Where does the buck stop in Process Safety Management?

I have been viewing the numerous developments in process safety in India with great interest. The Indian Chemical Council has taken a big interest in Process Safety and is collaborating with the Center for Chemical Process Safety of the US. While it is good that a great awareness of Process Safety Management is being created in India, where does the buck stop as far as Process Safety Management goes? The composition board of directors of many chemical organisations in India are changing with fewer and fewer companies having technically qualified people at the helm.With due respect to the immense experience that other directors bring, I see an erosion in technical competence at the board level. While risk based process safety does bring in process safety metrics to the board's attention, it needs technical competence to analyse these metrics. Ultimately, the culture of the organisation trickles down from the decisions that the board takes. What is the long term solution to this issue? No amount of management systems is going to avoid a catastrophic incident. They will warn you adequately before a big incident happens, but unless someone at the board level is competent to analyse these warnings, you cannot prevent the incident. It boils down to basic human behaviour. Is a director on the board going to pay more attention to what another technically competent director is saying, or to the various process safety metrics he sees displayed but may not fully understand? I leave it to you to decide...
Meanwhile read an interesting article in the Fortune magazine in this link.

Drum bursting hazard - readers innovation

In my earlier post , I had mentioned an incident on the dangers of pesticide technical drums bursting when placed in a hot box or steam heated bath. A couple of readers Mr P.Kadhiravan and Mr P.Thulasiraman of Coromandel International Limited have devised a simple pressure relief system for the technical drums which they place in a steam bath for melting. Their pressure relief device is screwed on to the drum in the bung area after removing the drum cap. A photo of their innovation is shown. Kudos to them! And thanks to them for sharing this information.

Share your incidents!

I thank readers of this blog for their continued support. I request readers to send in short descriptions of process incidents they know, to me at bkprism@gmail.com for publication in the blog. I will give the reader credit for the input. The company's name need not be mentioned.Thanks in advance!

Enforcing Process Safety Management

I always wonder that even in the US where PSM is mandatory and companies face stiff fines, there are always violations taking place. Recently OSHA has proposed to fine a seafood company a total of $279,000, for deficiencies in its process safety management program. "The inspection identified other PSM hazards that resulted in 12 serious citations, with $84,000 in proposed fines. These conditions included failing to update process safety information, conduct an incident investigation of a January 2001 ammonia leak, certify or evaluate the PSM program every three years as required, establish and implement procedures to maintain changes in the process, and provide and document employee training".
Read the full article in this link

Engineering control to avoid deaths

The recent train accident at Sainthia station when a speeding train rammed into a stationary one,has raised many questions.An excellent article in Forbes India magazine describes the various engineering controls that are available to prevent such accidents. The article mentions that "There is a range of technological solutions that can remove the scope for human error and make the system fool-proof. The Indian Railways have experimented with a range of solutions to improve its safety record, but none of them has been scaled up nationwide either due to the lack of budget or simply because the powers-that-be had other priorities. When asked, a senior executive in the Indian railways, in charge of technology implementation, prefers to maintain a stoic silence on the issue. Former railway officials, however, are far less sanguine. “The job must be ruthlessly done and the management must not shy away from shedding blood,” says a former Chairman Railway Board who did not wish to be quoted".
In the chemical process industry also, I observe many cost cutting initiatives affecting engineering controls. As long as nothing happens, nobody dies!
Read the full article in this link.

Gas leak from storage tank

Thanks to Abhay Gujar for sending this news. The Hindustan Times has reported a gas leak from a chemical company in Kalyan. Another article reports that the gas that leaked was Hydrochloric acid.
Read more about the incident in this link
The MSDS of Para Toluene Sulfonyl Chloride which was reportedly stored in the tank, indicates that it is water reactive. Read the MSDS in this link.

Safety valves and runaway reactions

I was participating in a HAZOP study of a reactor where a runaway reaction was possible.There was a serious discussion about the reaction kill system, when one of the participants asked what the operators will do if a runaway reaction occurs. The operations chief who was participating immediately answered - run away!He had witnessed an actual runaway reaction in which the reactor started rumbling, gaskets blew, safety valve lifted,and the operators ran away. Know the design basis of your safety valves. This is important for management of change and for writing operating procedures.

