Lessons from emergency response

That's me standing in yellow bunker gear (First left, next to Instructor) during the intensive emergency response training course at Dubai in 1996! In my 32 year career, I have seen many plant emergencies and there are always some lessons to be learnt. Murphy's law always applies during emergencies! But it is always better to be prepared both mentally and physically. An article by FEMA on one of the worst chlorine releases in the USA (70 MT was released) summarises the lessons learnt from that incident:
"Lessons Learned
1. The problems associated with a high-risk occupancy in one jurisdiction, creating a prob­lem in a different jurisdiction, present obvious challenges for emergency planning response agencies.
In this case the responding agencies worked well together, but the deficiencies of the regulatory and planning processes were a major focus of attention after the incident.
2. The Incident Command System (ICS) proved to be extremely effective in this incident, par­ticularly in coordinating the efforts of several different agencies at the scene.
The ability to assign major responsibilities to command officers from different fire depart­ments, without any problems, is evidence that the personnel are trained and prepared to operate effectively.
3. The lack of effective radio communications between agencies was a problem at this incident.
Cellular telephones were used very effectively to supplement public safety radio capabilities and proved to be reliable under these circumstances. In other situations cellular telephone service has been compromised by the number of persons trying to use the systems under emergency conditions and particularly the heavy use of the systems by news media personnel. The loca­tion and time of day may have been key factors in making the cellular network responsive in this incident. Note: Centel Cellular will block off communications allowing only emergency personnel phones to work if the system starts to overload.
4. The decision between evacuating residents and warning them to remain indoors, with win­dows and outside air inlets closed, is often critical.
In this case, it was considered more practical to keep patients inside the hospital than to expose them to the outside atmosphere. This took into consideration the susceptibility of the patients to chlorine exposure, the ability to exclude outside air from the ventilation system and the avail­ability of medical personnel and equipment inside the hospital. Some area residents reported that they were notified to evacuate and were exposed to the chlorine cloud while waiting for busses to pick them up. The risk of exposure during evacuation may have been greater than the risk if they had remained indoors.
5. The use of buses operated by fire department personnel is a practical means to evacuate residents.
It is more feasible to have firefighters drive buses than to train bus drivers to use SCBA. It is equally difficult for firefighters using SCBA to convince residents to expose themselves to the outside atmosphere in order to evacuate, unless the residents are already in distress. The contin­gency plan, sending a crew of SCBA-equipped firefighters on a bus to enter and evacuate an area in immediate danger, is a practical innovation.
6. Police officers, who are not provided with or trained to use SCBA, were effective in evacuat­ing areas ahead of the contamination, but could not function in the contaminated areas.
Several police officers who were assigned to traffic control or to assist with evacuation were exposed to the chlorine cloud and transported themselves to medical facilities for evaluation in the later stages of the incident.
7. Due to the relatively low concentration of chlorine in the gas cloud, in this case, the pre­dominant medical condition was limited to short duration respiratory irritation.
Chlorine is detectable by odor at very low concentrations and is a respiratory irritant between 3 and 30 ppm. Individuals with chronic respiratory problems, such as asthma, were quickly affected and accounted for most of the hospital admissions.
8. It proved to be extremely difficult to determine the size, shape, and movement of the chlorine cloud.
Helicopter observation was a valuable asset, particularly with increasing daylight. Ground sam­pling over large areas is difficult to coordinate and requires careful mapping to be effective. An attempt was made to predict dispersion of the chlorine using CAMEO (a computer model pro­gram), but complicated factors of terrain, slope, temperature, wind velocity, relative humidity, and an unknown rate of release made predictions extremely difficult.
9. The application of water to the vapor cloud was considered in this situation to accelerate the evaporation of the pooled liquid.
Conventional wisdom suggests that massive applications of water spray could absorb chlorine from the air, resulting in a dilute liquid solution. Chlorine has a low rate of solubility in water, and, with a large leak, there is a concern that applying less-than-sufficient volumes of water would create a corrosive fog. Applying water to a container of liquefied chlorine could heat the contents to their boiling temperature and cause the container to rupture. It is often difficult or impossible to estimate the flow and rate of vaporization from a leak to make such determinations.
10. The delay in notification of the fire department and other agencies indicates a problem with plant personnel and the established standard operating procedures at the facility.
A review of communications tapes reveals that no call was received by the police or fire depart­ments for this incident from the facility. A private-sector ambulance provider had been requested to respond to transport plant employees who had been exposed to the chlorine gas.
11. While emergency procedures had been planned for the chlorine facility itself, there was no specific plan for notification or evacuation in the event of a chlorine leak or other emer­gency extending beyond the property line.
Due to the risk created by the chemical industries in the area, the need for emergency warning systems should be evaluated. This level of planning requires both private- and public-sector participation.
12. The fact that the incident occurred at the facility where the CHLOREP Team equipment was stored caused unusual problems. Most of the equipment that could have most valuable in trying to secure the leak could not be reached because it was in the Hazmat area. This included the SCBA units normally used by the team members, which are of a different type from those used by area fire departments. Another chemical plant in the area was able to provide the needed SCBAs for the plant members on the entry team".

