Speech by Jordan Barab of OSHA on Process Safety Management

At a speech by an OSHA official Jordan Barab,the following have been highlighted by the speaker:
"First: Effective process safety programs and strong workplace health and safety culture are critical for success in preventing catastrophic events.
Second: Industries need to learn from their mistakes. We know the major causes and we know the remedies. Yet lessons learned are not applied and the same problems surface to threaten workers again and again.
Third -- and I'm not telling you anything you don't already know: Numbers don't tell the whole story. Focusing on low DART rates alone won't protect you from disaster. New metrics are needed.
Now, let's explore these ideas a bit more.
Let's look at Concept number one: Effective process safety management systems and workplace safety culture are critical for success in preventing catastrophic events.
In the Baker Panel Report, issued after the BP Texas City explosion, the panel devoted considerable space to the importance of effective process safety systems and the need to build a strong corporate safety culture.
Process safety failures are typically low-frequency but high-consequence events. Our PSM systems have to be strong, and we cannot wait until we have an incident to discover that they were not.
What it comes down to is organizational culture. To paraphrase Professor Andrew Hopkins (whose work I'm sure you are all aware of): Workplace culture is not just an educational program that gets everyone to be more risk-aware and think "safety first." It's deeper and more ingrained than this. Hopkins and the Center for Chemical Process Safety have defined culture as "the way we do things around here."
What I'm talking about is a set of practices that define the organization and influence the individuals who make up the organization. This kind of pervasive, systemic organizational safety culture must come from the top -- and it must be expressed with transformative action, not just simple slogans.
Next: Concept Number Two: Industry must learn from its mistakes.
For three years now, OSHA has had in place a Refinery Process Safety Management National Emphasis Program. We are deeply troubled by the significant lack of compliance we are finding in our inspections, and with the number of serious refinery problems that continue to occur.
Time and again, our inspectors are finding the same violations in multiple refineries, including those with common ownership -- a clear indication that concerns and findings are not being communicated across corporations or throughout the industry or even within different units in the same refinery.
Consistently throughout the course of the Refinery NEP, we have found that over 70 percent of the citations fall into the top four PSM elements:
• Mechanical Integrity
• Process Safety Information
• Operating Procedures
• Process Hazard Analysis
Let's talk about these top four elements:
1. In MECHANICAL INTEGRITY, problems include failure to perform inspections and tests, and failure to correct deficiencies in a timely manner. This is a particular concern given the aging of refineries in the United States.
2. PROCESS SAFETY INFORMATION, including failure to document compliance with Recognized and Generally Accepted Good Engineering Practices to keep process safety information up to date, and to document the design of emergency pressure relief systems.
3. OPERATING PROCEDURES: failure to establish and follow procedures for key operating phases, such as emergency shutdowns, and using inaccurate or out-of-date procedures.
4. PROCESS HAZARDS ANALYSIS, including lack of attention to human factors and facility siting, and failing to address PHA findings and recommendations in a timely manner -- or, all too often, failing to address them at all.
More than a year ago, OSHA sent a letter to every petroleum plant manager in the country, informing them of these frequently cited hazards. Yet, a year after this letter went out, our inspectors continued to find the same problems in many facilities.
And, finally: Concept Number Three: The problem with numbers.
In any business or organization, one of the problems we find when trying to measure performance is determining how and what we measure.
Unfortunately, as we've discovered, having good numbers on your OSHA 300 logs doesn't correlate with having an effective process safety program.
The classic example of this is BP-Texas City, which had very good injury and illness numbers prior to the 2005 explosion that killed 15 workers and injured 170 others. This tragedy, of course, revealed serious process safety and workplace culture problems at the facility despite the good numbers the company had on paper.
It was noted in press reports that many of the workers killed at BP Texas City had just finished a meeting that touted their safety record. More recently, it was noted in the press that BP executives were on the Deepwater Horizon drill in platform in the Gulf of Mexico, celebrating their excellent safety record shortly before the explosion and fire that led to the deaths of 11 workers. In the days following that catastrophe, company officials continued to wave their low injury and fatality rates as a defense while workers widows planned funerals.
There's a message here: Boasting about favorable safety rates while workers are dying doesn't make a company look like a serious employer; and trade organizations that give awards to their members based solely on a lack of slips, trips and falls doesn't make them look like they are seriously addressing serious problems.
Don't misunderstand me: We need to keep reporting and tracking the numbers -- DART rates are useful -- but employers must not let those numbers lull them into a false sense of security. Looking only at these numbers doesn't warn us about pending doom from cutting corners on process safety
To ensure strong PSM systems, we need to do a better job of identifying useful leading indicators. We all recognize the stock market's investment warning that "past performance is no guarantee of future success." This also applied to the low-frequency, high-consequence events that process safety programs guard against.
The chemical and petrochemical industries must continue to develop and track leading indicators to measure the performance and continuously improve process safety management systems".
In my experience, the points that have been highlighted by the speaker are time and again found lacking in many industries.
Read the full speech in this link

