6 workers drown in Lucknow Ketchup Factory

Alas, it's happened again. A worker fell into a ketchup tank in a ketchup factory in Lucknow, India. In the process of trying to save her, another 5 co-workers lost their lives. In any confined space entry, the job of the man watch is to call for help if anybody inside needs to be rescued. Train your operators on rescue techniques and most importantly train them to overcome the natural feeling of going inside the confined space without proper protection to rescue a fallen co-worker.
Read more of this incident in this link.

Dangers of chemical reactions

Unexpected chemical reactions are dangerous and can kill.Whenever a new product is envisaged, it must be taken through a proper management of change process, including understanding of process chemistry.Even though this incident happened in 2008, it underscores the importance of knowing what you are doing. Read about the incident in this link.
More recently, another accident occurred at a chemical factory at Ankleshwar where two people died. Read about the incident in this link.

OSHA will not ban Gas Blowing of pipelines

A news article in the Wall street journal mentions the following: "OSHA administrator David Michaels, in a news briefing Thursday, said his agency is putting the power industry "on notice that it is inherently dangerous" to conduct gas blows and he said the industry "must assure worker safety," if it persists.
But he said he wouldn't put an emergency order in place that would prohibit gas blows until the agency studies it further. "We would love to be able to ban it, but we can't," he said.
The chairman of the Chemical Safety Board, which investigated the incident, said Thursday that OSHA's response to the Kleen Energy explosion was insufficient despite it being even though it is the third-largest recommended fine in a single accident in agency history.
"I believe there should be an emergency response to an emergency situation," said Rafael Moure-Eraso, the board's chairman, a former academic.
After the board's probe, big equipment makers including General Electric Co. and Siemens AG said they would tell their customers to substitute compressed air or nitrogen for natural gas. Utility American Electric Power also said it would avoid the procedure based on the board's findings and its own analysis".
Read the full article in this link.

Fire in chemical godown at Bangalore

Thanks to Mr Sritharan for sending the following information:
Please find the news on the fire which broke out in a chemical (solvents and thinners) storage godown in Shivajinagar, Bangalore. The godown was located in a densly populated commercial and residential area. As usual the fire dept says that the godown did not have the necessary license only after the incident and do not have proper procedures to check out these violators.
Also the news reports that the local people started pouring water as soon as they saw the fire without knowing that some water sensitive chemicals can indeed aggrevate the situation. Only the trained fire fighters should handle these types of chemical fires.
Read the news article in this link.

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.

Mnagement systems and Process Safety

The Indian chemical industry is on a path of vibrant growth. Many chemical manufacturing units recognize the need to manage process safety as the consequences of a chemical accident today are enormous. However, organisations also need to realise that management systems alone will not help. Getting certified to ISO 14001,OHSAS 18001 or Responsible Care etc cannot by itself prevent a disaster. It is the Management of these systems that will prevent one!By this I mean how does the top management utilise these systems to prevent a disaster? In many organisations in India I have observed that when a key top management person like the CEO changes,and a new CEO arrives,these management systems may go for a toss if the new CEO was not as focused on them as the previous one! How do we ensure continuity of effective implementation of systems? My answer is that profits should never override process safety and other management systems. This is easier said than done! Read an interesting article in this link.

Chlorine Safety

The Aditya Birla company has a nice practical presentation on chlorine safety which you can access through this link.

Missing incident investigation deadlines

In many process safety audits , I keep observing that detailed investigation of incidents keep missing their deadlines. This speaks of the culture of the organization. When we don't learn from incidents, we will repeat them. I was reading a news item in Times of India which mentions about the investigation of the Mangalore air crash. I quote from the article " What happens when Directorate General of Civil Aviation (DGCA) officials violate their own rules? Nothing. It's been over a month and a half after Mangalore air crash and no preliminary investigation report has been released yet, though the country has a rule that puts a 10-day deadline for filing one. Little wonder, then that the rule concerning accident/incident investigation is hardly known in the aviation industry as it has almost always been violated.
If this can happen in the Indian aviation industry, I am worried!!!
Read the full article in this link.

Ticking time bombs!

