three people lost their lives and my heart goes out to the bereaved families. A news item in the Hindustan Times indicates that the incident took place at 1140 hrs in the shift conversion section. The gas in the shift conversion section in an ammonia plant will primarily consist of hydrogen.

Process Safety - Phosgene hose leak update

A news article on the EPA investigation of the phosgene hose leak at DuPont's Belle, US facility in January 2010,indicate the following:
1. "This type of hose should be replaced every two months "due to the extremely hazardous nature of phosgene," EPA said. At the time of the Belle plant leak, the hose had been in use for seven months.The hose was 5 months overdue for replacement"
2. "The flexible, braided-steel hose was also the wrong kind of equipment to use in the first place because of the extremely hazardous nature of phosgene"
3."EPA also said that this type of hose should be installed within six months of its fabrication. This particular hose was fabricated in May 2008, but was not installed by DuPont until June 2009".
DuPont is world renowned for their high safety standards and I wonder what went wrong.
Read the full article in this link

Process safety and societal risks in India

I was going through a risk assessment report prepared for an organization that was planning to increase production capacity using a toxic chemical as a raw material. This chemical is received through pipelines traversing through public areas. I found one thing startlingly out of place. The report used outdated population data in the vicinity of the pipelines. Unauthorized settlements were everywhere near the pipeline and this was not considered in the report. This is a peculiar problem in India. How can we rely on population statistics when the data itself is dynamic on a day to day basis! One other thing that always perturbs me is that I doubt if the user of the report understands the assumptions made and is really able to understand the report.
Just having a colorful report with a lot of drawings indicating toxic end points and red zones does not really mean you have identified the risks involved.While such reports are mandatory from a regulatory perspective, it is better that the organization revisit these reports periodically based on changes in population density.

Lord Tony Newton,independent chair of the Buncefield Investigation Board says "The system should in future consider the total population at risk – societal risk – at each new development application. We should not continue to allow surrounding populations to increase without considering the consequences". I really do not know how we can implement this in India unless there is strong enforcement by the regulatory agencies.

Process safety and fatigue

It is disturbing to note that fatigue probably played a part in the new US power plant explosion that occurred when lines were being blown with natural gas. It appears that one of the victims who died in the explosion was working 12 hours a day, seven days a week, for six months. If operators are being allowed to work without break even in the US, imagine the plight in India!The pressure of commissioning a plant to meet target deadlines often result in people working overtime. With more and more activities being outsourced, industry must be careful that this problem is tackled to avoid incidents. What is more worrying is that the aviation industry in India is reporting incidents of pilot fatigue due to inadequate rest periods.If it can happen in the aviation industry, it can happen in the chemical industry too!

Process safety -Pressure Relief and Flame out devices - Take care of them!

According to a news release dated 8.3.2010, "The U.S. Department of Labor's Occupational Safety and Health Administration has cited BP North American Inc. and BP-Husky Refining LLC's refinery in Oregon, Ohio, with 42 alleged willful violations, including 39 on a per-instance basis, and 20 alleged serious violations for exposing workers to a variety of hazards including failure to provide adequate pressure relief for process units. Proposed penalties total $3,042,000.Forty-two willful citations with proposed penalties totaling $2,940,000 are proposed as follows:

1. Thirty-eight (38) per-instance, willful citations with penalties totaling $2,660,000 allege as follows:
1. Twenty-six instances allege deficient pressure relief, a violation of 29 CFR parts 1910.119(d)(3) and 1910.119(j)(5), with total penalties of $1,820,000;
2. Three instances allege the lack of flame-out protection on heaters and a furnace, a violation of 29 CFR 1910.119(d)(3), with total penalties of $210,000; and
3. Nine instances allege facility-siting hazards, a violation of 29 CFR 1910.119(e)(5), with total penalties of $630,000.
2. Four willful citations with penalties totaling $280,000, allege as follows:
1. Lack of pressure vessel information, a violation of 29 CFR 1910.119(d)(3), with a penalty of $70,000;
2. Cross-connections between fire-emergency water supplies and process systems, a violation of 29 CFR parts 1910.119(d)(3) and 1910.119(e)(5), with a penalty of $70,000;
3. Failure to conduct thickness measurements at designated test sites and as required at the flare header, a violation of 29 CFR 1910.119(j)(4)(ii), with a penalty of $70,000; and
4. Failure to conduct thickness measurements in accordance with RAGAGEP, a violation of 29 CFR 1910.119(j)(4)(iii), with a penalty of $70,000".
Of particular interest is the twenty six instances of deficient pressure relief and three instances of lack of flame out protection.

