Parkinsons Law for Process Safety Management

I have formulated Parkinsons Law for Process Safety Management:
1.If there is an incident in one plant, rest assured that the same incident will reoccur after 5 years!
2. If there is an incident in a plant that belongs to a large group of plants, rest assured that it will not be shared with others in the group.
3. If there is pressure on profits, the first thing to get compromised will be process safety.
4. If the person at the top does not have a perception of process safety risks,process safety will get compromised, no matter whatever systems are implemented!
5. Process near misses will continue to be missed till a major incident occurs.
A OSHA representative has testified before the senate subcommittee on safety in energy industries. The following are quoted from his testimony:
"In the wake of the Texas City explosion, OSHA initiated a national emphasis program with the goal of inspecting the process safety management programs of almost all of the nation's oil refineries. "I am sorry to report that the results of this NEP are deeply troubling. Not only are we finding a significant lack of compliance during our inspections, but time and again, our inspectors are finding the same violations in multiple refineries, including those with common ownership, and sometimes even in different units in the same refinery. This is a clear indication that essential safety lessons are not being communicated within the industry and often not even within a single corporation or facility. The old adage that those who do not learn from the past are doomed to repeat it is as true in the refinery industry as it is elsewhere. So we are particularly disturbed to find even refineries that have already suffered serious incidents or received major OSHA citations making the same mistakes again.
"Consistently throughout the course of the Refinery NEP, we have found that more than 70 percent of the violations we are finding involve failures to comply with the same four essential requirements:
"Process Safety Information: Frequent process safety information violations include failure to document compliance with Recognized and Generally Accepted Good Engineering Practices, (or RAGAGEP, which consists primarily of industry technical guidance on safe engineering, operating or maintenance activities); failure to keep process safety information up to date; and failure to document the design of emergency pressure relief systems.
"Process Hazards Analysis: We are finding many failures to conduct complete process hazards analyses. Often, there are significant shortcomings in attention to human factors and facility siting, and in many cases employers have failed to address process hazard analysis findings and recommendations in a timely manner, or, even to address them at all.
"Operating Procedures: Operating procedures citations are for failure to establish and follow procedures for key operating phases, such as start-ups and emergency shutdowns, and for using inaccurate or out-of-date procedures.
"Mechanical Integrity: This is a particular concern given the aging of refineries in the United States. Violations found by OSHA typically include failure to perform inspections and tests, and failure to correct deficiencies in a timely manner. In the Delek Refinery case mentioned above, for example, OSHA discovered multiple substandard pipes being operated, and the naphtha pipe whose explosion killed two workers and hospitalized three others had already ruptured once within the past few years.
"I have been deeply frustrated by these results.Over a year ago, we sent a letter to every petroleum refinery manager in the country, informing them of these frequently cited hazards. Yet, a year later, our inspectors are still finding the same problems in too many facilities. Clearly, much more work must be done to ensure effective chemical process safety.
Read the whole testimony in this link.

Excellent Hazards of hot work video from CSB

This is a must see for all those involved in hot work, including chemical, oil and gas and food processing industries. What surprises me is that the same mistakes are being repeated again and again. India, with its very young workforce needs to keep educating its workforce and this CSB video is excellent. I myself have witnessed three fatalities due to hot work incidents similar to those described over 25 years ag0.
See the video in this link. Kudos to the CSB!

Bhopal Gas Disaster - Precedence of Profits over People?

As expected the verdict on the Bhopal gas disaster in the Indian court has raised a hue and cry in the media. While definitely agreeing that the verdict is too little,too late, I think we are missing the bigger picture here. What has India done to prevent another Bhopal type of disaster? In the USA, OSHA CFR1910.119 Process Safety Management became mandatory in 1992 for facilities handling, storing and manufacturing highly hazardous chemicals above a certain threshold quantity. There is no such rule in India even today. Why? Even the enforcement of the other existing rules is weak due to rampant corruption. I quote from MJ Akbar's article in the Times of India:
"If there is any explanation for Delhi's fudge-and-fuss approach, it can only lie in the Indian elite's very real indifference to the poor. What, one wonders, would have been the reaction if Carbide had leaked its poison over Lutyens' Delhi rather than five kilometers from the old Bhopal city? Would Anderson have spent 25 years in Tihar rather than a villa in Hampton's?"
Read MJ Akbars article written before the verdict in this link

Decisions and Disasters -2

A friend of mine who is in top management in a large organization sent me this article about the BP oil spill, highlighting the following points:
"With the schedule slipping, Williams says a BP manager ordered a faster pace.Williams says going faster caused the bottom of the well to split open, swallowing tools and that drilling fluid called "mud."
We actually got stuck. And we got stuck so bad we had to send tools down into the drill pipe and sever the pipe,Williams explained.There's always pressure, but yes, the pressure was increased.He discovered chunks of rubber in the drilling fluid. He thought it was important enough to gather this double handful of chunks of rubber and bring them into the driller shack. I recall asking the supervisor if this was out of the ordinary. And he says, 'Oh, it's no big deal.' And I thought, 'How can it be not a big deal? There's chunks of our seal is now missing,'Williams told Pelley.
The BOP is operated from the surface by wires connected to two control pods; one is a back-up. Williams says one pod lost some of its function weeks before. "The communication seemed to break down as to who was ultimately in charge," Williams said. What strikes Bea is Williams' description of the blowout preventer. Williams says in a drilling accident four weeks before the explosion, the critical rubber gasket, called an "annular," was damaged and pieces of it started coming out of the well.
Investigators have also found the BOP had a hydraulic leak and a weak battery".

