Did inferior raw materials cause the cordite factory blast?

A newspaper article reports that insiders of the Cordite factory believe that supply of poor quality material could be to blame for the blast that killed 5 workers on November 25. I have observed that the trend in the industry is to go for the lowest cost (L1). While process safety does not prohibit you from going for the least cost supplier, ensure that you do not create process safety problems due to inferior quality. Read the article in this link.

Chemical Terrorism and mock drills

The department of homeland security in the US has recently conducted a mock drill for a terror attack induced scenario. The scenario was three simultaneous accidents - ammonia leak from rail tanker, sulphuric acid leak from rail tankers and a train derailment with chlorine tankers.
In India, though we do have a Chemical Accidents (emergency planning, preparedness and response) rules, 1996, we have a long way to go before we are truly prepared for what the US is already prepared.
Read the article about the mock drill in this link.

Radioactive sources and process safety

Some instruments use radioactive sources for their functioning. Also, radioactive sources are maintained by large chemical companies who use them for radiography of welds etc. Maintain the radioactive source as per the conditions required by law. In a recent incident, an oil company was fined 300,000 pounds after exposing workers to radiation. The article mentions the following:

"The incident happened while Schlumberger was contracted to undertake wireline logging operations as part of the Maersk drilling programme for the Cawdor oil well. During the process a logging tool fitted with a radioactive source was supposed to be lowered into the well, the court heard. But the lowering process failed and the radioactive source lay on the drill floor for about four hours before being found, during which time 14 workers were exposed to radiation. The Health and Safety Executive said it was "only by good fortune" that the mistake had been discovered before it had more serious consequences"."Had someone held it, even just for a few minutes, they would have received a significant radiation dose which may have resulted in injuries to their hands and increased their risk of developing cancer in later life."

Read the article in this link.

Diving to disaster - lessons from the Air India incident

O   On 26.5.10, Air India express flight (Boeing 737-800 NG aircraft) from Dubai to Pune, when on normal flight, suddenly plunged from 37000 feet to 30200 feet. The commander of the flight had over 6000 hours of flying with 870 hours on similar type of aircraft while the copilot had total of 1310 hours with 968 hours on similar type of aircraft. The commander was 39 years old and the copilot was 26 years old. The commander went out of the cockpit to the washroom after the plane was on autopilot. He was only out for a few seconds when the plane started diving down. The copilot was not responding to open the cockpit door. Finally the commander opened the door with an emergency access code and entered. The flight was then stabilised and landed safely later. The reasons for the incident was that the copilot, while adjusting his seat, inadvertently pushed the control column, resulting in the plane diving down. He then reportedly panicked and could not open the cockpit door for the commander to enter. The investigation report has great parallels to process safety. On reading the report the following facts emerge:

1. The commander when asked why he left the cockpit to the washroom without asking the cabin steward to be in the cockpit (as is standard practice in the aviation industry – not to leave any pilot alone in the cockpit) reported that it was not in the SOP.
2. The co pilot has reportedly told investigators that he panicked when the dive occurred and the overspeed alarm was blaring.
3. The simulator training given to qualify the pilots does not include the scenario of autopilot engaged and control column pushed inadvertently.
4. The position of chief of training for Air India has been lying vacant since June 2008.

Lessons to be learnt:

1. Make sure your SOP’s are current
2. The age of the copilot was 26 years old. He panicked when the situation occurred as he was not trained to handle the situation.Make sure your control room operators are properly trained in all scenarios. Use simulator training to educate them
3. Make sure critical positions like process safety, training and HR (other than operations) are filled up with competent personnel.

Read the full report in this link. Kudos to the DGCA for putting the report up on their website!! The transparency of the government may, I hope, slowly result in the formation of an investigating agency like the CSB for investigating chemical incidents in India!

Beware of that spark!

Electrical hazardous area classification is often a confusing item for plant personnel. They are more familiar with pressures, temperatures and the like. But basic understanding of the different terminologies should be understood. An article mentions the following:
"Installing electrical and automation panels in hazardous areas requires use of one of three protection methods: explosion-proofing (EXD), purge and pressurization (EXP) or intrinsic safety (IS).
EXD contains the pressure of the explosion, and then cools it through a critical flame path to a level that will not ignite the surrounding environment.
EXP protects the environment by segregating hazardous material from the ignition source before equipment is powered. First, explosive mixtures are purged from the enclosure; then a positive pressure is maintained inside the enclosure to insure hazardous gasses do not propagate back in during operation.
IS protection limits the energy entering the hazardous area to a level incapable of igniting the easiest ignitable concentrations of gas/air mixtures under fault conditions".
Read more of the article in this link.