Purging of Natural Gas Lines - Adding fuel to the fire?

The CSB had issued urgent recommendations on the natural gas explosion at Con Agra on June 9,2009. The incident occurred when natural gas lines were being purged free of air using natural gas itself.The CSB urgent recommendations include
(a) Purged fuel gases shall be directly vented to a safe location outdoors, away from personnel and ignition sources
(b) If it is not possible to vent purged gases outdoors, purging gas to the inside of a building shall be allowed only upon approval by the authority having jurisdiction of a documented risk evaluation and hazard control plan.The evaluation and plan shall establish that indoor purging is necessary and that adequate safeguards are in place such as:
• Evacuating nonessential personnel from the vicinity of the purging;
• Providing adequate ventilation to maintain the gas concentration at an established safe level, substantially below the lower explosive limit; and
• Controlling or eliminating potential ignition sources
(c) Combustible gas detectors are used to continuously monitor the gas concentration at appropriate locations in the vicinity where purged gases are released
(d) Personnel are trained about the problems of odor fade and odor fatigue and warned against relying on odor alone for detecting releases of fuel gases

It is not safe in the first place to allow purging of an air filled pipeline with natural gas. You can never control or eliminate all potential ignition sources. PERIOD!!
See the CSB recommendations in this link.
See my latest post on this subject

Domino effect and Process Safety

An interesting article on Domino Effects in the developed countries mentions the following "A study of 261 accidents involving domino effect has been carried out. The main features have been analyzed: origin, causes, consequences and most frequent sequences. The analysis has shown that the most frequent causes are external events (31%) and mechanical failure (30%). The storage areas (37%) and process plants (27%) are by far the most common places where domino accidents have occurred. The most common sequence in the event trees resulted to be explosion–fire (21%), followed by release– fire–explosion (15%) and fire–explosion (14%)".
While the study concludes that "The historical analysis has shown that the frequency of domino effect accidents has decreased over the last two decades. Most of these accidents have occurred –as could be expected– in the most industrialized countries (from which, furthermore, more information is available). The most frequent sequences are explosion–fire, release–fire– explosion and fire–explosion. From the analysis of the causes, although the most frequent ones are external events and mechanical failure, a relatively high frequency is found for human error. This would indicate the need to further promote the training of employees, as well as an additional improvement of safety measures, specially in storage areas".

As more and more chemical industries are coming up in India, it becomes very important to study facility siting issues.Incidents like the Jaipur fire clearly indicate the need for a stronger implementation of facility siting rules.
Read the whole article in this link.

Dangers of melting contents of drums

A chemical manufacturer in India has been asked to pay to pay $8.37 million for a fire that destroyed a Houston-based pesticides maker's warehouse and offices in Pasadena six years ago.
The fire apparently took place when Chloropyrifos drums were placed were placed in a “hot box” in the Houston company's Pasadena warehouse for melting, based on procedures provided by the manufacturer. However, during the melting process, the contaminated chemicals exploded and caught fire.It appears that the drums contained chloropyrifos contaminated with solvent.
It is quite common in pesticide manufacturing to put a drum in a steam bath or a hot box to melt the drum contents. But as this incident shows, you must understand the dangers before doing it.....
See this article for more details.

Process Safety in India -PCPIR's

To promote investment in the chemical sector and make the country an important hub for both domestic and international markets, the government is in the process of setting up Petroleum, Chemicals & Petrochemical Investment Regions (PCPIRs). As per the PCPIR policy ,this is to "attract major investment, both domestic and foreign, by providing a transparent and investment friendly policy and facility regime.These PCPIRs would reap the benefits of co-siting, networking and greater efficiency through the use of common infrastructure and support services. They would have high-class infrastructure, and provide a competitive environment conducive for setting up businesses. They would thus result in a boost to manufacturing, augmentation of exports and generation of employment".
Isn't the setting up of these PCPIR's a good opportunity for the Government to implement mandatory process safety norms in these PCPIR's?

The future of Process Safety in India

A recent news item on February 26th indicates that in the immediate future, Oil Industry Safety Directorate (OISD) is likely to be announced as the single window agency to ensure safety in the oil & gas sector and is also expected to be vested with all necessary statutory powers to fulfill its responsibilities. Several other regulatory changes and announcements that are in the pipeline and expected to be unveiled over the next few months.
What is the future of process safety in India? Do not be surprised if a Chemical Safety Board, similar to the US is set up. Do not be surprised if investigation reports of incidents are put up on the web. But for this to happen, I feel there has to be a strong impetus to the Government to bring in such changes. I am only hoping that another Bhopal is not the impetus!
While on the subject, let us visit the subject of awards and incidents. In my experience, many companies have won many safety awards but then there is a fatal accident. An award for process safety performance cannot be judged by visiting the unit for a few days. It requires commitment day in and day out from top management to really achieve top class process safety performance. I feel that an organization would be better off if it sits back and takes a good look at its performance in process safety periodically.