Fire in oil tank

A fire that reportedly started in an oil tank in China that was earlier involved in a fire and had remnants of oil left in it has been reported. It is reported that workers were dismantling the affected tank when it caught fire. Do your job hazard analysis well before any hot work. Its these small things that count.Read the article in this link.

An appeal to readers - Share an incident!

I appeal to readers of this blog to share at least one process incident a month for the benefit of all. You need not mention the company's name. I have been receiving contributions regularly only from a few readers. Even if you write a brief few lines of the incident, it would be enough. Thanks in advance!

Do not forget Bhopal!

Tasleen, 26, who was poisoned by the Bhopal gas leak, cares for her disabled daughter. Photograph by Alex Masi
Every day, the people working in the chemical industry must realise that process safety is for the good of people - people inside the plant and people outside the plant. The horrors of the Bhopal Gas Disaster continue even today. We should not forget Bhopal. I think it will be a good practice for every chemical plant to organise a"Don't Forget Bhopal" day on December 2nd or 3rd every year and remind all managers of the things that went wrong at Bhopal and the lessons learnt from Bhopal..
See the human impact of Bhopal in pictures in this link.

Critical utilities are important for process safety

A news article reports that a refinery in the US has been flaring gas after loosing a big transformer which shut down the grid. I have been observing cases of transformer failures causing plants to either run on reduced capacity or shut down. Electrical systems are key for process safety. They are silent and appear docile but when they fail, they can cause a process upset that may lead to a catastrophe. Maintain you key utility systems with the same fervor as you would maintain your plant!
Read the news article in this link.
The EPA has reported an accident in 1999 involving a plant converting bauxite to alumina in a series of steam-heated pressure vessels. A loss of power stopped all pumps including those that circulated process material through heat exchangers for cooling. However, steam injection stayed on causing temperatures and pressures to increase. Pressure relief valves and piping were blocked or choked with solid deposits hindering their ability to relieve the increasing pressure. Several vessels over-pressured and exploded. The force of the explosion and release of highly corrosive caustic material injured 29 employees and extensively damaged the plant.

A third eye for process safety

After the BP oil rig disaster, authorities in the US are now planning to monitor the critical parameters of all oil rigs from land. An article mentions that the system will "put real-time data from offshore wells in front of government-employed petroleum engineers, who could keep a close watch during vital drilling operations or whenever anomalies are detected.Many drilling contractors and oil companies already use high-tech monitoring systems to keep track of what's happening offshore -- even from computer centers hundreds of miles inland".
Now while this is a good idea, it throws up another window regarding security of such networks. Just imagine if someone was able to unauthorizedly break into these networks!
I personally feel that while technology can be an enabler,it cannot solve all problems. Read the full article in this link.

The importance of corrosion monitoring and control in Process safety

What you do not see is most dangerous in Process Safety. Corrosion is a major problem in the chemical process industry and I am observing a disturbing trend. Regular painting and maintaining of metallic structures and equipment is often delayed when budget pressures dominate. Corrosion is insidious. It slowly and surely kills. If you do not have a good corrosion monitoring and control system, you will one day run out of luck, with disastrous consequences. An article by Dr A K Samant of ONGC mentions the following:"Corrosion control is an important consideration. The periodic monitoring techniques and analytical assessment of corrosion severity is very important and critical since it provides the direction to ensure proper utilisation of materials and corrosion control methodologies. Therefore, correct and appropriate condition assessment techniques should be used to avoid premature failure and ensure maximum safety".
Read the full article in this link

A missing word causes an accident!

Mr Yigal Riezel, Process Safety Management Consultant mentions about an explosion in a gas oil tank that was attributed to the use of nylon rope for taking a sample of tank contents.The operator lowered a nylon rope attached to the sampling device through the sampling hatch on top of the tank. This caused a static electricity spark. After the explosion, in which the operator was killed, the investigation determined that the special precautions mentioned in the tank sampling procedure of tank sampling included the following remark: “In order to reduce the potential for static charge, nylon or polyester rope, cords or clothing should be used”. The committee immediately sent the finding to the originators of the standard and got a fast reaction apologizing for a typing mistake by missing the word NOT before “be used”.