Incident at DuPont plant hospitalises two

An article mentions that two workers were exposed to monomethyl amine which was released from a railcar sample line while taking sample.
Read the full article in this link

Fire in a chlor alkali plant and citations from OSHA

A blast in a chlor alkali plant in China has been reported to have killed three people. Resons are being investigated. Read the article in this link.
In another development, OSHA has cited Huntsman Petrochemical of Houston Texas of violations in PSM. The article is quoted below:
"OSHA began its investigation June 7 in response to an incident in one of the company’s process units.Alleged serious violations include failing to incorporate operating procedures for all safety devices in the company’s operating guide; adequately train employees in safe operating procedures; properly shut down process equipment; identify and isolate all energy sources to the equipment; and to ensure lockout/tagout energy isolating devices such as line valves prior to employees performing maintenance on the equipment. A serious citation is issued when there is a substantial probability that death or serious physical harm could result from a hazard about which the employer knew or should have known. The company has 15 business days from receipt of the citations to comply, request an informal conference with OSHA’s area director in Houston, or contest the citations and penalties before the independent Occupational Safety and Health Review Commission".

Read the article in this link.

Fire in natural gas furnace in ammonia plant

A news report mentions a in a furnace in an ammonia plant due to rupture of a natural gas pipeline.
When I was shift in charge in an ammonia plant 30 years ago, we used to light up the start up heater for heating up the ammonia convertor. This furnace was a natural draft and naphtha fuel fired design. We used to keep increasing the firing while closely monitoring the rate of heating up. The pressure in the gas coil was 220 Kg/cm2. The burner flames used to be coming out of the top of the stack during the final phases of heating. Luckily we never had any incident of coil rupture in this heater or otherwise I would not be here today!!
Furnace can Kill if you mistreat them. Read your operating instructions, have your protection systems maintained and conduct periodic inspection of the coils.
Read the article in this link.

Axial misalignment causes a fatigue failure -Quantas A380 incident

The ATSB which is conducting investigations into the engine failure incident that occurred to the Airbus A 380 aircraft on November 2010, has mentioned the following in a safety alert:"A subsequent examination of the aircraft indicated that the No 2 engine had sustained an uncontained failure of the Intermediate Pressure (IP) turbine disc. Sections of the liberated disc had penetrated the left wing and the left wing-to-fuselage fairing, resulting in structural and systems damage to the aircraft. The No 2 engine was removed from the aircraft and disassembled in an authorised engine workshop for examination, under the supervision of the Australian Transport Safety Bureau. In addition, a large section of liberated IP turbine disc was also recovered from Batam Island for examination. Those examinations are ongoing. Recent examination of components removed from the failed engine at the Rolls-Royce plc facility in Derby, United Kingdom, has identified the presence of fatigue cracking within a stub pipe that feeds oil into the High Pressure (HP) / Intermediate Pressure (IP) bearing structure. While the analysis of the engine failure is ongoing, it has been identified that the leakage of oil into the HP/IP bearing structure buffer space (and a subsequent oil fire within that area) was central to the engine failure and IP turbine disc liberation event.

Further examination of the cracked area has identified the axial misalignment of an area of counter‑boring within the inner diameter of the stub pipe; the misalignment having produced a localised thinning of the pipe wall on one side.

Misaligned stub pipe counter-boring is understood to be related to the manufacturing process. This condition could lead to an elevated risk of fatigue crack initiation and growth, oil leakage and potential catastrophic engine failure from a resulting oil fire".

Read the full report in this link. Those of you who are responsible for asset integrity in chemical plants - please note that it only requires a small error to cause a big disaster.

The lessons from Bhopal – Relevant more so today

26 years ago, on the night on December 2nd/3rd, 1984, on a wintry night in Bhopal, thousands of men, women and children died an excruciating death when MIC leaked from the Union Carbide factory. The survivors and the next generation children born to those exposed to the gas still are suffering from the effects of the gas. Bhopal is an ongoing tragedy and should never be forgotten. The lessons from the Bhopal Disaster are very relevant even after 26 years:
1. Do not cut costs without looking at the effects on process safety
2. Maintain all your layers of defense.
3. Continually ensure that competency of personnel operating and maintaining plants are updated and current
4. Be prepared for the worst case scenario.
5. Understand the risks and measures to eliminate / reduce or control them
6. Learn from your past incidents. Those who do not learn are condemned to repeat the incidents.
7. Pay heed to your process safety management system audit reports
Read my older post comparing the Bhopal and the BP incident of 2005 in this link

Maintain your mitigation systems - they are your last lines of defense

A news report mentions that a hydrofluoric acid leak in a plant has been effectively contained by the plants mitigation systems, which worked as they were intended to do. Many of operating personnel (myself once included!) do not give enough importance to mitigation systems thinking that they will never be needed. Mitigation systems (dyke walls water sprays, interceptor dykes etc) are not required normally but are very useful in low frequency high potential incidents. In the said incident the article mentions that the company says that they haven't had a leak like this in "years and years".
Read the article in this link