Read the full article in this link

Process Safety Two Day Training at Chennai on 12th and 13th August,2010

Folks!
I am pleased to announce a two day training session on Process Safety Management on August 12th and 13th,2010 at Chennai. The course is a highly practical one and will benefit the participants. For further details please see this link.
If you want the brochure and booking form to be sent to you, please contact me at bkprism@gmail.com

Process Safety and POP's

No, I am not talking about Persistent Organic Pollutants! I'm talking about Pressure On Profits. Time and again, we see accidents happening even in the World's biggest companies who have all systems in place including OHSAS 18001,ISO14001,PSM, behaviour based safety and other programs, conducted HAZOP and LOPA studies etc. A current example is the BP oil spill in the Gulf of Mexico.Why does this happen? While everyone agrees that ultimately it is the human being who is the weakest link in any system, how do we ensure that safety is always looked at all times including times of pressure on profits? On one side OSHA is increasing the monetary penalties for deficiencies. Whether this will spur organizations to invest in process safety – we will have to wait and see. Ultimately decisions linked to spending and investments have a cascading effect on the whole organisation and finally lead to an accident. I was talking to the Head of Safety of a large organisation who had done a HAZOP study for a new facility. He lamented the fact that even though he had presented to the board the fact that the new plant was commissioned with only 50% of the HAZOP study recommendations implemented, there was no reaction from the board! This could be due to two reasons – a lack of perception of process safety risk and the lack of competence required to understand it. It’s a chicken and egg situation. The Baker Panel report on the BP Texas refinery accident in 2005 had suggested that BP appoint a person with process safety knowledge on its board, but as far as I know, BP has not appointed anyone.

Process Safety - controlled by Leadership, HR and Finance!

Having investigated numerous process incidents over my 30 year career, I have come to some mundane conclusions which I am sure everybody knows...
1. No amount of management systems can prevent an incident unless the top management (leadership) send the correct signals!
2. Process safety is understood by the operations and maintenance departments but not understood by the Human Resources (HR) department!The HR department should play an important role in understanding competencies, skills and training required for Process Safety. But in many organisations, the HR department does not really understand the requirements of process safety. However, in one organization, I did see a very responsive HR department - its head was an ex-operations man!
3. Last, but not the least, Money makes the World go around! Without allocating adequate resources, audit findings, HAZOP reports recommendations, LOPA recommendations, incident investigation recommendations - all of them are meaningless and remain on paper till a catastrophic incident happens.
The BP oil spill has instilled great fear among Oil and Gas companies who fear that the regulations will be tightened very much and they need to spend a lot of resources.
Meanwhile, new management systems keep on coming, companies keep getting certified and accidents continue to occur......
Stay tuned!
PS: I am not a Pessimist!

Understand the hazards of chemicals!

Two students in the USA were reported to be in critical condition early Wednesday after being burned by a chemical explosion.Investigators with the Atlanta Fire Department confirm the students were mixing chemicals for "recreation" and not as part of a legitimate class project. They describe the explosion was an accident.In your lab, are your personnel aware of the hazards of all the chemicals they use? I heard of an incident where a lab technician in a plant (the Lab was located in the control room building) was taking a bottle of solvent and using the lift (elevator) when he accidentally dropped the bottle. The solvent went down the elevators floor and collected in the well. A spark ignited the solvent and the person had to be rescued from the elevator.
Read the article about the students in this link

Transportation emergencies and GIS

I know in India, that the Andhra Pradesh Government is using the Geographical Information System (GIS) for disaster management. I read a paper on "Assessment on the Consequences of LPG Release Accident in the Road Transportation via GIS Approaches". The authors have suggested integrating the results from consequence analysis to GIS tools, to get an accurate picture for disaster management. The advantage of this method is that the point of accident can be moved to any location using the GIS and a new result will be displayed for the LPG accident at the new location.
Read the full article in this link

Emergency Response in the BP oil rig fire - Shades of Piper Alpha?

A detailed article in the Wall Street Journal about the lack of command and control system after the BP oil rig fire eerily brings back memories of the lack of emergency response after Piper Alpha disaster in 1988. In the BP oil rig fire emergency response, the article mentions the following points:
"The chain of command broke down at times during the crisis, according to many crew members. They report that there was disarray on the bridge and pandemonium in the lifeboat area, where some people jumped overboard and others called for boats to be launched only partially filled.
The vessel's written safety procedures appear to have made it difficult to respond swiftly to a disaster that escalated at the speed of the events on April 20. For example, the guidelines require that a rig worker attempting to contain a gas emergency had to call two senior rig officials before deciding what to do. One of them was in the shower during the critical minutes, according to several crew members.
The written procedures required multiple people to jointly make decisions about how to respond to "dangerous" levels of gas—a term that wasn't precisely defined—and some members of the crew were unclear about who had authority to initiate an emergency shutdown of the well".
We seem to not learn from previous disasters like Piper Alpha where similar confusion existed after the fire!
Read the full article in this link.

Fire in Chemical Factory

This youtube video shows a fire in a chemical plant in Andhra Pradesh. The official says that the plant was not in operation since 2006 and did not have permission to operate. But when you see the fire it appears that large quantities of flammable chemicals were stored in vessels that were very close to each other. See the video in this link.