The incident of old chlorine gas cylinder leak at Mumbai Port Trust raises a question. How many such ticking time bombs are still there? The Indian Gas cylinder rules are well written but I have observed that people give scant respect to gas cylinders. Domestic LPG cylinders being tossed about is one case. In the Mumbai Port Trust incident the FIR has been raised against "unknown persons". Isn't the port responsible for all hazardous cargo in its facility? I quote a NDTV news item "That is supposed to be an empty cylinder of chlorine, but sometimes you have residual chlorine which remains in the cylinder and that leaked out," explained Rahul Asthana, the Deputy Chairman of the Mumbai Port Trust.
How does one know it is empty unless it is confirmed? How did residual chlorine remain in the cylinders??
A friend of mine also points out that many chlorine cylinders are used in thermal power plants and municipal water treatment plants and that they store a large number of chlorine tonners. I am only reminded of Dr Trevor Kletz's statement " What you don't have cannot leak!"
Read the NDTV article in this link.

BP Oil Spill - an interesting take

I read an interesting article in Forbes.com where the writer mentions the following:
"The job of senior executives (or politicians and regulators) is to think the unthinkable. While few risks truly justify a "never failing" attitude, those that do should follow my five reliability principles:
1. Multiple things must line up before failure can occur (catastrophic failures are extremely rare).
2. Junior management error is the most frequent root cause. Why protect against something that probably won't happen?
3. Very carefully control configuration changes. In BP's case the drilling rig was being disconnected at the time of explosion.
4. Look for unintended interactions between adjacent systems. For instance, unexpected freezing conditions prevented the first BP well cap from working.
5. Be very, very careful toward the very end of long-term projects. On the day of the BP explosion plaques were being distributed to employees for seven years of uninterrupted safety".

Point number 2 in which the writer mentions that Junior management error is the most frequent cause is linked to organisational culture. With the Indian workforce becoming younger and younger, I observe a shift in the Plant manager's perception of risk. They are becoming more blind to risk due to inexperience and lack of training, and conflicting signals from top management (Top management talks about safety but does not back up its actions with resources). A recipe for disaster!
Read the full article in this link.

Hot Work Accidents

25 years ago, I was witness to an incident where a new pipeline was being prefabricated by supporting it on a "empty" drum. Unfortunately the drum had been earlier used for draining naphtha from a vessel and still contained naphtha vapours. We were inside the control room (about 40 meters from the hot work) when the welder started welding two pieces of the pipe supported on the drum. The explosion could be heard inside the control room. The heavy pipe was lifted 15 feet into the air and fell on the welder killing him.
The basic precautions for hot work include a written work permit system, monitoring the work place for combustibles/flammables, ensuring that no flammable material enters the hot work area/equipment by proper positive isolation,containing the sparks from the hot work and proper training of both permit issuer and receiver. In many plants I visit, the operations and maintenance personnel think it is the job of the safety officer to check these points. You must understand that is the primary job of both the permit issuer and the permit receiver to check all these points before they carry out the work.Let us not kill more people.

Texas City to the Gulf

An article "Blast at BP Texas refinery in 2005 foreshadowed Gulf disaster" by Propublica mentions the following about the BP Texas city refinery incident:
Soon after the merger, BP demanded a 25 percent budget cut across all its U.S. operations.
Among the reductions at Texas City:
* Cut inspectors and maintenance workers by the dozens to save just over $1 Million.
* Eliminate safety calendars: $40,000 in savings.
* Reduce purchases of safety shoes for employees: $50,000 in savings.
* Eliminate safety awards: $75,000 in savings.
An outside auditor that Parus had hired, produced what was probably the most damning internal report [2] ever to emerge from the Texas City refinery. After surveying more than 1,000 workers and interviewing hundreds, the auditors concluded that the plant's employees had an "exceptional degree of fear" of a catastrophe, and that "blindness" across the entire corporation prevented critical safety information from reaching the top levels of BP management. It also said that poor conditions at the plant created hazards "you would never encounter at Shell, Chevron, Exxon, etc."
The 62-page report included direct quotes from some of the workers:
"The heroes around here are the ones working to the production goals and who complete them early. 80 to 90 per cent of what gets recognized is doing it fast counts."
"Telling the manager what they want to hear, that gets rewarded. For example, one person who had cut costs, done a lot of Band-Aids with maintenance and had a quit-your-bellyaching, quit-your-complaining attitude was rewarded in the last reorganization. When his replacement was brought into his previous maintenance position, his replacement found that not a single pump was fit for service; air compressors, not one spare was fit for service."
"Units are 90% of the time run to failure, due to postponing turnarounds [maintenance]. So making money or saving money for that particular year looks good on the books. This is a serious safety concern to operating personnel. We do not walk the talk all the time. Costs and budgets are preached to reduce costs."
Read the full article in this link.