Read the excellent article in this link.

Hot work incident and hydrogen peroxide fire

An accident during a hot work has claimed the life of one person in the USA. It is reported that hot work was going on a pipeline containing coal tar solvent when the explosion occurred. Make sure that your equipment are free of flammables before you allow any hot work.Read the news article and see the video in this link.
Thanks to Abhay Gujar for sending information on a hydrogen peroxide fire in Australia.About 1000 L of H2O2 apparently caught fire in this incident. See this link.
A good write up on the hazards of Hydrogen peroxide by Solvay Chemicals is given in this link The write up mentions the following
"Hydrogen peroxide is a powerful oxidant,and improper handling or use of the product can create potential hazards. For example:
• If hydrogen peroxide solutions come in contact with eyes, severe injury or even blindness can result.
• Hydrogen peroxide will irritate and possibly cause chemical and/or thermal burns on the skin.
• Ingestion may be fatal.
• Decomposition of hydrogen peroxide generates heat and gas which can result in rapid pressure buildup leading to pressure bursts of inadequately vented containers.
• Decomposition of hydrogen peroxide can generate sufficient heat and oxygen to initiate combustion of ignitable materials.
• Oxygen enrichment of hydrocarbon vapors resulting from the decomposition of hydrogen peroxide can result in vapor phase explosions.
• Hydrogen peroxide can form explosive mixtures with some organic substances.Hydrogen peroxide aqueous solution is noncombustible. If involved in a fire, it may decompose, yielding oxygen that supports combustion. Decomposition in confined spaces may result in pressure burst. If involved in a fire, keep containers cool by spraying with water. For fire fighting, use only water; do not use other extinguishing agents. Keep upwind and operate from a safe distance. Firefighters should wear full personal protective equipment (bunker gear) and SCBA (self contained breathing apparatus)".

Facility siting - fiberglass tanks and radiated heat

An incident in the US highlights the need for a careful evaluation of siting (location) of fiberglass tanks. In the incident, a fire from a hydrocarbon relaease due to an equipment failure led to the melting of a fiberglass tank containing hydrochloric acid. The HCl spilled into a dyke area. If you are using fiberglass tanks for storing hazardous chemicals, take into consideration the heat radiated from nearby potential sources of fires.
Read about the incident in this link.

Dangers of pneumatic testing

Pneumatic testing is carried out in certain cases where water should not be permitted in the system and for other design considerations. However pneumatic testing can be deadly if certain precautions are not followed. The Alberta Boiler Safety Association has provided the following tips:

"Due to the large amount of energy stored in compressed gas and the potential hazard of a sudden release of this energy, pneumatic testing should be avoided if at all possible. The data in Table 1 illustrate the comparative risk of a pneumatic test versus a hydrostatic test:

A pneumatic pressure test should only be considered if a hydrostatic test has been carefully reviewed and determined not to be feasible. When pneumatic testing is necessary, there are many critical safety precautions that must be considered. Some important considerations are:
a) Code of construction requirements for pneumatic test (e.g., UW-50 for ASME Section VIII Div. 1).
b) A determination of the energy stored in the test fluid. Calculations may be made based upon the isentropic expansion of a confined gas. 
c) Test site preparations and related precautions including removal of unauthorized personnel, isolation of test site and a determination of the restricted distance for the pneumatic pressure test. The restricted distance is the distance from the item(s) under test at which barriers are placed to prohibit access, and the distance at which the test is monitored.
For the example cited above, with approximately 2,000,000 ft-lbs of stored energy (equivalent to one pound of nitroglycerine) the restricted distance using the NASA Glenn Research Center methodology would be 80 feet.
d) Test medium, pressure source and pressure and temperature ranges during testing.
e) Provision of pressure relief valves, which must be sized to handle the maximum output of the pressure source, to avoid excessive testing pressure.
f) Material specifications of the vessel or system involved in the test. For materials whose resistance to brittle fracture at low temperature has not been enhanced, a test temperature above 60 ºF (16 ºC) should be used to reduce the risk of brittle fracture during the pneumatic test.
g) Precautions taken to prevent gas expansion temperature drop and thermal stresses due to temperature gradients".
Read the article in this link.

In February 2009, a LNG pipeline undergoing pneumatic testing killed a worker when it exploded.Here is the link for that accident along with pictures.