Natural Gas Blowing of pipelines causes accident

The CSB has released a statement that mentions that the explosion at the Kleen energy plant in the US occurred during the blowing of new pipelines with natural gas to clear them of debris. There were a number of possible ignition sources.It appears that this is a "common" practice in power plants. I wonder if people are forgetting the basics: flammable gas + air + ignition source = Fire or explosion!
It is very dangerous to assume that ignition sources will not be present!

Monitor your Pressure Safety valves for fugitive emissions

An incident in the US highlights the need to ensure that operational checks are conducted to detect any fugitive emissions from PSV’s. It was reported that about 1.5 tonne of a toxic chemical had leaked from the PSV over a period of two weeks. The leak was finally detected when mass balances did not match. If you have PSV’s discharging to the atmosphere that are mounted on top of vessels tanks and other equipment, ensure that you implement a fugitive emission monitoring program to detect any leak from the safety valve. Many large atmospheric ammonia storage tanks have their PSV’s located on the tank top and any leakage from these valves cannot be detected from the ground level. With more and more habitation coming up near maximum accident hazard units, it becomes imperative that you implement a proactive monitoring PSV leak monitoring program.

Process safety - Do not forget the human being in your design!

Some experts predict that in the future, there will not be any control rooms, but operators and managers individually wearing hi tech equipment like personalized visual displays and control units that will be networked and will be used to control plants. Whatever the future, one thing is sure - the human is going to be around! And continue to commit the same mistakes!! Some examples of design "googlies" are given below:
1. If you install an orifice plate to restrict flow as part of your design, be sure one day it will be removed.
2. If you install an instrument on top of a vessel or equipment and expect the operator to note down the reading, be sure that the reading one day will be noted without the operator going to the top.
3. If you design a tank for full pressure and not for vacuum, when there is a chance of vacuum formation, be sure that the tank will collapse one day due to vacuum.

If you forget to think like an operator, be sure your design will fail one day!!
This also raises another point. In the future is it possible to operate a plant that does not depend on human beings? Ultimately, there will have to be a human being who is looking after that technology and he can also make mistakes!

Advanced instrumentation at Refinery

Please read this article

The Worlds Largest Foundation Fieldbus Project
Reliance Petroleum Limited Needed Foundation Fieldbus to Manage the Most Complex Refinery in the World

A picture of the control room is also given in the article.The article also mentions that over 200 of the commissioning staff were given troubleshooting training.

Jaipur oil depot fire - Sharing of Incident Report

Kudos to the Oil Industry Safety Directorate for posting the independent investigation committee report on the Jaipur oil depot fire. (Click MB Lall report in their website).As far as I know this is a first in India for sharing incident reports and this is a very positive change for process safety in India.
On reading the report, the following points come out:(I am quoting from the report)
1."Uncontrolled Loss of Primary Containment in the form of a jet of gasoline:Policy issues - Safety not given adequate priority".
2."It was observed that safety shut down system envisaging closure of all Motor Operated Valves (MOV) at the inlet and outlet, immediate to the tanks was provided in design and installation but had been decommissioned, a few years ago, probably after 2003, due to some operational issues. The exact timing of the above is not known to the current operating officers".
3."No External Safety Audit for last 6 years.Internal Safety Audit inadequate as it could not point out any deficiency in design or procedures & practices".
4. "The certifications such as ISO, NSC awards, Greentech awards, Ministry of Labour awards etc., are all based on documentation submitted by the organizations and not on field verifications and safety practices. The awards/recognitions mesmerize the higher management besides giving wrong signals about safety management systems leading to complacencies. It is, therefore, recommended that time and efforts be directed towards annual safety audits by involving non-company experts so as to have unbiased reports. The companies should be cautioned to be circumspect about utilizing agencies and organizations who claim to be providing expert safety advice and assessment"
I THINK THE ABOVE STATEMENTS CLEARLY INDICATE WHERE THE PROBLEMS ARE!
Update 3.7.10:
A reader called Atul has sent me this query"But how can this be a case of individual fault ? My Brother in law was attending his fathers funeral at the time of accident and could do nothing about it.
In depot fires across the globe, its the Corporation which are at fault and fined. People are given compensation. In India, the employees are put into Jail! Is this a JUSTICE system which you are proud of?"
I request Atul to read my latest post on the subject in this link