PVC pipes fire

A fire occurred in a place in Netaji Nagar, Thirumullaivoyal, Chennai,where PVC pipes were stored in the open. The photo in the paper indicates voluminous clouds of smoke from the fire.Dioxins are produced during a PVC fire and I am not sure if the public and the firefighters were aware about its hazards.
Another article mentions the following about the hazards of a PVC fire:
During 9-12 July, 1997, at least 400 tonnes of PVC were burned in a fire at Plastimet Inc, Hamilton , Ontario ( Canada ). The facility was storing bales of "jet trimmings" from a manufacturer of automobile interiors. Analysis of soot and ash samples after the PVC fire at the plant, revealed levels of dioxin 66 times higher than permitted even for industrial land. This one fire increased the annual dioxin emissions for the whole of Canada by 4 percent in 1997. Residents were advised not to eat local garden produce or allow their children to play on the grass.
Read the article of the fire in this link
Read the article about hazards of dioxins in this link

Cell phones - an ignition source?

Today, at a meeting of like minded people, we had an interesting discussion on how the use of a cell phone may be dangerous in a classified area.One of the participants opined that is is static electricity when using a cell phone that develops the spark that could prove to be an ignition source. Whatever the methodology, it is prudent not to use cell phones in a classified area. An incident in a platform in the Gulf of Mexico in 2002 is quoted below:
"A contract panel specialist was working on an open platform master control panel that used supply gas for the instrumentation. The contractor stated he was carrying a cellular phone that was turned on and rang while he was working on the panel. The employee claimed that when he flipped the bottom piece of the cellular phone to answer the call, a flash fire occurred causing second degree burns on his forearms and “sunburn” on his nose and cheeks. At the time National Safety Alert No. 5 was issued, it was believed that the cellular phone may have ignited the flammable gases or vapors in the area of the open platform master control panel when the phone had been flipped open to receive the incoming call.As part of the investigation of this fire, they sent the hand held cellular phone involved in the flash fire to an independent third party testing laboratory.
Although the cellular phones’ battery provided sufficient energy to ignite the test gases during the testing it did not. As a result, it was the opinion of the independent third party testing laboratory that it is unlikely that the cellular phone would have ignited a flammable mixture of methane or propane under actual field conditions and that the cause of the flash fire was something other than the cell phone.
Based on this information and investigation, we were unable to conclusively identify the ignition source of the fire. However, we have not ruled out the possibility that the fire could have been ignited by static electricity, a spark from the metal master control panel door coming into contact with a metal handrail, or a wrench striking metal inside the control panel".
Read more of the article in this link
Read a brochure by Shell in this link

Safeguards and Regulators

The BP oil spill incident has thrown up an interesting fact. While regulators in two major oil-producing countries, Norway and Brazil require acoustic switches to activate an underwater valve that shuts down the well even if the oil rig itself is damaged or evacuated, the US regulators do not require them. Norway has had acoustic triggers on almost every offshore rig since 1993. How do regulators decide what is necessary? I suspect this again has to do with study of safety integrity levels and the perception of risk. Read the full article in this link

Decisions and Disasters

An article titled "BP Decisions Set Stage for Disaster" alleges the following about the BP oil spill:
A Wall Street Journal investigation provides the most complete account so far of the fateful decisions that preceded the blast. BP made choices over the course of the project that rendered this well more vulnerable to the blowout, which unleashed a spew of crude oil that engineers are struggling to stanch.
BP, for instance, cut short a procedure involving drilling fluid that is designed to detect gas in the well and remove it before it becomes a problem, according to documents belonging to BP and to the drilling rig's owner and operator, Transocean Ltd.
BP also skipped a quality test of the cement around the pipe—another buffer against gas—despite what BP now says were signs of problems with the cement job and despite a warning from cement contractor Halliburton Co.
Once gas was rising, the design and procedures BP had chosen for the well likely gave this perilous gas an easier path up and out, say well-control experts. There was little keeping the gas from rushing up to the surface after workers, pushing to finish the job, removed a critical safeguard, the heavy drilling fluid known as "mud." BP has admitted a possible "fundamental mistake" in concluding that it was safe to proceed with mud removal, according to a memo from two Congressmen released Tuesday night.
Finally, a BP manager overseeing final well tests apparently had scant experience in deep-water drilling. He told investigators he was on the rig to "learn about deep water".
The last point mentioned scant experience. I am seeing a trend in many Indian Companies that indicates a steep decline in competency of personnel working in chemical industries. The lack of competency is acute at the manager level where decisions are taken during an emergency situation. With the advent of the software industry, many engineers prefer a "soft" job with them rather than sweat it out in a chemical industry! Is the stage set for another Bhopal??
Read more of the article in this link

BP oil spill

An article in the Telegraph mentions that "Tony Hayward, whose leadership during the catastrophe has come under fire, insisted that his success at shaving $4bn off BP's costs last year had not contributed to lower safety standards.
"We have let people down in our defence of the shore, and we are going to redouble our efforts," he said, adding that cuts did "not have anything to do" with the accident". Read more in this link

Process Safety – Reacting after an incident?

Why do organizations react only after incidents occur? Are they missing the signals coming loud and clear before a major incident happens? My understanding of the situation is that as long as nothing happens, process safety is assumed to be working. If anything does happen and there is major incident, all hell breaks loose and quick fix solutions – like becoming World Class in Safety are immediately thought of. What top management in many organizations are missing out is that there are enough warnings in the form of external and internal audit reports, incident reports and near miss reports that sound alarm bells before a major incident occurs. These signals are not picked up by the top management in time. While becoming World Class by adopting a best in class organizations’ practices is good, there is one important difference between copying a system and copying culture. A system can be copied quickly but culture cannot. In Indian conditions, it is very difficult to change culture quickly. It is a 24 by 7 job that has to be done by top management with unwavering support in times of resource crunches also. While a quarter on quarter growth in profits is demanded by the shareholders, why is not a quarter on quarter growth in safety performance also not demanded? I’m perplexed!!!

