CO the deadly killer

Seven people have been reported hospitalised in a toffee manufacturing factory in UP after inhalation of carbon monoxide. CO is a deadly killer and in confined spaced and in places where improper combustion of fuels take place, one has to be very careful. Read the article in this link.

PSM and the Texas A & M Bonfire - good analysis

H Badat has made a comparision of the Teaxs A & M bonfire incident and the elements of PSM. It is a good effort and it can be viewed in this link.

CSB Report on Bayer CropScience Explosion finds multiple deficiencies led to Runaway Chemical Reaction

The CSB has released the report on the 2008 Bayer Crop Science explosion. The news release indicates the following:

"In a report scheduled for Board consideration at a public meeting this evening in Institute, the CSB found multiple deficiencies during a lengthy startup process that resulted in a runaway chemical reaction inside a residue treater pressure vessel. The vessel ultimately over pressurized and exploded. The vessel careened into the methomyl pesticide manufacturing unit leaving a huge fireball in its wake.
The report found that had the trajectory of the exploding vessel taken it in a different direction, pieces of it could have impinged upon and possibly caused a release from piping at the top of a tank of highly toxic methyl isocyanate (MIC).
The accident occurred during the startup of the methomyl unit, following a lengthy period of maintenance. The CSB found the startup was begun prematurely, a result of pressures to resume production of the pesticides methomyl and Larvin, and took place before valve lineups, equipment checkouts, a pre-startup safety review, and computer calibration were complete. CSB investigators also found the company failed to perform a thorough Process Hazard Analysis, or PHA, as required by regulation.

This resulted in numerous critical omissions, including an overly complex Standard Operating Procedure (SOP) that was not reviewed and approved, incomplete operator training on a new computer control system, and inadequate control of process safeguards. A principal cause of the accident, the report states, was the intentional overriding of an interlock system that was designed to prevent adding methomyl process residue into the residue treater vessel before filling the vessel with clean solvent and heating it to the minimum safe operating temperature.

Furthermore, the investigation found that critical operating equipment and instruments were not installed before the restart, and were discovered to be missing after the startup began. Bayer’s Methomyl-Larvin unit MIC gas monitoring system was not in service as the startup ensued, yet Bayer emergency personnel presumed it was functioning and claimed no MIC was released during the incident.
CSB Investigations Manager John Vorderbrueggen noted that a major contributing factor to the accident was a series of equipment malfunctions that continually distracted operators. “Human factors played a big part in this accident, and the absence of enforced, workable standard operating procedures and adequate safety systems meant that mistakes could prove fatal. For example, operators were troubleshooting several equipment problems and during the startup, inadvertently failed to prefill the residue treater vessel with solvent. A safety interlock was designed to stop workers from introducing highly-reactive methomyl, but it was bypassed as had been done in previous operations with managers’ knowledge. Once the chemical reaction of the highly concentrated methomyl started, it could not be stopped, and the temperature and pressure inside rose rapidly, finally causing an explosion.”
Read the news release in this link.

Another fire at IOC depot

A depot at a lube blending unit of Indianoil Corporation (IOC) experienced a major fire on Monday night. IOC is a government owned company. IOC also had a very major fire in Jaipur in 2009. Wonder what was the cause of this incident!
NDTV has a video in this link.