Disposal of old ammonia gas cylinders

I am really not sure whether the guys in this video really know what they are doing. They are reportedly disposing old ammonia cylinders.. watch this video and comment....

LPG tanker accidents

Thanks to Abhay Gujar for sending information about these LPG road tanker accident.
You can view them in this Link

The importance of P & ID's in process safety

The Piping and Instrumentation Drawing (P & ID) is the heart of any plant. There is always a debate about whether your P & ID's reflect the current as built status. With newer people joining the organisation, it is important that your P & ID indicates all the relevant information. Jeff Ratush has made a good presentation which I have attached in this link

No Safety, No Moolah!

A news article mentions that safety will be the sole criterion for judging employee performance in the fourth quarter for BP, as per an internal memo from BP CEO.
"The memo, written by new chief executive Bob Dudley, was sent to employees on Monday, the story said.
The sole criterion for judging performance in the 2010 fourth quarter would be "each business's progress in reducing operational risks and achieving excellent safety and compliance standards," said the memo.
The change was designed to ensure an incident such as the "Deepwater Horizon tragedy" never happens again, the story said".
Read the full article in this link. and in this link too

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.

Don't underestimate the power of water!

In 2009, a massive failure of the power generation turbine at a hydroelectric plant in Russia killed about 74 people. According to Wikepedia, the root cause was attributed to lack of complete bolting of the turbine casing cover. The consequences were horrendous.Do not underestimate the power of water in a process plant. Water hammer, flashing of water into steam are hazards that can cause severe damage to plant equipment. Train your operators on these hazards.
Read about the failure in this Wikepedia link.
See amazing photos of the disaster in this link.

Chlorine Gas leak reported from pipe

A news item reports that chlorine gas leaked from one of the pipes crossing a road in a factory in Chennai. From the picture that is accompanying the article it appears that the leak occurred near a culvert. Read the full article in this link.
While I am not commenting on the cause of the leak, if you have pipes carrying hazardous chemicals crossing roads through culverts, ensure that they are inspected for corrosion and thickness reduction. Especially vulnerable are the drain and vent points. Your mechanical integrity program must cover this.

Natural gas pipelines - emergency isolation valves

The recent natural gas pipeline explosion in San Bruno, USA has raised an important point. It appears that the company employees had to drive through rush hour traffic for more than an hour to close manual valves to isolate the leaky pipeline.
In any pipeline transporting hazardous material, remotely operated emergency isolation valves must be provided to immediately isolate the supply of the hazardous material safely. Also, test them to ensure they are in operating condition.
Read the full article in this link

Control systems - do not complicate things!

The last decade has seen a huge change in the control systems of process plants with advanced DCS systems and other new technologies being deployed. I personally feel that the onus lies on the customer to implement only what he requires and will be useful to operators during an emergency / for trouble shooting and not to implement the complete solutions that come along with the package. I have seen in many incidents that the cause of the incident was caused by too much information coming to the operator from the system thus overloading him and diminishing his capabilities to act correctly.
I strongly believe in the principle that WE HAVE TO KEEP IT SIMPLE YET FUNCTIONAL!
Why do we have to complicate things and then work on uncomplicating them?
Read an article on the dangers that are brought on by newer technologies and control systems in this link

Run to failure or run to safety?

The Vice President of the USW, a body representing workers has mentions that "the oil industry's run to failure mentality concerning equipment gets worse every day. He also said that the union will not give up its campaign to have enforceable health and safety language.He added that "It's all about money. The refiners run the units longer to sell as much product as possible."
Mr Rafael Moure Eraso chair of the US Chemical Safety Board said that "We see a growing crisis of safety in the oil sector." He cited the Gulf rig disaster as well as recent explosions and fires at onshore production, processing, and refining facilities.
Mr Beevers said that the industry needs to bring back shorter periods between turnovers, which are times when a refinery is shut down for maintenance.
Mr Moure Eraso said that operators have told him that turnarounds that normally occur every two to three years are happening now every four to five years. They have said that broken equipment is not immediately addressed and workers are told to work around the problem".
This is a classical production Vs Safety question. How do you decide the intervals between planned shutdowns for maintenance? Of late, due to market pressures, many organisations are increasing the duration between shutdowns.In the interest of process safety, this decision has to be made very carefully after weighing all options, including ageing of the plant,process incidents and maintenance data.
Read the full article in this link.