Process Safety and Asset Integrity

Maintaining asset integrity is one of the key areas of process safety. As I observe more and more competition in the Indian Chemical Industry,I am beginning to observe a lack of long term focus towards maintaining asset integrity. With current high attrition rates in the chemical industry, it is only natural that a plant manager tends to "adjust" his focus on maintaining asset integrity to ensure that nothing happens during his tenure.This is also mentioned in the investigation report of the BP Texas refinery incident.Many organizations are implementing process safety management systems without a long term approach. Such systems will bring in more complacency than doing good.Another worrying factor is the lack of competency to manage asset integrity programs. I have observed many "in house" asset integrity teams influenced by their organizational culture in such a way that they get blinded to reality.Top management feels everything is hunky dory when suddenly something fails and everybody wakes up!The UK HSE chair has said "Never allow short-term business pressures to blind you to the real and potentially devastating human and business consequences of neglecting process safety and asset integrity"
I will end with a joke - I was chairing a HAZOP study for a Bio Ethanol Plant coming up in South Africa when one of the participants jokingly asked me "Does'nt all your negative thinking affect you?". Well, Process Safety is not about negativity, but about worrying about things that are so obvious to you but not obvious to others!

"Non observance of safety norms caused Jaipur oil depot fire"- investigation report

The investigation committee into the Jaipur oil depot fire has pointed out the lack of written operating procedures, absence of leak stopping devices and lack of understanding of hazards and risks as root causes of the incident. See this report for further details.
The committee also has recommended improving operating discipline. This requires a lot of commitment from top management. Operating discipline is easy to bypass in times of cost pressures. I have observed many times that incidents are caused when operating discipline is set aside even though management knows that it is being bypassed. Process Safety Audit reports should be given due weightage by management. The observations pointed out in the audit report are indicators that something is wrong and unless they are attended and root causes are found out, a big incident could occur. How many times can we be lucky?
See other opinions in this link

Hazards of natural gas - explosion in an US Power plant

On 7th February, an explosion was reported in a US power plant. The mayor of that place put it very nicely when he said "Something happened that should not have happened and something did not happen which should have happened".
The explosion involved natural gas. Many facilities use natural gas for power generation, heating and in furnaces. Natural gas is also a raw material for the manufacture of ammonia. Natural gas is like electricity - a bad master but a good servant. For it to be a good servant, your operators must know the hazards of inadequate purging (removal of oxygen from pipelines/vessels) before admitting natural gas.In fact the US Chemical safety Boards had just three days before the incident issued a warning about the hazards involved in natural gas purging - see this safety bulletin
See this link for a video posted on youtube about the incident.
My book details the various methods of purging of equipment and pipelines.

Separate your shutdown system from control systems

Today,for cutting costs,many plant owners are trying to incorporate shutdown actions using the control system itself. For example, if there is a control valve that has to close when a predetermined shutdown point is reached, the instrument air to this valve is cut off using a solenoid valve and the valve is designed to "fail close".You must always keep your shutdown system independent from the control system. This is important from an emergency safe shutdown point of view. There is an interesting case study presented in this link where the shutdown system was designed to be independent from the control system. The control system valve did not close during an emergency due to a failure of a solenoid valve but the separate shutdown system acted safely.
I have investigated many process incidents where the shutdown system was connected through the control system and it failed to operate. In fact in one of the Ammonia plants in Europe a friend told me that every critical shutdown valve is provided with redundant solenoids for greater reliability. Have a relook at all your critical shutdown systems. Its better to be safe than to be sorry!

Reacting in an emergency - Lessons from the Hudson River Landing

On 15th January, 2009, an airbus flight suffered bird hits on both engines after take off. The pilots had to react quickly and they landed the plane safely on the Hudson river thus saving lives. Split second decisions had to be taken and they took the right decisions. A beautiful simulation of the incident is given in this youtube link.
In a chemical plant emergency, all the years of training and experience will come into play. A wrong decision taken during the emergency could lead to an unsafe condition. Of course, if you have your shutdown systems working well, they will automatically shutdown the plant safely. But there are many other things the DCS operator has to do after a shutdown. This is where his training comes in. How are you training your plant operators to handle emergencies? Is experience from actual emergencies shared and lessons learnt? In India, many of us do not take mock drills seriously. Your lives may depend on it!
Plant operators and shift engineers are the first line of defense against a catastrophe and are you investing in their training?

Runaway Reactions - Run away if you do not have data!