Catastrophic risk management

I read a nice article which succinctly summarizes how to identify and cover potential catastrophes their business might face. This is true for the Chemical industry also. I am quoting from the article below:
"1. Identify catastrophic events which could close your operations down in each of your business units and in each region/country in which you have set up shop. Every element of your product range and geographical footprint has its own set of unique risks.
Events can be classified as "internal" where a multiple failure of in-house systems can lead to catastrophe; or "external" where adverse political, economic or natural developments or shocks can cause premature extinction. For example, the range of events can include accidents, civil wars, state expropriation of assets, market collapse, massive disruption of supply chains and earthquakes/flooding.
2. Imaginatively play a scenario on each event highlighting the causal chain which can lead to the catastrophe and the impact on the business of the catastrophe itself. Where possible, select flags which may indicate a rise in the probability of the event occurring such as the abnormal withdrawal of a tide before a tsunami hits the beachfront.
3. With probability of occurrence on the vertical axis and seriousness of impact on the horizontal axis, locate each scenario on the chart so that you have a real feel for the ones you should prioritise in terms of response strategies and tactics. Which are the real catastrophes waiting to happen?
4. Make a list of all the organisations who have relevant roles to perform in the event of a catastrophic scenario materialising. In particular, work out where they fit in the decision-making structure and specifically the people in each organisation to contact as the disaster unfolds. Remember actions taken in the first 48 hours usually determine public perceptions about your competence in handling the event.
5. Just as a catastrophic fire scenario requires preventative measures as well as emergency procedures should it break out in a building or forest plantation, so each catastrophe scenario should carry its own sequence of pre-event and post-event drills. Each option should be subjected to a cost-benefit analysis so that you have the best drills in place to prevent the event happening and to contain it if it happens.
Simple, but very few companies – even among the top multinationals – practice catastrophic risk management. As for the example I quoted at the beginning on extreme weather events, the pieces that are missing are steps 4 and 5".

Read the full article in this link.

Leak detection in buried pipelines

A technique of leak detection in buried pipelines transporting hazardous chemicals has been reported in an article. The article mentions that "Distributed strain/deformation and temperature sensing for pipeline integrity monitoring is a useful tool that ideally complements the current monitoring and inspection activities, allowing a more dense acquisition of operational and safety parameters. The measurements can be performed at any point along the pipeline. Furthermore, the monitoring is continuous and does not interfere with regular pipeline operation in the way that other maintenance can. The method can also be applied to non-piggable pipes".
The article also mentions that the technique successfully detected a leak in a buried pipeline carrying brine. Read the article in this link.

Risk management - the risk is in the management!

Many articles are written about corporate risk management and its statutory requirements. Risk management in a chemical manufacturing company must also take into account the technological, asset integrity and manpower competency risk. In the board's of chemical manufacturing companies, there must be someone to understand these specific risks that are inherent in chemical units. Risk matrices when presented to the board often do not really communicate the risks the company is facing. No board of directors want an incident to happen.It is the failure in communicating these risks to the board that is most worrisome. At the present rates of attrition of management personnel in chemical industries in India, there may be a gap in risk communication to the board, with the result that an incident happens later.
When I conduct process safety management audits, I often observe a huge gap between what is happening at the ground level and the board's perception of management of process safety. The Baker panel report after the BP incident specifically recommended that a member of the board in chemical units must be someone who understands the process safety issues and can communicate the risk to the rest of the members of the board. But this is yet to happen. It is not a question of culture. It is a question of commitment. Without commitment there is no culture.

The report on the BP oil rig disaster - familiar lessons, familiar root causes

The Report to the President of USA by the National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling has been released.
I have summarized the key points from the investigation report:

"The final moments:
Down in the engine control room, Chief Mechanic Douglas Brown, an Army veteran employed by Transocean, was filling out the nightly log and equipment hours. He had spent the day fixing a saltwater pipe in one of the pontoons. First, he noticed an “extremely loud air leak sound.” Then a gas alarm sounded, followed by more and more alarms wailing. In the midst of that noise, Brown noticed someone over the radio. “I heard the captain or chief mate, I’m not sure who, make an announcement to the standby boat, the Bankston, saying we were in a well-control situation.” The vessel was ordered to back off to 500 meters. Now Brown could hear the rig’s engines revving. “I heard them revving up higher and higher and higher. Next I was expecting the engine trips to take over. . . . That did not happen. After that the power went out.” Seconds later, an explosion ripped through the pitch-black control room, hurtling him against the control panel, blasting away the floor.
Brown fell through into a subfloor full of cable trays and wires. A second huge explosion roared through, collapsing the ceiling on him. All around in the dark he could hear people screaming and crying for help.
Steve Bertone, the rig’s chief engineer, had been in bed, reading the first sentence of his book, when he noticed an odd noise. “As it progressively got louder, it sounded like a freight train coming through my bedroom and then there was a thumping sound that consecutively got much faster and with each thump, I felt the rig actually shake.” After a loud boom, the lights went out. He leapt out of bed, opening his door to let in the emergency hall light so he could get dressed. The overhead public-address system crackled to life: “Fire. Fire. Fire.”
Root Causes (failures in industry):
BP’s management process did not adequately identify or address risks created by late changes to well design and procedures. BP did not have adequate controls in place to ensure that key decisions in the months leading up to the blowout were safe or sound from an engineering perspective. While initial well design decisions undergo a serious peer review process155 and changes to well design are subsequently subject to a management of change (MOC) process,156 changes to drilling procedures in the weeks and days before implementation are typically not subject to any such peer-review or MOC process. At Macondo, such decisions appear to have been made by the BP Macondo team in ad hoc fashion without any formal risk analysis or internal expert review. This appears to have been a key causal factor of the blowout.
Halliburton and BP’s management processes did not ensure that cement was adequately tested. Halliburton had insufficient controls in place to ensure that laboratory testing was performed in a timely fashion or that test results were vetted rigorously in-house or with the client. In fact, it appears that Halliburton did not even have testing results in its possession showing the Macondo slurry was stable until after the job had been pumped. It is difficult to imagine a clearer failure of management or communication.
BP, Transocean, and Halliburton failed to communicate adequately. Information appears to have been excessively compartmentalized at Macondo as a result of poor communication. BP did not share important information with its contractors, or sometimes internally even with members of its own team. Contractors did not share important information with
BP or each other. As a result, individuals often found themselves making critical decisions without a full appreciation for the context in which they were being made (or even without recognition that the decisions were critical).
Transocean failed to adequately communicate lessons from an earlier near-miss to its crew. Transocean failed to adequately communicate to its crew lessons learned from an eerily similar near-miss on one of its rigs in the North Sea four months prior to the Macondo blowout. On December 23, 2009, gas entered the riser on that rig while the crew was displacing a well with seawater during a completion operation. As at Macondo, the rig’s crew had already run a negative-pressure test on the lone physical barrier between the pay zone and the rig, and had declared the test a success.163 The tested barrier nevertheless
failed during displacement, resulting in an influx of hydrocarbons. Mud spewed onto the rig floor—but fortunately the crew was able to shut in the well before a blowout occurred.Nearly one metric ton of oil-based mud ended up in the ocean. The incident cost Transocean 11.2 days of additional work and more than 5 million British pounds in expenses.
Decision making processes at Macondo did not adequately ensure that personnel fully considered the risks created by time- and money-saving decisions. Whether purposeful or not, many of the decisions that BP, Halliburton, and Transocean made that increased the risk of the Macondo blowout clearly saved those companies significant time (and money)".

For those of you who are interested in reading the complete report, here is the link. (File is large, be patient...)

Another reactor blast....and another tank blast

An explosion in a reactor in a plant in Vapi has injured at least 6 workers. As per news articles, The blast was powerful and had occurred due to "rupturing of a safety valve". Reading between the lines, it appears it is another case of a reaction gone wrong and inadequate rupture disc sizing.The sizing basis of safety valves and rupture discs need to be documented and understood by plant operators.
The blast wave from the explosion reportedly damaged windows and buildings. Blast waves are extremely dangerous. Read an explanation in this link.
Read the articles in this link: Link 1 and Link 2

Another incident reported is the explosion of an ammonia cylinder or tank in an ice factory in Karnataka. Read about it in this link.