Oil fire in pipeline in China

Thanks to NP Rao for sharing this powerpoint show of the firefighters in China fighting the fire and subsequent oil spill in the oil pipeline in China.

Overfilled rail tanker "burps" isobutane!

An incident has been reported in the US where an overfilled rail tanker was overfilled and it appears that the safety valve lifted momentarily, causing what observers report as a burp! A passerby called 911 and the excess isobutane was transferred to a road tanker. Many of the chemicals in India are transferred in rail tankers. Ensure that they are not overfilled. It will not show up immediately but as the day warms up, there is a likelihood of overpressurising of the tanker.
Read more of the news and see the video in this link.

Process safety - Its lonely at the top!

Imagine what Tony Hayward the erstwhile CEO of BP must have gone through following the oil rig accident. In India, prosecutions of the "Occupier" are on the increasing trend. An article mentions that "There are few places on earth more lonely than the space occupied by a corporate executive who is potentially responsible for a process safety mishap resulting in significant injuries to property, the environment and people. Often, support for such executives at that time can be seen by governmental authorities and the public as a failure of the corporation to take responsibility for the consequences of the catastrophic incident. On the other hand, abandoning such individuals in their time of need—particularly as they are subjected to regulatory and criminal investigations and the initiation of civil lawsuits—is seldom in the best interests of the corporation.
The best time to consider these issues is long before the adverse critical incident occurs. Most state laws require indemnification of employees charged with wrongdoing during the course of their employment, as long as those employees are ultimately exonerated. In addition, broad corporate indemnity provisions and directors and officers (D&O) insurance policies are available to protect such employees".
Read the full article in this link

The human consequences of a fire accident

Many chemical plant personnel take work permit systems for granted. It just becomes a piece of paper after some time. From time to time a harsh reality check is required for people to understand the dangers of hot work and working with flammable materials. I came across an article which is an amazing tale of a fire accident survivor who is now a professional speaker. His name is Spencer Beach and he has written a book about his ordeal. He was gravely injured in a fire accident with a solvent/thinner. The photo attached in the article is not for the lighthearted. But I felt that people should realise the human impact of a fire accident. Read more of this article in this link.

Running blind - the dangers of reactive chemistry

There is a lot of ignorance about reaction hazards in the batch processing industry. As long as incidents do not occur, operators of reactors that handle reactive chemicals seem to think that it will never happen to them. The fallacy is that we seem to think that big reactors are safe as they look strong! It is the other way around in reactive chemistry! If you do not know the sizing basis of your cooling/condensing systems, your vent/scrubber systems and details of the reactions you are handling, you are running blind! Read a basic article on dangers of reactive chemistry in this link.

OSHA warns power plant operators on hazards of natural gas purging

Further to the explsoion in a new power plant that occurred due to purging of natural gas lines with natural gas instead of other safer alternatives, OSHA has come out with a warning to all power plant operators. Read it in this link.

Hazardous chemicals lying in Indian Ports

Outlook magazine has brought out an article on the hazardous chemicals lying in various Indian ports. Recently, chlorine gas had leaked from old cylinders in the Mumbai Port. The article mentions that 92.4 metric tonnes of methyl monomer, a toxic compound used for making plastics, has been lying at the New Mangalore port since June this year. The article also mentions that more than 203 metric tonnes of various kinds of hazardous substances lies scattered around Mumbai port; another 200 metric tonnes lies awaiting disposal at the Jawaharlal Nehru Port Trust. Read the full article in this link

Pesticides - safety and health information

Thanks to Ajay Pancholi for sending the useful link for all health and safety information about pesticides. See this link

Fire in GAIL plant kills one

A fire in a GAIL plant has killed a deputy manager. GAIL is the national distributor of natural gas. The accident happened at their Auraiya plant. Read more of the accident in this link.
Abhay Gujar also sent the news that the fire occurred in the crude hexane reboiler in unit-1 during a routine maintenance operation.
Hope the oil industry safety directorate investigates the incident and puts up the reasons for the incident on their website....