Confined spaces

Good handbook by MOEF and others in this link. Please share with all your personnel. Big file, be patient!

Blowout Preventer

What is a blowout preventer? In the Deepwater Horizon oil rig disaster, it is suspected that the blowout preventer failed. Please see Wikepedia's explanation given below:
BOPs come in a variety of styles, sizes and pressure ratings, and usually several individual units comprise a BOP stack. Blind rams are designed to close an open wellbore. Pipe rams seal around tubular components in the well (drill pipe, casing, tubing, or coiled tubing). Shear-seal BOPs are fitted with hardened steel shearing surfaces that can actually cut through drill pipe and tool strings, if all other barriers fail. Since BOPs are important for the safety of the crew, as well as the drilling rig and the wellbore itself, BOPs are regularly inspected, tested and refurbished. Tests vary from daily test of functions of critical wells to monthly or less frequent testing of wells with low likelihood of control problems.Any of these BOPs may be installed underwater, normally with two hydraulic actuators.
Deepwater Horizon blowout
After the Deepwater Horizon drilling rig explosion on April 20, 2010, the blowout preventer should have activated itself automatically to avoid an oil spill in the Gulf of Mexico. Underwater robots were sent to manually activate the mechanism's switch, to no avail. As of May 2010[update] it is unknown why it failed.BP representatives suggested that the preventer could have suffered a hydraulic leak. Gamma-ray imaging of the preventer conducted on May 12 and May 13, 2010 showed that the preventer's internal valves were partially closed and were restricting the flow of oil. Whether the valves closed automatically during the explosion or were shut manually by ROV is unknown.
Please see this link for a pdf version powerpoint presentation of BOP (large file-be patient!).

Organisational culture and Process Safety

I always keep wondering why companies spend so much money on implementing behaviour based safety systems when in real life, what is actually required is the behaviour of top management towards process safety! If top management are able to track and recognize the process safety issues that need attending to, then the organizational culture will be conducive for the success of PSM. A walk around by top management to every nook and corner of their plant once in 6 months is adequate for them to understand the PSM issues!Organizational safety culture must come from the top and it is free to implement!
A recent OSHA report mentions the following:
Since the BP Texas City explosion in 2005, OSHA has counted over 20 serious incidents in refineries across the country.
Last year, OSHA completed an investigation of a naphtha piping failure and release, in which the resulting explosion and fire seriously injured three workers; two other workers, relatively young at 49 and 53 years old, died. One of these two workers was killed in the explosion; the other struggled for 13 days in the hospital before dying from severe burns. Within the unit where this rupture occurred, OSHA discovered multiple pipes that were operating below their retirement wall thickness. In fact, the very line that ruptured had previously ruptured and had to be replaced a decade earlier. As this tragedy makes clear, this type of breakdown maintenance is simply unacceptable. Good mechanical integrity programs are absolutely essential to safe refinery operation.
In 2007, water freezing in liquid propane piping resulted in a jet fire and a rapid evacuation of the entire refinery. Three workers, aged 33, 35, and 42 were seriously burned and hospitalized. Investigators found that a Process Hazard Analysis team had recommended installing remotely operable shut-off valves, yet the recommendation was improperly closed as "complete" by the previous owner. In fact, the valves had not been installed at all. The lack of these shut-off valves impeded workers' ability to control the propane release before it ignited. The refinery learned a hard lesson: It is essential to rigorously follow up on PHA findings to ensure that hazards are adequately controlled. Failure to abate serious hazards can have deadly consequences.
In 2008, at another facility, an explosion in a hydrocracking unit blew the head off a process water filter. The debris struck and killed a foreman; he was 53 and had been with the company for 30 years. OSHA's investigation revealed that an inadequate start-up procedure had allowed hydrogen gas and air to accumulate in the top of the filter where it was likely ignited by pyrophoric deposits. OSHA learned that some operators had recognized the hazard and used an undocumented alternate approach that was actually safer, but the procedure had never been updated to incorporate the safer practice. The result of following the faulty procedure was a violent explosion and the needless death of a refinery worker ? and a reminder that having safe, complete, and accurate operating procedures is essential to safe operations in process units.

Facility siting and hazardous chemicals

Greenpeace has sent a blimp over a chemical plant in Delaware, as part of a worldwide campaign to eliminate toxic chemicals. Their focus is on toxic chemicals that could spread in an airborne plume if released suddenly by an accident or terrorist attack. The article mentions that "Federal risk management reports indicate that up to 660,000 people live in potential “downwind” areas at risk in the event of a sudden, complete release from one of the 90-ton chlorine tank cars routinely parked at Edge Moor in east Wilmington.A similar accident at the Chambers Works operation, near the Delaware Memorial Bridge, could endanger 2 million people, by federal estimates".
In India, the problem is more acute.Residential dwellings are allowed to come up in the no man zone surrounding hazardous chemical factories.
Read the full article in this link

Cyclone Laila and Headcount procedures

Today's Times of India carries an article mentioning that cyclone Laila uprooted one of the anchors of the ONGC oil rig Sagar Vijay in the Bay of Bengal, thus destabilising the rig. The article also mentions that ONGC could not give the exact number of people on board at the time of the incident.How robust are your headcount procedures? Test them in surprise tests. During mock drills everything is hunky dory but when an emergency strikes, are your systems telling you the exact number of personnel inside your facility? A proper head count system prevents body counts.
When I worked in the Middle East, I was also a volunteer firefighter for the plant firefighting team. We had an elaborate head count system for firefighters also, to ensure that all firefighters are accounted for. It is better to plan for the worst.It does not cost much but can save lives!