Corncobs to Ammonia

I read an interesting article that would be of use to my friends in the Ammonia Industry. A company called Syngest is setting up a plant to convert corncobs to ammonia.
"The bio-ammonia plant will turn 150,000 tons of corncobs into 50,000 tons of anhydrous ammonia annually, enough to fertilize 500,000 acres of land. The process involves a pressurized oxygen-blown biomass gasifier operating in an expanding bed fluidized mode. After the resulting syngas is cleaned, the carbon monoxide portion is shifted to maximize hydrogen, which is purified and catalytically reacted with nitrogen to make ammonia. Syngest has procured 75 acres for the plant, five of which will be used for the facility itself and the rest for biomass storage. The plant will require 10 percent of available corncobs within a 30- to 40-mile radius".
I was wondering that even after so many years,the production of ammonia still needs high pressures and temperatures.When will we see an inherently safer process?
Read the full article in this link

Process Safety and Bottom of the Pyramid!

I am borrowing a phrase from the late Dr Prahalad, Management Guru, when he was mentioning the fortune to be mined at the bottom of the pyramid.As far as process safety goes., misfortune lies at the bottom of the pyramid!
A news article mentions today that 9 IOC officials, including the GM of the oil depot have been arrested by the police for the Jaipur oil depot fire. The report quotes the incident investigation report by an independent panel which mentions that "human error, lack of safety procedures and design flaws were found to be the major reasons responsible for the fire.The basic or root cause is an absence of site-specific written operating procedures, absence of leak stopping devices from a remote location and insufficient understanding of hazards, risks and consequences,M.B. Lal, who chaired the independent inquiry committee, said. In a 2003 audit, the Oil Industries Safety Directorate found that the remote leak stopping device was not working at the Jaipur terminal. The inquiry found that despite the recommendation in 2003, the device was never operational in the last six years, he added".
Does it not speak of an organizational safety culture issue??
Read the article in this link.

Cost cutting Vs Process Safety

An excellent article in the Wall Street Journal mentions the following in the aftermath of the BP oil spill:
'Early on June 5, 2008, a piece of steel tubing ruptured on BP PLC's vast Atlantis oil platform in the Gulf of Mexico. The tubing was attached to a defective pipeline pump that BP had put off repairing, in what an internal report later described as "the context of a tight cost budget."
The rupture caused a minor spill, just 193 barrels of oil, but BP investigators identified bigger concerns.
They found the deferred repair was a "critical factor" in the incident, but "leadership did not clearly question" the safety impact of the delay. The budget for Atlantis—one of BP's most sophisticated facilities— was "underestimated," resulting in "conflicting directions/demands."
Until the April 20 explosion of the Deepwater Horizon oil rig in the Gulf, Mr. Hayward repeatedly said he was slaying two dragons at once: safety lapses that led to major accidents, including a deadly 2005 Texas refinery explosion; and bloated costs that left BP lagging rivals Royal Dutch Shell PLC and Exxon Mobil Corp.
An internal BP presentation from December 2007, early in Mr. Hayward's tenure, noted that there had been 10 "high potential" incidents at BP facilities in the Gulf since the start of that year, including one December case in which a worker suffered an electric shock but survived. A common theme, the report found, was a failure to follow BP's own procedures and an unwillingness to stop work when something was wrong.
"As we enter the last two weeks of 2007, we are experiencing an unprecedented frequency of serious incidents in our operations," Richard Morrison, vice president for Gulf of Mexico production, wrote in an email to staff. "We are extremely fortunate that one or more of our co-workers has not been seriously injured or killed."
Read the full article in this link