Narural gas pipe explosion inUSA

A natural gas pipelines explosion in the US town of San Bruno has devastated the area.A news article mentions the following:
"The force of the explosion was large enough to level the area immediately around the blast’s epicenter. NTSB teams, as well as local investigators, are combing through the blast zone looking for evidence that will allow them to determine the cause. The primary problem with useful evidence in a fire investigation is the simple fact that much of it burns up during the event. Therefore, investigators have to look beyond the physical evidence to gain insight as to what really went wrong. Investigators are looking at the maintenance and safety records of the gas main in question, to see if red flags appear. They are also looking into the personal records of all individuals who worked on that particular section of pipe. This includes, drug problems and the general performance records of key individuals involved in the pipe’s maintenance.
Once the gas main has been designed and stringent regulations have been met, it’s up to qualified contractors to safely install the pipe. Lengths of pipe are specially welded together by trained pipe welders and this presents a potential problem. Anytime there is human interaction in the process of building something, the question arises; did that individual do their job correctly? The same holds true for the entire construction process. There have been numerous construction related disasters that were caused by insufficient materials, poor safety regulations and cost cutting. While there is no indication that these forces are at work here, the question still arises, was human error the driving factor in this accident? Mathematically, the odds are sadly in favor of human error".
Read the article in this link

How good and robust are your natural gas line inspection procedures? Are they getting implemented?

Abandoned cylinders and now abandoned tanks!

A fire in an abandoned tank in the Chennai port trust indicates that after the recent chlorine gas leak from abandoned gas cylinders in Mumbai port, we do not seem to learn our lessons. It appears that hot work was in progress in the vicinity of the abandoned tank when it caught fire. Read the full article in this link

Ammonia transfer hose leak incident

An incident has been reported where a ammonia transfer hose developed a leak in a factory in China. Hoses are the weakest link in any system and you have to implement a proper mechanical integrity plan in place to avoid incidents. Read the article in this link.

BP oil rig disaster internal investigation report

BP has released their internal investigation report of the oil rig disaster in the Gulf of Mexico. The report is obviously an initial investigation on the causes and does not go into why the failures occurred. This is stated by BP as follows:
It may also be appropriate for BP to consider further work to examine potential systemic issues beyond the immediate cause and system cause scope of this investigation. The summary of the report findings are given below:
1. The investigation team concluded that there were weaknesses in cement design and testing, quality assurance and risk assessment.
2. The investigation team concluded that hydrocarbon ingress was through the shoe track, rather than through a failure in the production casing itself or up the wellbore annulus and through the casing hanger seal assembly.
3.The investigation team has identified potential failure modes that could explain how the shoe track cement and the float collar allowed hydrocarbon ingress into the production casing.
4.The Transocean rig crew and BP well site leaders reached the incorrect view that the test was successful and that well integrity had been established.
5.The rig crew did not recognize the influx and did not act to control the well until hydrocarbons had passed through the BOP and into the riser.
6.If fluids had been diverted overboard, rather than to the Mud gas separator (MGS), there may have been more time to respond,and the consequences of the accident may have been reduced.
7.The design of the MGS system allowed diversion of the riser contents to the MGS vessel although the well was in a high flow condition. This overwhelmed the MGS system.
8.The heating, ventilation and air conditioning system probably transferred
a gas-rich mixture into the engine rooms, causing at least one engine to overspeed, creating a potential source of ignition.
9.Through a review of rig audit findings and maintenance records, the investigation team found indications of potential weaknesses in the testing regime and maintenance management system for the Blow out presenter (BOP).
Point no. 8 is a repeat of the ignition source in the BP Texas city refinery explosion where a pick up truck took in vapours through its air intake and triggered the initial explosion.Are we learning from our incidents?
Read the executive summary of the report in this link.

Oleum gas leak

A news article has reported an oleum gas leak from a facility in Miami. The article mentions that a temporary evacuation was done and the officials do not believe much of the gas was released. Read more of the article in this link.

The BP oil rig disaster

A presentation in the Global maritime Congress 2010 by Clay Maitland about the cause of the BP oil rig disaster mentions the following:
What were the underlying causes of the disaster?
• Complacency and routinism; the tendency of those within a large organisation to avoid testing established policies.
• “Bean-counteritis”; a failure to examine constraints on risk management budgets.
• Collectivism; a conviction that existing company policy is, by definition, the best that could possibly be. In American parlance, this is often called “drinking the company Kool-Aid.” It entails a rejection of rigourous analysis of internal management systems,and their appraisal for possible deficiencies.
• A failure, from top to bottom, to subject these systems to outside scrutiny, in the manner of the International Maritime Organisation’s Member State Audit Scheme.
• A tendency to stigmatise concern for the environment as something repugnantly radical, “Greenpeace Socialism”, “tree-hugging”, etc.
• Most significantly, the failure to establish a risk control or safety awareness mindset at all levels of the corporate hierarchy,particularly at middle-management levels, and to effectively offset a “get it done, at the lowest possible cost” attitude at the “coalface”.
Read the full presentation in this link