Dust explosions and vacuum cleaners

The CSB has been doing a great service by increasing awareness about dust explosions. Dust explosions can occur in sugar, sawdust, coal, and in fact anything that is combustible including combustible metals. Housekeeping plays a very important part in eliminating dust in the work area. Industrial vacuum cleaners are available to do the job safely. One such cleaner is given in this youtube link. I am not endorsing their product but I thought that the video was a good one!

Hydrogen incidents

Click here for the site. This site is a useful site for incidents connected with hydrogen. For those of you dealing with this dangerous gas, these incidents will help you understand its dangers. Hydrogen is handled in refineries,ammonia plants and chlor alkali industries.

Blowing of natural gas lines

Finally the CSB has released a statement about natural gas blowing of pipelines. A survey has been conducted by CSB. "According to the survey, using natural gas to clean pipes remains the most common single practice in industry, employed by 37% of respondents. The other respondents reported using nitrogen, which is nonflammable, or inherently safer alternatives such as air, steam, or cleaning pigs. On February 25, 2010, eighteen days after the explosion at Kleen Energy, the CSB stated that natural gas blows were “inherently unsafe” and urged industry to seek alternatives".
Even last week, I had warned a natural gas user to prevent the blowing of lines with natural gas itself instead of using nitrogen. Read more of the CSB statement in this link.
Read my earlier post on the topic in this link.

Confined spaces are deadly

Time and again, we realize how deadly a confined space can be but lives continue to be lost. The number of deaths we have read in newspapers involving conservancy workers entering sewers and asphyxiated by hydrogen sulfide are countless. In chemical plants,refineries,food industry, transportation industry, power generation, pulp, paper and other industries, deadly gases can accumulate inside confined spaces. No wonder they are called silent killers. CO, H2S, CO2,CH4, Ammonia, paint,thinners, solvents, nitrogen are all deadly inside a confined space. Reactions that take place inside confined spaces including fermentation can make the confined spaces deadly.
Treat your confined spaces with respect. Have a proper confined space entry permit that is enforced.Read some of the accidents in confined spaces in this link
The CSB video on hazards of nitrogen in confined spaces can be viewed in this link.
Read an interesting article on confined space threats to farmers in this link!

Oleum release incident - CSB findings

The CSB has released its final report on the uncontrolled oleum release from INDSPEC Chemical Corporation in Petrolia, Pennsylvania, which forced the evacuation of three surrounding towns in October 2008.Oleum was released when a tank transfer operation was left unattended during weekend operations and an oleum storage tank overflowed.
The CSB investigation has determined that the normal power supply for the three oleum transfer pumps was equipped with a safety interlock, which would automatically shut off the flow of oleum when the receiving tank was full, thus preventing a dangerous overflow. However, the oleum storage building also had an auxiliary or 'emergency' power supply that had been installed in the late 1970s. It was originally intended as a temporary measure to keep the pumps functioning during interruptions of the normal power supply but eventually the emergency power supply became a permanent fixture. Facility management never installed interlocks for the emergency power and written operating procedures did not address how or when the emergency power supply should be used.
The CSB case study report identifies four key safety lessons for companies:
- In the 1980s, the facility changed the structure of the emergency power supply from temporary wiring to permanent conduit. The facility did not evaluate the significance of this change.
- The facility installed the emergency power supply without the engineering controls that already existed on the normal power supply.
-The facility's storage system design required operators to transfer oleum on the weekend to ensure operations were unaffected during the week. Operators used a work practice developed years earlier to transfer oleum using two pumps concurrently. This work practice was never recorded in written operating procedures.Management must remain vigilant in evaluating how work is actually performed.
- The facility never included information on the emergency power supply in piping and instrumentation diagrams and written operating procedures. Personnel hazard assessment (PHA) teams were therefore unable to evaluate the consequences of emergency power supply use.
Read the report in this link

Importance of Near misses in process safety

A newspaper report (Hindu dated 14.5.10) indicates the following points about the oil spil in the Gulf of Mexico:"Oil executives ignored warning signs in the hours before the Deepwater rig explosion in the Gulf of Mexico last month, a congressional hearing heard on Wednesday.
In a second day of hearings, the U.S. House of Representatives' energy and commerce committee said documents and briefings suggested that BP, which owned the well; Transocean, which owned the rig; and Halliburton, which made the cement casing for the well, ignored tests in the hours before the 20 April explosion that indicated faulty safety equipment".
No major incident occurs without warning. Do not ignore your near misses!Read more of the article in this link

Bhopal Gas disaster and the recent BP oil spill

A newspaper report indicates that the verdict on the Bhopal Gas Disaster court case will be delivered on June 7th,2010 in a Bhopal Court in India. During the trial, 178 prosecution witnesses and 3008 documents were examined. The disaster happened in 1984 and the wheels of Justice move slowly! Cut to the recent BP oil spill in the Gulf of Mexico last month. Already the US house of representatives has begun an inquiry to pinpoint responsibility and accountability. In the Bhopal gas disaster, the entire liability was settled for 470 million US dollars. In 1989 a oil tanker called Exxon Valdez spilled oil in Alaska and the damages reportedly paid by Exxon was US dollar 5 billion. Exxon reportedly paid US dollar 940 each for every penguin that was contaminated with oil and had to be cleaned. In contrast, the Bhopal gas victims damaged for life received US Dollar 500 each!(Source: Greenpeace report).
Lets us wait for the verdict in the Bhopal Gas Disaster!!