Celanese and Process Safety

I had the privilege working for 8 years in a methanol plant in Saudi Arabia, a joint venture with Celanese,USA, from 1990 to 1998.Their focus on process safety at that time itself was very good.A recent article mentions the following:
"In 2009, Celanese sponsored a process safety symposium in conjunction with the China Petroleum and Chemical Industry Association (CPCIA). The goal was to explain the philosophies of process safety, share how Celanese manages its safety programs, and raise awareness of how to avoid catastrophic injury or loss of facilities.
A key message of the event was that the industry, government and companies were all responsible for process safety and must work together to make process safety improvements. This symposium was such a success that Celanese is again cosponsoring a process safety symposium in September 2010".
Read the full article in this link.
Hope they come to India!

A little hydrogen can do a lot of damage!

A news article reports that an explosion caused by hydrogen gas in a University of Missouri biochemistry research lab on Monday injured four people and destroyed the laboratory.
"The explosion blew out the windows of the third-floor lab and breached the wall between the lab and an adjacent office. When fire fighters arrived on the scene, they found a small fire covering an area of about 5 square feet, Davison says. One sprinkler head was activated, but investigators aren't sure whether it activated from the fire or from the blast of the explosion. The source of the hydrogen gas was a standard 55-inch-tall steel gas cylinder, which did not explode".
Read the full article in this link

Gas blowing of pipelines - CSB's recommendations

In my earlier post, I was dead against the blowing of new pipelines with natural gas to clear debris as there is a potential for an explosion or fire to take place where the gas is vented. The CSB, after investigating the explosion in the Kleen energy power plant has made similar recommendations to OSHA and others. I am quoting from their report:
Promulgate regulations that address fuel gas safety for both construction and general industry. At a minimum:
a. Prohibit the release of flammable gas to the atmosphere for the purpose of cleaning fuel gas piping.
b. Prohibit flammable gas venting or purging indoors. Prohibit venting or purging outdoors where fuel gas may form a flammable atmosphere in the vicinity of workers and/or ignition sources.
c. Prohibit any work activity in areas where the concentration of flammable gas exceeds a fixed low percentage of the lower explosive limit (LEL) determined by appropriate combustible gas monitoring.
d. Require that companies develop flammable gas safety procedures and training that involves contractors, workers, and their representatives in decision-making.

Read the full report and recommendations in this link.

TWO DAY TRAINING ON PSM IN CHENNAI AUGUST 12th and 13th, 2010

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
HURRY! SEATS FILLING UP FAST!

Heed the warnings!

An article in CBS News website indicates that the BP Gulf of Mexico incident was not a one off incident. There was another incident in another BP oil rig in 2003 where a similar incident occurred but the gas did not ignite!
"Shortly after lunch on November 27, 2003, Oberon Houston was in his office beneath the helideck of BP’s Forties Alpha oil platform in the North Sea, off the coast of Scotland. One of a select group (1 percent of BP’s staff) of young engineers and managers targeted by the company for rapid advancement, Houston, 34, was working out maintenance plans for the coming week when he heard what he thought was a deafening explosion.Only it wasn’t an explosion. A gas line had ruptured-allowing thousands of pounds of pressurized gas to escape at supersonic velocity. That caused a thunderous sonic boom. Debris from the burst pipe and its cladding rained down, adding to the impression that “an artillery shell had just hit the platform.” The escaping gas quickly formed a huge and potentially lethal cloud around the rig. Now the threat of an actual explosion was very real. The smallest spark would detonate more than a ton of methane gas.
No one died or was even hurt that day on Forties Alpha, thanks in part to high winds that helped to disperse the gas after about 20 minutes of extreme danger to the platform and its crew of 180 people. But Houston, the number two in command aboard Forties Alpha, knew full well what could have happened. “Unlike a similar incident on the ill-fated Piper Alpha platform,” he observes, referring to an earlier accident in the North Sea, “the gas did not ignite, so what could have been a major disaster for myself and everyone else on board was averted by sheer luck.”
Though Forties Alpha could have produced a similar conflagration, it was nothing more than a near miss which was soon forgotten. BP admitted breaking health and safety laws by failing to guard against corrosion on the ruptured pipe that allowed the gas to escape. It was fined $290,000. The bigger loss came in early 2004. Houston resigned, and BP lost one of its best young engineers."
Read the full article in this link

Bhopal Gas Disaster Verdict 7.6.10 - Will we ever learn?