Fireworks factory blast in Malta

An article in the Times of Malta mentions about a fireworks factory blast. the reasons mentioned are very true for the firework factories in India also. The fireworks manufacturing industry is unorganized and employs labourers who are not literate. As part of Corporate Social responsibility, the larger players in the chemical industry in India need to assist these unorganised and small scale players to improve their safety while handling hazardous chemicals.
Read the article in this link.

Fire in a parcel van in a train due to hexane

Thanks to VB Shritharan for sending this news and link about a fire in a parcel van in a train in Yeshwantpur station due to hexane! I am left wondering how the Railways allowed Hexane to get inside a parcel van! Read more of this article in this link.

Caustic soda and process safety

Caustic soda (sodium hydroxide) is a commonly used chemical. Its main uses are in the manufacture of pulp and paper, alumina, soap and detergents, petroleum products and chemical production. Other applications include water treatment, food, textiles, metal processing, mining, glass making etc.
Caustic soda is a also a basic feedstock used in the manufacture of a wide range of chemicals. The Dow Chemical Co. has useful data on process safety aspects related to storage and its design.
Please see the following links:
General storage system guidelines
Storage tank design guidelines
Piping systems

Another fire in oil rig

Another fire has been reported in an oil rig in the Gulf of Mexico,though it is reported that this rig was not in operation. The article also mentions that there are 3400 oil rigs in the Gulf of Mexico producing 1/3 of the US oil requirements. Read more of the incident in this link.

Bhopal and BP – different approaches – different people

An article compares the difference in approaches between the Bhopal Incident and the recent BP oil rig disaster. “Both Union Carbide and BP received clear warning that their operations in Bhopal and Horizon Deepwater were not well managed and therefore had significant safety risks. Over 10 years before the actual catastrophe,a 1973 Union Carbide report signed by the Warren Anderson himself, highlighted that the unproven nature of Bhopal’s technology. In a 1982 safety review, Union Carbide’s own experts also emphasised the serious risk of substantial leaks of “toxic materials” at Bhopal. BP too received adequate warning of impending problems at Horizon Deepwater. A number of internal investigations alerted senior BP managers that safety and environmental rules at Horizon Deepwater were not being properly adhered to.”
Read the full article in this link.

Are your back up systems really capable of back up?

A report of an incident in an aircraft which suffered a cabin depressurization in flight and had to make a rapid descent reinforces the need to ensure your back up systems are working and reliable. It appears that the flight was operating with a single compressor feeding both the cabin pressurisation systems. Due to the high demand, the air temperature and pressure were higher. However the aftercooler was not cooling the air sufficiently due to a cooler fan problem. This led to the compressor shutdown on high air temperature and subsequent loss of cabin pressure. Read the full incident in this link.

Fail safe or Fail unsafe?

The blowout preventer that failed in the BP oil rig disaster was meant to be fail safe. But why did it fail? There is an excellent video from the NY Times explaining what could have gone wrong. Layers of protection analysis is supposed to find these weak links, but in my experience, LOPA depends heavily on the time available for the team to do it, the experience of the team and finally what is done with the recommendations. Watch the NY times video in this link.

Vacuum hazards - Another one bites the dust!

I came to know yesterday of an incident in India where a pressure vessel collapsed due to vacuum. The hazards of vacuum in vessels that are not designed for them is great. Please see my earlier post on the subject.

Dangers of Solvents inside confined spaces

The CSB has released an excellent video of 5 deaths occurring in a confined space in a hydroelectric plant in USA. The workers were using MEK (Methyl Ethyl Ketone) , a highly flammable solvent inside a confined space when it caught fire most likely due to static electricity. The CSB report has raised three points:
1.The contractor selected for the job was selected based on the lowest quotation even though his safety record was poor.
2.The current OSHA standard for confined spaces (CFR 1910.146) does not specify what additional precautions must be taken for working in a permit-required confined space with a potential flammable atmosphere, nor does it limit entry based upon measurable criteria such as a specific maximum percentage of the LFL, even though OSHA defines an atmosphere as hazardous when it exceeds 10 percent of the LFL.
3.There was no proper emergency plan for the work conducted
In India, the problems with contractors are numerous. Public sector units are required to go for three quotations and submit the job to the contractor with the lowest quote. This is also followed in some private players. Contractors are not trained adequately on the hazards of confined spaces. I know of at least three similar incidents in India where contractor employees died when flammable solvents caught fire inside a confined space.
See the video and report in this link.