Bhopal disaster - educating our future leaders

A news article mentions that, as part of standard 8 curriculum,the NCERT has introduced a new realistic account of the Bhopal gas disaster. I am happy that authorities are taking the correct steps and educating our children who will be future leaders of tomorrow. I strongly believe that the Bhopal Gas disaster and its lessons must be made mandatory for all students of MBA, chemical engineering,cost accountancy and chartered accountant aspirants.
The news article mentions the following:
"The Social Science edition, that was released this month, recounts the story of the Bhopal gas tragedy under the chapter Law and Social Justice. It not only has a report on the industrial disaster but also raises serious concerns about the fate of the gas-affected people and the weak environment laws in the country.It dwells on how taking advantage of weak environment laws and availability of cheap labour, environmentally dangerous plants open in developing nations.
Several photographs of the incident, victims, deaths and protests have been published in the book. The background colour of the pages has been kept black while the headlines and photo captions are highlighted in red colour.
A caption of one of the pictures says: "Dow, how many more must die?"
The account begins: "The world's worst industrial tragedy took place in Bhopal 24 years ago. Union Carbide (UC), an American company, had a factory in the city in which it produced pesticides. At midnight of 2 December, methyl-isocyanate (MIC) - a highly poisonous gas - started leaking from the UC plant..."
"Within three days, more than 8,000 people were dead. Hundreds of thousands were maimed."Most of those exposed to the poison gas came from poor, working-class families, of which nearly 50,000 people are today sick to work. Among those who survived, many developed severe respiratory disorders, eye problems and other disorders. Children developed peculiar abnormalities, like the girl in the photo."
"The disaster was not an accident. UC had deliberately ignored the essential safety measures in order to cut costs. Much before the Bhopal disaster, there had been incidents of gas leak killing a worker and injuring several."
"24 years later, people are still fighting for justice: for safe drinking water, for healthcare facilities and jobs for the people poisoned by UC. They also demand that (Warren) Anderson, the UC chairman who faces criminal charges, be prosecuted."
Criticising government apathy in allowing the factory to come up, a paragraph of the chapter reads: "Government officials refused to recognize the plant as hazardous and allowed it to come up in a populated locality. When some municipal officials in Bhopal objected that the installation of an MIC production unit in 1978 was a safety violation, the position of the government was that the state needs the continued investment of the Bhopal plant, which provides jobs."
It also has a comparative account of Union Carbide's safety system in Bhopal and its other plant in the United States."At West Virginia (USA.) computerised warning and monitoring systems were in place, whereas the UC plant in Bhopal relied on manual gauges and the human senses to detect gas leaks. At the West Virginia plant, emergency evacuation plans were in place, but non-existent in Bhopal."
I hope the contents of the book are not revised!
Read the article in this link.

Iphone app manages fatigue

An Iphone app has been developed that manages fatigue of flight crew. "The predictions are based on the Boeing Alertness Model developed jointly by Boeing and Jeppesen, which is based on a modified version of the long-validated Three Process Model of Alertness. This contains circadian and homeostatic components to yield predicted alertness.
The modular design of the fatigue risk management solution, however, allows operators to make use of alternative alertness models if desired.An iPhone application based on the Boeing Alertness Model called CrewAlert has also been released by Jeppesen. Available in the Apple App Store for $19.99, CrewAlert is billed as "the first app designed specifically to help airlines and their crews manage alertness and fatigue".This is an interesting development and maybe we in the chemical industry can use a similar type of app for managing worker fatigue!
Read the article in this link.

Ammonia leak incidents

An ammonia leak in a poultry company in US has forced the evacuation of 800 people. The leak occurred from a refrigeration system. The leak inside the plant was so thick the emergency workers "could'nt even see".
It appears that the plant was an "aging" plant. This again raises the question of how residual life assessment of equipment is tracked by companies.Read the article in this link.
Another ammonia leak from a gas cylinder in India which later caused a fire has also been reported. Time and again I see gas cylinders treated with scant respect in many companies. Read the articles about the ammonia incident in these links
Link 1
Link 2