Crisis management and the media

The BP oil spill and the media coverage about it throws up the powerful role of the internet in disseminating information. Companies must be fully prepared to handle such crisis. BP is also using twitter to keep the public updated on the oil spill containment efforts. In India, most of the the media coverage of any incident borders on the paranoid and is aimed at getting high viewership ratings at that instant. The Jaipur oil depot fire is a classic example of this. Companies must have a crisis management plan ready and test it periodically.

BP oil spill videos from youtube

Please see these videos for info on the BP oil leak.
1.Oil spill
2.Containment

Process Safety and Leadership

After the BP Texas disaster in 2005, the then CEO of BP Lord John Browne resigned and Mr Tony Hayward took over. An article mentions the following: 'When Mr. Hayward took over BP's leadership from John Browne three years ago this week, the company was at one of the lowest points in its history: badly run, accident-prone and accused in the aftermath of a deadly explosion at its Texas City refinery of putting profits before safety. Mr. Hayward turned BP around, boosting production, cutting costs and significantly reducing on-the-job injuries. Mr.Hayward set about radically simplifying the company and cutting costs. Senior executives were cut by a quarter. In all, 6,500 people, or just under 10% of its work force, lost their jobs. Last month, he was confident enough to talk of an irreversible "change of culture" at BP.None of that seems to matter now, as BP heads into the crisis grinder that has chewed up big names like Toyota and Goldman Sachs. And with about 5,000 barrels of oil leaking from the damaged well each day, Mr. Hayward knows it".
Read more about this interesting article in this link.
Read about the mitigation efforts in this link

Process safety information and BP incident

A number of articles are going around on the BP oil spill incident. In one of them, a whistleblower is supposed to have raised safety concerns about BP Atlantis, the world’s largest and deepest semi-submersible oil and natural gas platform. In this article it mentions the following "It was then that the whistle-blower, who was hired to oversee the company’s databases that housed documents related to its Atlantis project, discovered that the drilling platform had been operating without a majority of the engineer-approved documents it needed to run safely, leaving the platform vulnerable to a catastrophic disaster that would far surpass the massive oil spill that began last week following a deadly explosion on a BP-operated drilling rig.
BP’s own internal communications show that company officials were made aware of the issue and feared that the document shortfalls related to Atlantis “could lead to catastrophic operator error” and must be addressed.“The risk in turning over drawings that are not complete are: 1) The Operator will assume the drawings are accurate and up to date,” the email said. “This could lead to catastrophic Operator errors due to their assuming the drawing is correct,” said Duff’s email to BP officials Bill Naseman and William Broman. “Turning over incomplete drawings to the Operator for their use is a fundamental violation of basic Document control, [internal standards] and Process Safety Regulations.” Read more of this article in this link.

BP Oil Spill

The latest BP oil spill in the Gulf of Mexico could turn out to be bigger than the Exxon Valdez spill. The President of the US himself has flown to Louisana for a first hand look. One would have thought that after the BP Texas Disaster in 2005, many checks and balances would have been put to prevent another disaster. We will have to wait and see the results of the investigation...
See photos of the spill in this link

Process safety in batch operations

What goes around comes around! As far as process safety incidents in batch process go, I sometimes despair whether we will ever learn from previous incidents. Last year I had investigated some batch process incidents, the causes of which are very very familiar - incompatibility,scale up issues, heat removal issues, MSDS issues and raw material storage issues. For those of you working in the batch process industry, the UK Chemical Reaction Hazards Forum is a good place to get information on batch incidents. Share these incidents with your operating personnel and check whether it could happen in your organization. For further details go to this link.

What I learnt in Process Safety – A tribute to my senior managers at Madras Fertilizers Ltd

32 years ago, I joined the ammonia plant in Madras Fertilizers as a graduate engineer trainee and then went on to be shift in charge and assistant manager in the ammonia plant. The lessons I learnt in process safety from the senior management* are still fresh in my mind. There was no PSM system, no ISO 14001, no OHSAS 18001, but in the ten years I was there, there was no serious process safety incident!
The senior management then were all experts in plant operation and maintenance – you could not fool them! Their decisions were taken appropriate to the risk involved and clearly communicated. They also made sure that critical jobs which had a process safety issue were always supervised by them by giving clear instructions and follow up. This way we knew when we were going off track and correct ourselves before anything happened. They were true “managers” – who played the fine line between process safety and production with such a finesse, you could not but admire and learn from them.
We did take a lot of “process safety risks” when there was a situation, but it was a calculated and clearly communicated risk – with the result, we were always under control.

Cut to today – Today in many plants, there are distinct gaps between what senior management think what is going on as far as process safety is concerned and what is actually happening at the ground level. Why is this happening? My own understanding of the situation leads to the following:

1.Some of the senior management do not have an understanding of the plant – they may be qualified MBA’s but in a chemical plant, what matters most at senior management level is their conceptualization of key process safety risks!
2.Many Senior management do not want to hear “bad news” related to process safety but welcome “bad news” related to sales and profits. I compare the senior management I started my career with many of the senior management today – the difference is that “bad news related to process safety” used to be ferreted out by the senior management I worked with, even though I may think it was not necessary to tell them!
3.Many boards of directors in present chemical companies do not have a clear understanding of the difference between process safety and occupational health and safety.
4.Senior management are led astray by the numerous certifications of ISO 14001/OHSAS18001 etc. leading to a false sense of complacency.
5.Many of the reactions of management today after a process safety incident are of a knee jerk reaction. A comprehensive long term approach is lacking. Everyone wants to safeguard their remaining time with the organization!