The Bhopal Gas Disaster Court verdict on 7.6.10 highlights the following:
The following are major contributors to the disaster:
1. Gradual but sustained erosion of good maintenance practices.
2. Declining quality of technical training of plant personnel, especially its supervisory staff.
3. Depleting inventories of vital spares.
4. MIC is a highly dangerous and toxic poison, even then storage of huge quantity in large tanks was undesirable. The capacity and actual production in the Sevin Plant is not required such a huge quantity to be stored.
5. The VGS (vent gas scrubber)and refrigeration plant were not adequate to the need of hour and more so they were out of order at the relevant point of time.
6. The nitrogen pressure was not adequate for long before the incident, so it was not maintained and hardly cared about.
7. The Public Information System was failed, neither the State Govt. nor the UCC or UCIL took any steps to appraise the local public.
8. Other alarming systems were also failed.
Together these factors combined to cause the multiple failures that underlay the calamitous incident, causing a vast destruction of life.
In my various assignments of investigating incidents,some involving fatalities,one or more of the above similar causes keep repeating.Why do we NOT want to learn from mistakes? Its because of a human fallacy - the longer it gets, the more you forget about an incident!

Dangers of Toxic gas cylinders

A newspaper report today indicates that at least 35 people were taken ill when they inhaled chlorine. It appears that the chlorine leaked when someone tried to steal the brass valve! Read more of the article in this report.
In 2009, there was a leak of chlorine form corroded abandoned chlorine gas cylinders.A water purification machinery was abandoned and four chlorine cylinders containing 300 tonnes of chlorine were dumped outside. Over the years, they corroded and finally developed a leak which impacted the villages nearby. Read more of this incident in this link.
Take care of your gas cylinders whether they contain toxic gas or otherwise. They can be potential time bombs!

Could another Bhopal occur in India?

I wish I could confidently say NO to the question!Though the big players take precautions,it is the small and medium scale chemical industries that require a lot of improvement.There are approximately 1700 Maximum Accident Hazard (MAH) units in India and they are supposed to carry out mock drills twice a year. Mr Bhardwaj, Member, National Disaster Management Authority is quoted as follows in an article in the Economic Times:
Mr Bhardwaj of the Authority strongly believes that such major accident hazard (MAH) units must adhere to all norms including executing two mock drills in a year. In fact, during the last four years, only 130 mock exercises took place out of which 33 happened to be in chemical industries. “We are emphasising more on prevention of such incidents rather than reacting to those. Yet, we need to prepare for any eventuality. Our mock-drills are big learning lessons as they also involve district administration,” Mr Bhardwaj says.
Read the full article in this link

Bhopal and BP - I don't know!

On Thursday, BP's CEO Tony Hayward testified before the US Congress on the spill incident. His answers to the questions put forward by the congressmen reminded me of the answers Union Carbide personnel gave the then Police Chief soon after the gas leak.The police chief had asked what was gas had leaked and what was the antidote. The answers he got was "I don't know". In Thursday's hearing, the CEO of BP also has replied in a similar tone(I am quoting from the article) "I wasn't involved in any of that decision-making," he said.Were bad decisions made about the cement?"I wasn't part of the decision-making process," he said. "I'm not a cement engineer, I'm afraid."
Also, "I am not a drilling engineer" and "I'm not an oceanographic scientist."
What about those reports that BP had been experiencing a variety of problems and delays at the well?"I had no prior knowledge."
At one point a frustrated Rep. Henry Waxman, D-Calif., the chairman of the House Energy and Commerce Committee, interrupted the CEO. "You're kicking the can down the road and acting as if you had nothing to do with this company and nothing to do with the decisions. I find that irresponsible."
Hayward quietly insisted: "I'm not stonewalling. I simply was not involved in the decision-making process."
Rep. Eliot Engel, D-N.Y., voiced the committee's frustrations as the afternoon wore on. "You're really insulting our intelligence," he said. "I am thoroughly disgusted."
Waxman told the BP executive that in his committee's review of 30,000 items, there was "not a single e-mail or document that you paid even the slightest attention to the dangers at this well."
There is a lesson to learn from this - how robust are your risk communication systems so that the bad news reaches the top? Read the full article in this link

Emergency response - How ready are you?