Strong oxidiser causes oil pipeline blast

A new report indicates that the pumping of a wrong chemical into a pipeline that had just completed unloading of crude oil. The report states that "An investigation has found that a desulphurising chemical was mistakenly pumped into pipelines after a tanker had stopped unloading crude at the port city of Dalian last Friday, triggering the explosion, the State Administration of Work Safety said in a statement posted on its website.The 0.9-meter-diameter oil pipeline exploded at 6 pm on July 16, triggering a smaller adjacent pipeline to also explode, the statement said.
The explosion occurred as workers from the Shanghai-based QPRO Inspection and Technical Service. continued to inject desulfurizer into the pipeline after the 300,000-ton tanker had finished unloading its oil at 1 pm.
Produced by the Tianjin-based Huishengda Petroleum Technology, the desulfurizer was strongly oxidizing, according to the statement".
Read more of the article in this link
For a translation in English of the same accident, read about "Management of Confusion" in this link!.

Update on "Spraying of pesticides into AC ducts - possible cause of incident"

The pesticide involved in the incident I had mentioned in my earlier post is reported to be malathion. Read the MSDS of malathion in this link

Management systems - on paper or by commitment?

I have always been of the view that management commitment is something that cannot be spelt out on paper that we can expect top management to follow. Paper based management systems will remain on paper unless top management throws its full commitment behind it. Commitment is intangible. It is seen at the ground when decision are taken by managers that have an effect on process safety.Top management are also human. They also can succumb to pressure from stakeholders. I will give you an example. A leading chemical manufacturer I visited had all management systems in place and certifications.During my field visit, I observed a safety valve on an equipment isolated as it was prematurely lifting (popping) and causing loss of production. This safety valve had no redundancy. When I spoke to the Plant manager,he mentioned that all systems remain on paper and when the actual decision on safety is to be taken, he is expected to take action to maintain production targets!
Interestingly, BP, after the recent oil rig disaster itself is of the opinion that management systems alone cannot control risks. I am quoting from the article: BP said "there can be no assurance" that a major global deployment of its in-house Operating Management System would identify all risks or provide information on the right actions to take when things go wrong. The rollout will be complete this year.OMS was introduced as a key safety step following the large explosion in BP's Texas City Refinery in 2005, which killed 15 workers and injured 170. The system is being implemented across BP operations in locally-tailored modules, following global standards. It is now in all US sites and will be rolled out by the end of the year to the remaining few sites elsewhere that do not yet have it.
The OMS system, described by BP as the "cornerstone" of its safety efforts, was developed by BP in-house, built around Microsoft SharePoint and Performance Point. It helps integrate local standards and management systems, set priorities, define processes and measure performance, and is accessible on BP PCs as well as mobile devices used by engineers on the rigs.
But yesterday BP said: "Even after implementation of OMS has been completed, there can be no assurance that OMS will adequately identify all process safety, personal safety and environmental risk or provide the correct mitigations, or that all operations will be in compliance with OMS at all times." Read the full article in this link.

What is the solution to this problem? Top management should pay attention to external safety audits as they indicate things that may not be spotted by internal audit teams. I have also seen some managements asking the external auditors to tone down their findings. Now this is hara kiri!Here the moral ethics of consultants and auditors come into play. Whatever certifications or management systems the company employs, there must be a threadbare audit of decision making and management's tracking of safety management systems. Its only the acceptance of facts that will prevent an incident.

Spraying of pesticide in AC ducts - a possible cause of an incident

The Hindu Newspaper has reported that employees in a manufacturing unit had to be hospitalised due to the possible spraying of pesticides into an AC duct.The root cause is still being investigated. This raises a larger question of product stewardship. Pesticide Manufacturers in India do post all the warnings in their product but how do we ensure that they are all followed?
Read the article in this link.

Process safety -Humidity causes an incident!

An incident where humidity was the main cause of an incident involving ammonium persulfate has been reported. The incident occurred in a blender in which ammonium persulfate absorbed moisture and started decomposing. This forced the evacuation of 500 workers. See the MSDS of ammonium persulfate in this link.
Read the article about the incident in this link

Two day Process Safety Management Training at Chennai on August 12th and 13th

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 the participants can implement what they have learnt. 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

Hazardous waste facility explosion report

"A U.S. Chemical Safety Board (CSB) case study released today on the 2009 explosion and fire at the Veolia ES Technical Solutions L.L.C. facility in West Carrollton, Ohio, calls on the industry to improve safety standards covering hazardous waste processing, handling, and storage facilities. The Board also recommended that fire protection codes be revised to require companies to determine safe distances between occupied buildings and potentially hazardous operating areas.
The accident occurred on May 4, 2009, when flammable vapor was released from a waste recycling process, ignited, and violently exploded. The blast seriously injured two workers and damaged 20 nearby residences and five businesses. CSB investigators found that the north wall of the lab and operations building – where the victims were injured –was less than 30 feet from the waste recycling processing area where the flammable vapor was released.
CSB Chairman Rafael Moure-Eraso said, “This accident should not have happened. Our report notes that OSHA cited the company for inadequate attention to process safety management practices in the handling of flammable liquids. But in case of an accident, I believe it is absolutely critical that buildings at chemical facilities be sited safe distances from process equipment to maximize the safety of workers. We are making recommendations that would help ensure that operating areas with occupied buildings such as control rooms be sufficiently separated from process areas containing flammable liquids and gases that have the potential to explode.”
Read the report in this link.