*I pay a strong tribute to my former senior managers at MFL: (Late) Mr P.N.Arunachalam, Mr Jacob Eapen, Mr N.Gajendran and (Late) Mr S.Rangaiah

Process safety and security

Dow Chemicals has beautifully pictured their "integrated approach to chemical security management" on their website in this link
I wonder when India will really wake up to chemical security threats and bring in legislation and enforce it. With the threats of naxalites and external terrorists and the fact that a number of hazardous chemical units are based on the coast,it becomes imperative that a coordinated approach to chemical plant security is implemented. Let us not wait for an attack to happen!

Fire at Pharma Plant at Ankleshwar

An article in economic times mentions the following "A fire at pharmaceutical major Wockhardt’s Rs 300-crore Ankleshwar facility damaged one of its six manufacturing plants. It will take six months to recommission the unit, a company spokesman said.
The incident adds to the woes of a debt-laden Wockhardt, which had defaulted on payment of its overseas convertible bonds last year, and was forced to accept a corporate debt restructuring package that included sale of some company assets". Read the full article at this link.
While the cause is being investigated, it must be remembered that when companies go under loss, it requires a great effort to maintain safety systems.

Process safety - uncomplicate things!

In the Times of India April 28,2010, an article mentions that powerpoint is the US military's new enemy - A general is reported to have said "When we understand that slide (seen above), we would have won the war"! The same general has said that "Its dangerous because it can create the illusion of understanding and the illusion of control". Now what does this have to do with process safety? It is the same as the complicated powerpoint! Just because you perform a complex PHA, SIL study or conduct a management of change study does not mean everything is in control. I have seen many incidents occur even though such studies were conducted. Be practical while conducting these studies and do not go overboard!

Process Safety and Overflow protection

I read a nice article on high integrity overflow protection. In the article there is a statement that one of the key requirements of a high integrity overfill protection self certification program is "Acknowledged competency to review the design aspects of both mechanical- and/or electrical-components including component failure modes, fail-safe vs. fail-danger, any claimed automatic diagnostics, and internal redundancy in order to produce a quantitative failure rate (This number will eventually plug into calculations that determine if a particular design meets its defined SIL requirements".
I have observed many SIL (Safety Integrity Level) studies where the above competency becomes suspect. Many organisations think that just because they have completed a SIL study, they are safe. A SIL study starts from a good PHA (Process Hazard Analysis) study and here itself, if the competency of the people participating in the study is inadequate, then "garbage in, garbage out".
In many cases, there has been an overkill of recommendations from a SIL study, leading to the organization spending money unnecessarily.

Read more of the article in this link

Process Safety in LPG storage

At Vishakapatnam, the storage of LPG is being done in underground caverns as well as mounded storage. The underground storage facility is an engineering feat by itself.
"A safe method for the storage of large quantities of LPG is Cavern storage. In this method, LPG is stored in mined/artificial caverns at a depth of 160 m to 200 m below the sea level. Cavern is subjected to an external pressure by the saturated rock around the surface, which facilitates in the containment of LPG. The cavern storage is economical only for storage capacities above 50,000 mt and is feasible subject to the suitability of the rock, proximity to the ports with infrastructure for LPG receipt".
A nice description of the cavern is given by the company in this link.
For a draft paper on its construction and other details, please see this link.
HPCL, Visak has also constructed mounded storage of LPG. An article mentions that "Mounded storage of LPG i.e. creating a sand mound around the LPG storage vessels, which are placed above the ground level, is now increasingly being considered by HPCL as the best solution for protecting LPG vessels from BLEVE.
The mounded storage system provides the following advantages:
LPG stored in the form of mounded storage totally eliminates the possibility of BLEVE. The sand cover of 1 metre, which provides natural insulation from external heating, is adequate to outlast any fire in the surrounding areas. Water cooling systems are not required.
In addition, the mounding material provides good protection against most of the external influences like flying objects and pressure waves from explosions".
Read more of the article in this link

Process Safety Information

I was reading an article where it mentions that a company in the USA was penalized for not having proper process safety information. Specifically the article mentions the following:
"The piping system was not provided with labels to indicate the contents or direction of flow. The proposed penalty is $5,600.

• The process safety information pertaining to the equipment in the process did not include the piping and instrument diagrams. The proposed penalty is $5,600.
• The process hazard analysis did not address the hazards of the process. The proposed penalty is $5,600.
• The standard operating procedures for the anhydrous ammonia rail car offloading rack did not address how the operator was to inspect the coupling or ensure that the coupling was serviceable. The proposed penalty is $5,600.
• The employer did not establish and implement written procedures to maintain the ongoing mechanical integrity of process equipment. The proposed penalty is $5,600.
• The ammonia offloading rack, including the coupling on the liquid ammonia offloading arm, had threads that were worn, resulting in the coupling coming apart, releasing more than 8,000 pounds of ammonia.
• The alarm system for evacuation voice alert was unintelligible in all locations within buildings on the plant site. The proposed penalty is $2,400".
Read the complete article in this link.

