Knocked off valve causes ammonia leak

An ammonia leak has been reported in China, causing 3000 people to be evacuated.It reportedly began when a valve was "knocked off". Further details are not available.
Do you have proper controls inside your factory to prevent unwanted vehicle movement?
Read the news articles in Link 1
Link 2

Confined spaces are deadly!

The Ministry of Manpower of the Singapore Government has published a good flyer on hazards of confined space, with case studies of fatalities inside confined spaces covering ISO tanks, sewers, excessive inhalation of solvent vapours inside a confined space and CO poisoning.
See the flyer in this link and please share it with all your employees. It may save a life!

Lessons from the Tesoro Refinery Blast Investigation

The Washington State Department of Labour and Industries have investigated the above incident and issued citations totaling USD 2.39 Million. I have summarized the investigation findings and citations as follows:

•On April 2nd,2010 early morning, a blast at the Tesoro refinery in Anacortes, USA, occurred killing 7 personnel. The blast occurred due to the catastrophic failure of a feed effluent exchanger in the naphtha hydrotreating unit during start up. The exchanger was about 40 years old. The original refinery was started in 1950’s by Shell. Shell sold the refinery to Tesoro in 1998. The failed heat exchanger was not tested for last 10 years. Tesoro had planned an inspection in 2008 but did not carry it out.

•6 out of 7 personnel who died were not trained in the start up procedure.

•The frequency of Tesoro Refinery's inspection of the feed effluent exchanger was not consistent with applicable manufacture's recommendations, good engineering practices, and or prior operating experience.

•The Tesoro Refinery did not correct deficiencies associated with effluent exchanger shell and tube side warm up lines before further use or in a safe and timely manner

•Tesoro Refinery did not correct deficiencies associated with effluent exchanger companion flanges and temporary clamps before further use or in a safe and timely manner when the necessary means are taken to assure safe operation. (flanges were leaking during start up and steam lances held by personnel were used to dilute the leaks)

•Tesoro Refinery did not develop and implement written procedures for startup following turnaround, or after an emergency shutdown of exchangers that provided clear instructions for safely conducting activities involved in the process consistent with the process safety information that addressed steps for each operating phase.

•Tesoro Refinery did not establish and implement written procedures to manage the change made to the warm up steps during the March 2009 start up and those conducted in February and March of 2008 on the E6600 effluent exchangers.

•Tesoro Refinery did not establish and implement written procedures to manage the changes made to the operating limit minimum hydrogen oil ratio feed to Naphtha Hydrotreater.

•Tesoro Refinery did not establish and implement written procedures to manage the change made by placing mechanical clamps on the companion flanges between effluent exchangers E-6600 A/B and D/E on or about March 2009.

•Tesoro Refinery did not establish and implement written procedures to manage the change made by placing the Anacortes Corrosion Awareness and Management Program (ACAMP) on hold indefinitely beginning the third quarter of 2004.

•Tesoro Refinery did not establish and implement written procedures to manage the change made by discontinuing the process hazard analysis revalidation system that included mechanical integrity and corrosion control review in 2006.

•Tesoro Refinery did not establish and implement written procedures to manage the changes made by temporarily or permanently suspending inspection procedure I-08.07 on or about September 2009

•The Tesoro Refinery did not ensure that the 2006 Process Hazard Analysis Revalidation was consistent with the current process.

•The Tesoro Refinery did not update process safety information following changes made to the effluent exchangers on or about December 2005.

•The Tesoro Refinery did not investigate each incident which resulted in, or could reasonably have resulted in, a catastrophic release of highly hazardous chemicals in the workplace. Failure to investigate incidents could result in their recurrence and cause serious injury or death.

•Tesoro Refinery did not ensure that appropriate checks and inspections were performed to assure that equipment, such as the warm up lines and replacement tube bundle, were installed properly and consistent with the design specifications. Lack of quality assurance inspections and checks could lead to improper installations of process equipment and result in serious injury or death.

•Tesoro Refinery did not ensure that maintenance materials, spare parts and equipment were suitable for the process application for which they will be used, such as the bellows assemblies.

•Tesoro refinery did not ensure that all emergency responders and their communications were coordinated and controlled by the Incident Commander (IC).

•Tesoro Refinery did not assure that all Fire Brigade members were fully trained prior to the incident response on the morning of April 2nd, 2010.