Water and reactive chemicals = fire

A warehouse with old stored toxic chemicals has reportedly caught fire in Ukraine. The cause of the fire is due to rain water entering the warehouse and reacting with the chemicals stored and causing fire.
How well are your chemical warehouses protected from the elements?
Read the full article in this link.

Process Safety - Bhopal and BP- I Don't know!

It is eerie. 25 years ago after the Bhopal gas leak occurred, the then police chief met the security chief of Union Carbide and asked him what had leaked and what was the antidote. The answer was "I don't know". Cut to 2010. A news article mentions that "BP executives told U.S. investigators they didn’t know who was in charge of the doomed Deepwater Horizon rig in the Gulf of Mexico or who made key decisions before the vessel exploded in April, killing 11 workers and spewing millions of barrels of crude into the sea". The testimony from Wells, the highest-ranking BP executive to appear before the joint U.S. Coast Guard-Interior Department panel probing the catastrophe, frustrated Hung Nguyen, co- chairman of the panel, who said no one from BP has accepted responsibility for actions that led to the disaster.

“We’ve had so many vice presidents of drilling come before us, I can’t even keep track,” said Nguyen, a Coast Guard captain. “A lot of them answered ‘I don’t know, I’m not responsible’ for this or that. If everybody’s in charge, nobody’s in charge, is that correct?”
One interesting point mentioned by a manager was that he could not read the well cementing procedure in his blackberry due to its small size! Now did a blackberry cause the disaster?!!!!
Read the news article in this link.

PSM violations in refinery

OSHA has fined a Louisiana refinery for deficiencies in its PSM program.
Serious violations found include failing to provide accurate process safety information for piping and instrumentation diagrams, conduct incident investigations, provide written operating procedures, resolve recommended actions resulting from compliance audits, and adequately address the citing of control rooms and employees working in process units.
Read more of the article in this link.

Ammonia leak in refrigeration plant

An ammonia leak in a refrigeration plant in Alabama in USA has put 10 people in hospital including two in intensive care. It is reported that the was from piping.
Read more in this link.
As a spate of ammonia leak incidents have recently occurred from refrigeration plants in the USA, the CSB is investigating it in detail.

Process safety makes business sense!

A news item mentions that BP will pay a $50.6 million fine, negotiate another $30 million in penalties imposed by the Occupational Safety and Health Administration (OSHA), and undertake $500 million worth of repairs and upgrades at the Texas City plant where an explosion took place in 2005.
Under the agreement, BP will pay the $50.6 million fine and work out with OSHA how much of an additional $30 million in fines it should pay for other violations the agency has found on subsequent inspections at Texas City. BP will also spend $500 million to fix "process safety" problems it ignored on 28 separate plant processes.
Read more of the article in this link.

100 major oil and gas leaks from UK offshore

A news item reveals that there were nearly nearly 100 major oil and gas leaks from UK platforms in the past year. It is reported that there were 443 dangerous occurrences during the last year. Remember the Piper Alpha disaster in the North Sea in 1988. This data again reinforces my strong belief that technology alone will not solve our process safety problems. Its about people. Read the full article in this link.

Ammonia leak from broken pipe

An incident of a broken pipe leading to anhydrous ammonia leak has been reported in Lacona,USA. Authorities ordered a voluntary evacuation of the town. Just observe the lack of populated areas around the leak area. Catch this happening in India!
See the 15 photos of the leak and emergency response in this link.

Traces of phosphine gas reported emanating from MV Chitra

News reports indicate that traces of phosphine gas emanating from the damaged MV Chitra which was involved in a collision with another ship at Mumbai Port is delaying salvage efforts. The ship was reportedly carrying Aluminium phosphide, which is used as a pesticide and rodenticide. Aluminium phosphide on reaction with water generates phosphine. Wikepedia reports the following on phosphine:Phosphine gas may form explosive mixtures with air and can self ignite. The gas is heavier than air. When phosphine burns, it produces a dense white cloud of phosphorus pentoxide – a severe respiratory irritant.[8]
Also, Wikepedia reports the following about Aluminium phosphide:
In October 2002, Sir Derek Bibby, 2nd baronet and great-great-grandson of the founder and past chairman and president of the Bibby Line shipping company, aged 80 and terminally ill with leukaemia, committed suicide by consuming aluminium phosphide - the poison, hours later, caused his body to emit dangerous fumes forcing the evacuation of the hospital department where his body was being held.[4]
In February 2009, two children died in Jeddah, Saudi Arabia after a neighbouring house was fumigated with aluminium phosphide.[5]
In February 2010, two sisters died in Layton, Utah after the area around their home was treated with fumitoxin to get rid of rats. The two sisters, ages 4 years old and 15 months, died just three days apart from each other after experiencing identical symptoms.[6]
See the following links for further information
News item about phosphine gas leak
Aluminium phosphide
Phosphine