An article mentions the following: BP PLC's 582-page regional spill plan for the Gulf, and its 52-page, site-specific plan for the Deepwater Horizon rig vastly understate the dangers posed by an uncontrolled leak and vastly overstate the company's preparedness to deal with one, according to an Associated Press analysis. The lengthy plans were approved by the federal government last year before BP drilled its ill-fated well.Among the glaring errors in the report: A professor is listed in BP's 2009 response plan for a Gulf of Mexico oil spill as a national wildlife expert. He died in 2005.
The plan lists cold-water marine mammals including walruses, sea otters, sea lions and seals as "sensitive biological resources." None of those animals live anywhere near the Gulf.Also, names and phone numbers of several Texas A&M University marine life specialists are wrong. So are the numbers for marine mammal stranding network offices in Louisiana and Florida, which are disconnected.
How ready are you in your emergency preparedness? In some of the plants that I visit,I have noticed the site managements lackadaisical attitude towards the emergency response plan. It would be a good practice if the CEO of the company just activates a drill of the emergency plan without informing anyone about it. The skeletons would then come tumbling out! Read the full article in this link

Whistleblower policy for PSM and other systems

Today,organisations get certified to the whole gamut of ISO certifications and the management is lulled into a sense of complacency. I have observed a marked decline in the quality of certification and surveillance audits by certification agencies in India. Except for a few, many of the certification agencies also provide consultancy and training services for helping the organization to obtain certification.Though many organisations have a whistleblower policy, I feel there must be a separate whistleblower policy for any system deviation. This way at least the top management will come to know of what is going wrong in their systems!

Operating Procedures – Can they prevent accidents?

An article on the legal implications of the recent Bhopal Gas verdict quotes from the operating manual of Union Carbide “UCIL’s “Operating Manual Part-I – Methyl Isocyanate Unit” (October 1978), which the prosecution produced as evidence before the trial court, warned as follows: “…[i]t must be foremost in everybody’s mind that there is a probability of injury or accident round the corner. But these can be avoided if all are safety conscious and follow safety procedures strictly. Safety is our prime need. All chemicals like MIC, phosgene, HCl, CO, chlorine, MMA, chloroform and caustic soda, etc., however hazardous they are, can be handled safely by knowing the correct procedure. There is a correct way of handling them and there is ‘No Short Cut’. Any carelessness in operation will endanger you, your colleagues and everybody around you” (page 122).”
Just by having written procedures does not mean they will be followed. It depends on top management commitment to make the procedures work. And this is no easy work – it requires monitoring by top management on a 24 X 7 basis. With top management being busy always, looking at strategy, cost reduction, expansions etc, I feel that the focus sometimes does get lost. Read the full article in this link.

Bhopal - Blame it on the system!

Yesterday in an NDTV program on the Bhopal disaster verdict, the one conclusion that came through is to blame it on the system! Who designs systems? Cannot the government strengthen the systems? It is a travesty of justice for the Bhopal Victims. In 2004, on the 20th anniversary of the Bhopal Disaster, I met (Late) Ms Carolyn Meritt, then Chairperson of the CSB, at IIT Kanpur. She asked me one question, which I could not answer. Why is the PSM system not mandatory in India where Bhopal occurred? I am still looking for answers. See this youtube video on the reaction of Sathinath Sarangi, a bhopal activist.

Crisis Management - don't look at it only when it hits you!

Organisations tend not to invest on Crisis Management as they think it will never happen to them! It is a human fallacy to believe that as nothing bad has happened, nothing ever will happen. I was recently a witness to a major crisis in a chemical manufacturing unit and they were not prepared for handling it.The top management representative at the site had to deal with everything himself. Unless planning for crisis is done and periodically tested, you will not be able to manage it. See this excellent youtube video about the responses of BP CEO Tony Hayward starting from the accident in the Gulf,onwards.

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