Read the full citation in this link.

Process safety and the Stuxnet worm

A news article mentions the following: "A sophisticated worm designed to steal industrial secrets and disrupt operations has infected at least 14 plants, according to Siemens.Called Stuxnet, the worm was discovered in July when researchers at VirusBlokAda found it on computers in Iran. It is one of the most sophisticated and unusual pieces of malicious software ever created -- the worm leveraged a previously unknown Windows vulnerability (now patched) that allowed it to spread from computer to computer, typically via USB sticks.
The worm, designed to attack Siemens industrial control systems, has not spread widely. However, it has affected a number of Siemens plants, according to company spokesman Simon Wieland. "We detected the virus in the SCADA [supervisory control and data acquisition] systems of 14 plants in operation but without any malfunction of process and production and without any damage," he said in an e-mail message".
As technologies become more and more complicated, chemical plants are also becoming susceptible to attack through the software and other technologies they use. Do not be complacent about your plant software security systems. Many chemical companies ban USB sticks inside their premises.
Read more of the article in this link.

Cost Vs Process Safety - the perennial question

An article mentions that in the recent BP Deep Horizon oil spill, "Cementing contractor Halliburton had warned the well needed 21 so-called centralizers, devices used to reduce the risk of gas leaking into the well. But Mr. Walz testified that he felt a safe cement seal could be obtained by simply spreading out six centralizers BP already had. He said he and colleague John Guide thought that would "honor the modeling" from Halliburton.
That's as wishful -- and seemingly irresponsible -- as the response another BP engineer had given Halliburton before the disaster, saying that "hopefully the pipe stays centralized due to gravity."
BP engineers knew they were dealing with a difficult well and that more than 120 workers were at the Deepwater Horizon rig. Why, then, would BP personnel be so seemingly cavalier about a crucial part of the process? Mr. Walz and Mr. Guide may have provided the answer when they said BP employees are graded every year based on how much money they save the company".
Read the full artcile in this link.

Stronger Safety after an incident!

A news article mentions the following:
"Incoming BP boss Bob Dudley has announced the creation of a new safety division along with a management reshuffle that includes the departure of Andy Inglis, the head of the oil firm's key exploration and production division.
The group said the safety division would have "sweeping powers" to oversee and audit the company's operations around the world with the safety and operational risk department having authority to intervene in all aspects of its technical activities.
The powerful organisation is designed to strengthen safety and risk management across the group, following the Gulf of Mexico disaster that caused the biggest oil spill in US history. It will be headed by Mark Bly and report directly to incoming chief executive Dudley, who replaces Tony Hayward on Friday.
Dudley said: "These are the first and most urgent steps in a programme I am putting in place to rebuild trust in BP – the trust of our customers, of governments, of our employees and of the world at large. That trust is vital to the restoration of shareholder value which has been so adversely affected by recent events.
"Our response to the incident needs to go beyond deepwater drilling. There are lessons for us relating to the way we operate, the way we organise our company and the way we manage risk."
It is good that BP is reorganizing its safety functions. But in many companies, I keep hearing from the existing safety department that line managers do not pay heed to what they say! Look inwards into your organization and see if you are listening to you existing safety managers! They will have a lot to tell you. In fact prior to the BP Texas refinery disaster, it is reported that the safety manager had put up a slide on the key risks in which he mentioned "BP Texas refinery kills someone in the next few months"!
Read the news article in this link

H2S leak at Refinery

A news article has reported a H2S leak at a refinery in USA. A contractor is reported to have died, though it is not clearly known whether it was because of the leak.The leak is reported from a clamp that was installed to arrest a previous leak. Read the full article in this link.
Read another article about the leak in this link.

Toxic sludge flood disaster in Hungary

BBC has reported a flood of toxic hazardous waste which escaped from a reservoir in an alumina plant in Hungary.Four people have reported to have died.It is estimated that about 600,000 to 700,000 m3 of sludge escaped. If you are storing hazardous waste in your facility, ensure the storage meets all local regulations. Generally, it is human tendency to focus less on a waste storage facility when compared to a process plant. But your hazardous waste storage must be treated as an important part of your process safety program.
Read more in these links:BBC1 , BBC2
Deadly chemical reactions

Process Safety - Old is Gold If.....