Labs are as dangerous as process plants

Do not ignore safety in laboratories when concentrating on process safety. Many incidents occur in labs and R & D facilities. An incident in an university lab killed a girl when the pyrophoric chemical she was handling ignited. Investigate any incident in the lab or R & D with the same focus as an incident in the plant. Read more of the unfortunate incident in this link.

Update on Phosgene hose leak incident

A news report indicates that OSHA has cited DuPont and proposes fines for the phosgene hose leak incident that killed one employee. It is also interesting to note that one of the factors for the leak was physical corrosion below the manufacturers sticker label on the failed hose.
"OSHA said DuPont failed to:
-Properly inspect piping used to transfer phosgene.
-Perform a thorough process hazard analysis for its phosgene operation.
-Train workers on hazards associated with phosgene.
-Thoroughly inspect all high-risk sections of piping used to transfer oleum.
-Properly install energized electrical conductors.
The agency issues a serious citation when there is substantial probability that death or serious physical harm could result from a hazard the employer knew or should have known about".
Read more in this link

Gases can be deadly - Blast in coke oven

Thanks to Abhay Gujar for sending me this news to share with you.An explosion in a coke oven battery near Pittsburgh has reportedly injured 20 persons. "To make coke, coal is baked in special ovens for hours at high temperatures to remove impurities that could otherwise weaken steel. The process creates what's known as coke gas — made up of a lethal mix of methane, carbon dioxide and carbon monoxide".. Read more of the accident in these links:
Explosion At Pa. Coke Plant Under Investigation
Experts: Coke plants full of dangers, can be safe

Two people die in fertiliser plant fire

There are news reports that two people died and two were injured in a fertilizer plant fire in Libya on 11.7.10 when maintenance work was on. Work permit systems are enforced to prevent such loss of lives and I will post more details if I get it.

Cabon Monoxide - a deadly gas

A recent incident in the Durgapur steel plant highlights the danger of Carbon Monoxide (CO). Carbon monoxide is produced in ammonia, methanol plants, in refineries and in blast furnaces. Any improper combustion of fossil fuels will also lead to the generation of CO. CO binds with blood hemoglobin to form carboxyhemoglobin. Carboxyhemoglobin cannot take part in normal oxygen transport, thus reducing the blood’s ability to transport oxygen. Depending on levels and duration of exposure, symptoms may include headache, dizziness, heart palpitations, weakness,confusion, nausea, and even convulsions, eventual unconsciousness and death.Recently in the newspapers, there have been incidents of fatalities in cars where occupants have kept the AC running when the car was stationary. Leaks in the exhaust system allowed CO to enter the passenger cabin thus killing occupants. Read the report of the incident at the Durgapur steel plant in this link.

Public perception of Process Safety in India

Thanks to the media and internet and the demographics of India, a large number of the younger Indian generation are aware of the hazards of chemical industries and the importance of process safety management. In fact, the Bhopal disaster court judgment has raised awareness about the hazards of chemical industries. What can industries,industry associations and the Government do about it? I have a one word answer - transparency. Transparency in conduct of operations, transparency in incident investigation and sharing of incidents, transparency in law enforcement, transparency in environmental assessment processes, the list goes on.... The transparency International website indicates that for 2009, India has a corruption perception index of 3.4 on a scale of 1 to 10 where 1 is the most corrupt. We are at the bottom of the pyramid here! What does this have to do with process safety? Though the chemical industry is making an effort to improve safety and the public's perception of chemical industries, it will take a huge effort to really change perception. With daily newspaper reports of Government officials being caught taking bribes, a life has no cost in India unless it belongs to an influential person.
The recent Mangalore air crash has brought about some changes in investigating aviation incidents in India. In a similar way, a Chemical Safety Board on the lines of the US CSB (www.csb.gov) needs to be formed. All major chemical accidents need to be investigated independently and the reports be made public through the net.Meanwhile I keep praying that another Bhopal does not take place in India.