Process Safety - Effects of a Natural gas line rupture

Belgium's worst ever industrial disaster occurred on on July 30, 2004. At about 8:30am local time, people felt a strong smell of gas. The gas was leaking from an underground natural gas pipeline. Emergency responders arrived and were clearing the area when the gas caught fire and exploded. The official death toll was reported as 24. Please see graphic descriptions of the incident and its effects in this link.

Process Safety - oil rig explosion

An explosion has been reported at an oil rig contracted by BP. It appears that the CSB is considering investigating this incident. Please read full article in this link.

Process Safety and the Union's view

I read an interesting article about Process Safety and behaviour based safety and the unions perspective on it.In India, behaviour based safety is being bandied about by many as the ultimate solutions to all problems. Organisations have to understand that not only is the worker's behaviour responsible, it is also the behaviour of the top management that is also responsible for process safety!

Read the full article by the Steelworkers  union in this link

Process Safety and Albert Einstein!

I read an interesting quote by Albert Einstein - " Only two things are infinite - the universe and human stupidity. And I am not so sure about the former."
Now how does this apply to Process Safety? Time and again, we see human errors and human factors being the root cause of incidents! The incidents I investigate tell me that Einstein is laughing in his grave! Will we ever learn from our past mistakes?
Lets wait and keep our fingers crossed.

Process Safety - Fire at Ankleshwar plant

A fire occurred at a pharma company in Ankleshwar. "The blaze at pharmaceutical major Wockhardt Ltd’s factory in Ankleshwar on Saturday was brought under control today. Additional fire tenders had to be called in from Vadodara, Ahmedabad and Surat and kept on standby.
“The fire was almost brought under control last night, but due to leakage of certain chemicals, there was re-ignition in some parts of the factory. The fire was completely extinguished by Sunday evening,” said Manoj Kutariya, Manager, Fire Safety, Disaster Prevention and Management Centre. . Read more in this link.

Just last month, there was a fire in another unit at Ankleshwar. I had visited the Disaster Prevention and Management Center about 6 months back and I was very impressed with the facilities and the team headed by Mr Manoj. Kudos to them.

Process Safety - OSHA penalises plastics plant

OSHA has penalized a plastics plant for deficiencies. The article says "The violations include the company's failure to properly contain polyvinyl chloride dust particles; evaluate contractors' safety programs and procedures; properly inspect process equipment; provide fire retardant clothing for employees; require employees to wear adequate eye protection with side shields; provide proper training; and provide employees with an infirmary, clinic, or person trained in first aid. Additionally, inspectors identified hazards involving a lack of machine guarding; a deficient process safety management program; inadequate lockout/tagout procedures for energy sources; and unguarded machinery, floor holes, and walkways. OSHA issues a serious citation when there is substantial probability that death or serious physical harm could result and the employer knew, or should have known, of the hazard".

It is interesting to note that the investigation was launched on the basis of a complaint of an employee! Read the full article in this link.

Process Safety - Another day, another blast!

On Good Friday, another blast occurred in a refinery in the USA. The CSB will be investigating the incident but it appears that the CSB is now having its hands full with its investigators currently investigating other incidents. If this is the trend in the USA where PSM is mandatory, we must be very careful in India!

"A Washington state oil refinery hit by a deadly blast and fire early Friday was recently fined for safety violations amid what federal watchdogs call a troubling trend of serious accidents at refineries.
Three men died at the scene and two women died later at a Seattle hospital. Two other men were hospitalized with major burns over the majority of their bodies. It was the largest fatal refinery accident since a 2005 explosion at a BP American refinery in Texas killed 15 people and injured another 170.The Good Friday holiday blast rattled windows more than a mile away and has the most recorded fatalities since 15 workers were killed in a BP Plc incident in 2005 at that company’s Texas City, Texas, operations.
The Tesoro incident occurred as members of a seven-person crew were cleaning a heat exchanger in a unit handling naphtha, a volatile liquid chemically similar to jet fuel, Westfall told reporters.

The blast shook houses and woke people miles away, shooting flames as high as the refinery’s tower before the blaze was extinguished about 90 minutes later.
The blast occurred in a unit that was in the dangerous process of returning to operation, turning up heat and pressure, said Tesoro spokesman Greg Wright".

CSB Chairman and CEO John Bresland said, “The CSB has eighteen ongoing investigations. Of those, seven of these accidents occurred at refineries across the country. This is a significant and disturbing trend that the refining industry needs to address immediately.”

Read the complete article in this link

Process Safety – “Aging pipe fittings and plant mismanagement – a lethal combination”

An article mentions about aging pipe fittings and mismanagement. It mentions “Even the highest specification pipe fittings will fail, if they are not backed up with competent system management and the correct hardware. Too often, flanges are expected to carry more than their fair share of responsibility in preventing leaks and accidents”.
I have investigated a number of incidents where this exact reason has been the cause of a failure. This is a disturbing trend and it will help if plant management revisit their mechanical integrity program.
Read more of the article in this link

Process Safety – Shades of Bhopal?

“Bayer CropScience has agreed to pay a $143,000 fine to resolve safety citations stemming from a fatal explosion at its Institute plant in 2008.
A congressional committee report said the explosion came close to compromising a tank holding methyl isocyanate, or MIC. An MIC leak from a former Union Carbide plant in Bhopal, India, in 1984 killed thousands of people.
Union Carbide once operated the West Virginia plant, now owned by Bayer CropScience. MIC is used in the manufacture of insecticides at four different units at the sprawling 465-acre plant. One unit, the methomyl unit, was damaged in the explosion”.

Read the full article in this link

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!