A news report about an accident at a refinery in USA mentions that the cause of the incident was lack of inspection and maintenance of decaying 40 year old equipment. How are your maintaining your "old" equipment? Are your inspection philosophies revisited based on operating and maintenance experience? Personally, I have seen huge water pumps that are over 40 years old and are still supplying water to a large chemical manufacturing unit in India. The pumps are well maintained and look good enough to run for another 10 years!
The article mentions the following:
"On Monday, Silverstein said his inspectors determined the Anacortes accident was caused when a 40-year-old steel heat exchanger ruptured and spewed vapor and liquid that immediately exploded. Tests showed welds in the exchanger had developed cracks over the years. The rupture occurred along those weak points as the equipment was coming back online after maintenance.
Tesoro hadn't properly inspected the exchangers since 1998, and even then didn't test the most vulnerable areas, Silverstein said. Tesoro had planned to test them in 2008, but never did.
"If they had, we believe, they would have found the cracks that caused this explosion," Silverstein said. "They would have prevented this horrible incident from ever happening."
All seven workers who died had been standing near the exchangers. They were there in part, Silverstein said, because Tesoro had been unable in recent years to stop the equipment from leaking volatile, flammable gases.
So employees were positioned around the machinery in hard hats, gloves and goggles with "steam lances" — long tubes — they used to disperse the vapors. They also had to manually adjust valves during startup to make sure leaks didn't get out of control.
Read the full article in this link

The Human and Process Safety

Why is that we do not seem to learn lessons from incidents? One of the root causes of the 2005 BP Texas refinery incident was attributed to operator fatigue and overload. In many cases lack of training and troubleshooting skills are also mentioned. Do not neglect such warnings. An article mentions the following about the San Bruno gas pipeline accident:
"The San Bruno natural gas explosion has underscored a growing concern about the capabilities of utility employees who watch over the nation's pipelines and whose errors have been linked to a number of mishaps, some of them catastrophic.
The National Transportation and Safety Board has said among the questions it is investigating is whether workers at a PG&E pipeline-monitoring terminal in Milpitas were fatigued or poorly trained. And just eight days after the Sept. 9 blast, the federal Pipeline and Hazardous Materials Safety Administration moved to speed up adoption of a rule to insure that workers doing similar jobs at companies across the country are well-trained and rested -- especially since many of those workers put in 12-hour shifts".
"A 2005 NTSB study that scrutinized 13 pipeline mishaps involving various liquids from 1992 to 2004 found that "in ten of these accidents, some aspect of the SCADA system contributed to the severity of the accident." In many cases, the problems were aggravated when workers monitoring the systems failed to quickly recognize and respond to leaks. Among the accidents cited:
# An April 7, 1992, fire in Brenham, Texas, that caused three deaths and 21 injuries after a poorly trained worker failed to notice the changing pressure in a pipe, in part because the system didn't display data in a way the worker could easily interpret.
# On June 10, 1999, a worker failed to realize that a gasoline pipeline had ruptured and burst into flames in Bellingham, Wash., because the malfunctioning control system was providing erroneous data. As a result, it took more than an hour to shut the pipe's valves. Three people died and eight were injured.
# On Oct. 27, 2004, after a pipeline containing the caustic and potentially deadly chemical anhydrous ammonia ruptured in Kingman, Kansas, a worker misinterpreted alarms generated by a control system and mistakenly increased the flow of ammonia into the line. No one was killed or injured, but 204,000 gallons of the liquid flowed into a creek, killing more than 25,000 fish, including some threatened species.
"From 1990 to 2009, gas-line operator errors caused a little more than 5 percent of all the significant accidents nationwide, resulting in 8 fatalities, 150 injuries and $16.2 million in property damage, according to data kept by the Pipeline and Hazardous Materials Safety Administration. During the same period, operator error caused 11.5 percent of "serious incidents," which involve a fatality or an injury requiring hospitalization".
Read more of the article in this link.

Flammable gas detectors - use them properly

Flammable gas detectors which are widely used in the chemical industry are often not properly maintained. The use of improperly or wrongly calibrated detectors will lead to a false sense of security and may cause an accident. Read the guidelines given by International safety equipment association in this link

Explosion in Fertiliser plant in USA

A news article has reported an explosion in a fertilizer plant in USA. It is reported to have occurred due to a rupture of a high pressure Urea Ammonium Nitrate vessel.The noise from the explosion was reported to be louder than a sonic boom. Read more of the article in this link.