Dangers of turbine overspeed

In 1983, I was nearly killed when a 100 HP steam turbine driving a naphtha pump catastrophically disintegrated due to overspeeding caused by the choking of the pump suction strainer. I was standing near the turbine when I heard it suddenly speeding up. I managed to hide myself behind a concrete pillar before the turbine disintegrated. The mechanical overspeed trip malfunctioned and did not work.
Understand that rotating equipment have speed limits and make sure that your overspeed trip mechanisms are working properly.
I was saddened when I came across a news item about an incident in 2001 when a person was killed due to an overspeed of a turbine when it was being tested.
Read more about the incident in this link "Machinist Struck and Killed by Fragments from Ruptured Steam Turbine Housing"

Dangers in silos or bins

OSHA has reportedly fined a grain handling facility fined $721,000 after a worker was engulfed in a storage bin. The OSHA news item reports as follows:
"OSHA fined Cooperative Plus Inc. $721,000 after a near tragedy in February, when a worker in a storage bin was trapped in soybeans up to his chest in 25 degree weather. The worker was ultimately rescued after a four-hour ordeal. OSHA issued 10 citations against the Burlington, Wis., farmer-owned cooperative after inspectors concluded that the employer had willfully disregarded safety requirements by exposing workers to the risk of being engulfed and suffocated in grain storage bins. Two of the citations were for multiple egregious violations for failing to provide workers entering grain storage bins with body harnesses and lifelines and failing to provide an observer while other workers entered the grain bins. See the news release for more information about this case and OSHA's new grain storage bins fact sheet* for more information on engulfment hazards".
Unfortunately, this type of incident happens with disturbing frequency in the grain handling industry. In the last 10 months, OSHA fined two grain handling facilities more than $3 million after separate incidents in which a 17-year-old who had just graduated high school and a 52-year-old husband and father were engulfed and suffocated in grain storage containers. Last month, two Illinois teenagers (ages 14 and 19) were suffocated after being engulfed in a grain bin they had entered. A third young worker was hospitalized after being trapped in the bin for 12 hours.
OSHA has published a useful fact sheet on the hazards in silos, which is given in this link

Gas cylinder explosion incident

Treat your gas cylinders with respect. The Gas cylinder Rules are very clear in specifying the safety precautions to be taken. Gas cylinders not properly handled are ticking time bombs. An incident of gas cylinder explosion killing one person in Pune has been reported and the plant manager has been arrested. Please see the news articles in these links:
Gas cylinder explosion
Plant manager arrested

Process Safety Management - Its not all technical!

A huge wave of interest in Process safety generally occurs after a major incident. The Jaipur oil fire,the BP oil spill, the Bhopal gas disaster court verdict and other incidents have sparked a huge interest in process safety.The management of process safety does require a lot of technical competence. However the MANAGEMENT of Process Safety requires just that - its about people. Just pause back a bit - Bhopal - 1984.... reasons for the incident - cost cutting without assessing risks, ignoring warnings,poor emergency response planning... the list goes on. One or more of the same reasons keep coming up for the recent incidents also! Technology has changed rapidly and we have Safety Integrity levels, redundant systems, more reliable equipment etc etc but still accidents happen. Why? Because wrong decisions are taken by a human being. Whatever administrative frameworks we design and provide for risk based process safety, one day a human being is going to override the administrative framework and take a decision that ultimately causes an incident. I was jokingly mentioning to participants of a process safety seminar that as long as people exist, the job of a process safety management consultant will be in demand!Have a safe day!

Fire in Plastics Godown in Kolkata

Thanks to Abhay Gujar for sending news about a major fire in a plastics godown in Kolkata. Do we give the same importance for emergency preparedness to godowns and warehouses that store hazardous materials as we do for chemical manufacturing units? See a video of the fire in this link.

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