Human issues in the Deepwater Horizon blowout

An Interim Report on causes of the Deepwater Horizon oil rig blowout and ways to prevent such events by the committee for the analysis of causes of the Deepwater Horizon explosion, fire, and oil spill by the National Academy of Engineering; National Research Council mentions the following:
"1.The incident at the Macondo well and Deepwater Horizon MODU was precipitated by the decision to proceed to temporary abandonment of the exploratory well despite indications from several repeated tests of well integrity [the test type known as a negative (pressure) test] that the cementing processes following the installation of a long-string production casing failed to provide an effective barrier to hydrocarbon flow (Sections II and III).
2. The impact of the decision to proceed to temporary abandonment was compounded by delays in recognizing that hydrocarbons were flowing into the well and riser and by a failure to take timely and aggressive well-control actions. Furthermore, failures and/or limitations of the BOP, when it was actuated, inhibited its effectiveness in controlling the well (Sections III and IV).
3. The failures and missed indications of hazard were not isolated events during the preparation of the Macondo well for temporary abandonment. Numerous decisions to proceed toward abandonment despite indications of hazard, such as the results of repeated negative-pressure tests, suggest an insufficient consideration of risk and a lack of operating discipline. The decisions also raise questions about the adequacy of operating knowledge on the part of key personnel. The net effect of these decisions was to reduce the available margins of safety that take into account complexities of the hydrocarbon reservoirs and well geology discovered through drilling and the subsequent changes in the execution of the well plan (Section VI).
4. Other decisions noted by the committee that may have contributed to the Macondo well accident are as follows:
• Changing key supervisory personnel on the Deepwater Horizon MODU just prior to critical temporary abandonment procedures (Section VI);
• Attempting to cement the multiple hydrocarbon and brine zones encountered in the deepest part of the well in a single operational step, despite the fact that these zones had markedly different fluid pressures (because of the different fluid pressures, there was only a small difference between the cement density needed to prevent inflow into the well from the high-pressure formations and the cement density at which an undesirable hydraulic fracture might be created in a low pressure zone) (Section II);
• Choosing to use a long-string production casing in a deep, high-pressure well with multiple hydrocarbon zones instead of using a cement liner over the uncased section of the well (Section II);
• Deciding that only six centralizers would be needed to maintain an adequate annulus for cementing between the casing and the formation rock, even though modeling results suggested that many more centralizers would have been needed (Section II);
• Limiting bottoms-up circulation of drilling mud prior to cementing, which increased the possibility of cement contamination by debris in the well (Section II);
• Not running a bond log after cementing to assess cement integrity in the well, despite the anomalous results of repeated negative-pressure tests (Section II);
• Not incorporating a float shoe at the bottom of the casing as an additional barrier to hydrocarbon flow (Section II); and
• Proceeding with removal of drilling mud from the well without installing the lockdown sleeve on the production casing wellhead seals to ensure the seals could not be shifted by pressure buildup under the seals (Section II).
5. Available evidence suggests there were insufficient checks and balances for decisions involving both the schedule to complete well abandonment procedures and considerations for well safety (Section VI).
6. The decisions mentioned above were not identified or corrected by the operating management processes and procedures of BP or those of their contractors or by the oversight processes employed by the Minerals Management Service (MMS) or other regulators (Sections VI and VII).
7. Currently, there are conflicting views among experts familiar with the incident regarding the type and volume of cement used to prepare the well for abandonment.There are also conflicting views on the adequacy of the time provided for the cement to cure. These factors could have had a material impact on the integrity of the well (Section II).
8. The BOP did not control—or recapture control of—the well once it was realized that hydrocarbons were flowing into the well. Also, both the emergency disconnect system designed to separate the lower marine riser from the rest of the BOP and automatic sequencers controlling the shear ram and disconnect failed to operate (Section IV).
9. Given the large quantity of gas released onto the MODU and the limited wind conditions, ignition was most likely. However, the committee will be looking into reports (such as testimony provided at the MBI hearings) that various alarms and safety systems on the Deepwater Horizon MODU failed to operate as intended, potentially affecting the time available for personnel to evacuate (Section V).
10. The various failures mentioned in this report indicate the lack of a suitable approach for anticipating and managing the inherent risks, uncertainties, and dangers associated with deepwater drilling operations and a failure to learn from previous near misses(Section VI).
11. Of particular concern is an apparent lack of a systems approach that would integrate the multiplicity of factors potentially affecting the safety of the well, monitor the overall margins of safety, and assess the various decisions from perspectives of well integrity and safety. The “safety case” strategy required for drilling operations in the North Sea and elsewhere is one example of such a systems approach (Section VII)
Read the full report in this link.