A runaway reaction is an uncontrolled reaction that does not stop. It can cause catastrophic consequences like rupture of reactors and release of toxic gases. The understanding of reactive chemistry plays a big role in avoiding runaway reactions. Avoid the mistake of scaling up from R & D to plant production without understanding all the details of the reactions and its side reactions. The effect of change in operating parameters and batch recipe or quantity must also be understood. Recently a speaker at a seminar mentioned that many batch processes in India are being operated without complete knowledge of the reaction chemistry. I have also investigated number of incidents involving runaway reactions where operators were operating the batch without proper information on reaction kinetics.There are various scientific tools available to determine these data. Accelerating rate calorimeters, differential scanning calorimetry etc are some of them. Just because you have not experienced a runaway reaction incident, do not be complacent. The only hope of survival in a runaway reaction incident is to run away!
Watch this excellent CSB safety video on the hazards of reactions.

Don't Alarm your operator!

I have been following the subject of alarm management in a DCS (Distributed control system) with great interest. In many process incidents that I investigate (batch and continuous processes), I observe that the flood of alarms that appeared during the emergency effectively negates the usefulness of the alarm. The irony is that we bring in the DCS with its enormous capability and then realize that alarm management in the DCS is a big issue. The root cause of the problem is the misuse of the enormous capability of the DCS. When installing the DCS it is human tendency to assign all probable alarms, thinking that we are using the capability of the DCS! Now the International Society of Automation has brought out a standard called ISA 18.2 - management of alarms in process industries on June 23rd,2009. The definition of alarm as stated in the standard is "an audible and/or visible means of indicating to the operator and equipment malfunction,process deviation or abnormal condition requiring a response". How did we manage to forget this definition?

I was part of a team of process engineers and process operators in a World Scale methanol plant, where we sat down identifying whether each alarm that was provided was really necessary or not. To our surprise, at the end of the exercise, we had reduced the alarms by over 50%!. Today, there are alarm suppression software sold by various vendors, but I feel the solution is simple - DO NOT COMPLICATE THINGS AT THE BEGINNING ITSELF BY PROVIDING TOO MANY ALARMS!
To achieve the goal process Safety I am of the opinion that things must be kept simple. In other words, KEEP IT SIMPLE & SAFE (KISS!)

While on the topic of alarm management, I have also observed the other extreme in few cases - there weren't enough alarms provided. Such issues crop up not in process plants but in storage and transfer facilities where enough thought was not applied in identifying the alarms required.

Cars can be recalled but Chemical Plants cannot!

The papers are full of news stories about the car recalls for certain models by Toyota and Honda due to design glitches. In one incident, it was reported that a boy was killed when a fire occurred due to water entering a power window motor. In chemical plants, do we have the luxury of recalls? A design mistake may show up in a devastating way, killing many people. In todays plants, modifications are carried out for capacity increase, energy saving etc. But how sure are you that these modifications do not have design glitches? Cutting costs at the design stage has serious repercussions for process safety. Investment in good design costs money, but cutting costs in design may cost lives. Cars can be recalled but plants cannot. Does your organization have the capability for designing changes or modifications? Are you keeping yourself abreast about the latest design codes and standards? Think about it!

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.

The dangers of decommissioned equipment

Today's Times of India carries a news article mentioning that 7 workers were injured in a boiler blast when they were removing an abandoned boiler from the premises of an Industrial Explosive factory. It is reported that chemical residues on the floor caught fire and exploded when the workers were attempting to cut the pedestal of the boiler using hot work. How many of your plants, especially old ones, have decommissioned equipment that are not yet removed from service, while the rest of the plant is in operation? Decommissioned equipment that are left in situ pose dangers if they are not properly isolated by blinds. The best option is to remove the decommissioned equipment safely. Many incidents have also been reported in dead legs (piping that have stagnant liquid in them that corrode and leak after some time) after decommissioned equipment have been removed. These dead legs must be removed at the next available opportunity.
Study your complete plant to identify decommissioned equipment and develop a plan to safely remove them from service.

1 out of 1 or 2 out of 3?

Today many organisations are going in for two out of three redundant logic systems for trips. I often wonder how I managed to operate an ammonia plant 25 years ago, fitted with standalone pneumatic instrumentation and no DCS! With modern day electronics, isn't it expected that the reliability of an electronic transmitter will be better? Do not go in for two out of three transmitters just because it is more "reliable". Have you obtained data on mean time between failures of electronic transmitters? When you do a LOPA analysis do not go overboard. The risk criteria used in LOPA should reflect your organizations past incidents also. I have seen many overkills of LOPA studies done by consultants who just recommend two out of three systems at the drop of a hat!

Sharing of process incidents in India

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.

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.

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.

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

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.

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.

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.

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!

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.

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.

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.

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.