Confined space deaths

A fatality has been reported on Monday at a refinery in Singapore where a 34 year old Indian Worker reportedly died while carrying out maintenance work in a confined space.filled with nitrogen. Be very careful when working in confined spaces and with nitrogen inside. You cannot afford to relax your vigil even for a minute. Ensure your companies procedures are clearly understood by all contractors.
Read the article in this link.
Today's Hindu newspaper has reported that three workers in a Ranipet tannery were asphyxiated when they inhaled toxic gas in a chamber in a tannery. They had entered the chamber to lay new lines.
For all of you who work in the industry, remember that safety has no holiday. 

Process Safety - best built in design

I read an article about North Americas largest sulphuric acid plant (4500 STPD). The design of the plant took into account the requirements of PSM and they have used 3D modelling,simulation and CFD modelling etc to build in process safety and control of emissions at the design stage itself. One of the innovations is the use of novel expansion joints for the large diameter piping.The article mentions the following:
"The large plant size and expansion movements required special attention to thermal growth. MECS developed a Swivel Expansion Joint to use in place of a multi-bellows expansion joints when the thermal movement of the duct connecting the associated equipment was in more than one plane. An internal cable allows for multi-directional movement and also accounts for the internal pressure thrust being exerted from the single convulsion joint. This design eliminates the need for the external tie-backs that would be required when using a typical multi-bellows expansion joint".
It is always cheaper to build in process safety at the design stage itself instead of retrofitting later.
Download the article (large file 10mb) from this link.

Process Safety - enforcement is the key

A refinery in the USA has been proposed to be fined US$ 207,500/= for 45 alleged serious and 13 other-than-serious violations for exposing workers to possible fires, explosions and other hazards.
The news article mentions the following:
"OSHA inspected the refinery under its Petroleum Refinery Process Safety Management National Emphasis Program. The PSM standard emphasizes the management of hazards associated with highly hazardous chemicals and establishes a comprehensive management program that integrates technologies, procedures and management practices.
OSHA’s Baton Rouge Area Office began its inspection Sept. 15, 2010, at the company’s facility on Old Highway 7. Serious violations include failing to conduct adequate inspections and testing of piping and pressure vessels; ensure that employees in process and administrative buildings were provided adequate protection in case of an explosion; implement written operating procedures; resolve recommended actions resulting from compliance audits; provide an adequate confined space program; and provide an adequate lockout/tagout program for the control of hazardous energy.
Other-than-serious violations include failing to provide the required machine guarding and correct electrical hazards".
I was reading an article about two deaths due to an accident in a chemical factory in India. The article quotes the Director of Factories as follows 
"We filed charges against the company with negligence, issues of safety and standards of equipment, among others," .He said if the court agrees with the charges, there can be a fine ranging from Rs 25,000 to Rs 2,00,000 under the Factories Act, 1992, for causing deaths". Rs 2,00,000/= is about US $ 4500. You can draw your own conclusions!!
Read the article on the US refinery in this link
Read the article about the accident in the Indian Company in this link.

Chemical Safety Authority needed in India

It is good to note that a Civil Aviation Authority is being set up by the Govt. to address safety issues in aviation.As per a news article, "the proposed CAA, which would have administrative and financial autonomy, is also likely to keep a tab on the entire range of activities —from proper provision of air traffic services and licensing to financial fitness of airlines.Government plans to bring in a legislation to establish the CAA. Bhushan said the CAA would have a "lot of financial, administrative and procedural independence. We will be able to recruit (professionals) directly" instead of routing it through the Union Public Service Commission".
On a similar line, it would be good if a Chemical Safety Authority  on the lines of the Chemical Safety Board of the USA is set up in India. Read the article about the Civil Aviation Authority  in this link.

Inferno at German oil refinery

Thanks to Abhay Gujar for sending information on a major fire in a ship which was being loaded with gasoline in Germany. The article mentions the following:
"A police spokesman in the town of Lingen an der Ems, in the northwestern state of Lower Saxony, confirmed a series of massive explosions rocked the ship near an oil refinery on the Dortmund-Ems canal where the ship was being loaded late on Monday evening. A significant amount of fuel leaked out, with firefighters spending hours trying to tackle the blaze. Eventually, they brought the flames under control, preventing them from spreading to fully-loaded tankers nearby. All five crew members on the ship escaped the inferno, according to police, although one of the men suffered minor injuries".
Read the article and see photos in this link.

The importance of correct measurement in Process Safety

In February 2008, a stealth bomber of the US airforce crashed soon after take off. The pilots ejected safely but the loss was USD 1.4 billion. Wikepedia mentions the following about the cause for the crash...
"The findings of the investigation stated that the B-2 crashed after "heavy, lashing rains" caused water to enter skin-flush air-data sensors, which feed data to the computerized flight-control system. The water distorted preflight readings in three of the plane's 24 sensors, causing the flight-control system to send an erroneous correction to the B-2 on takeoff. The B-2 quickly stalled, became unrecoverable, and crashed. The sensors in question measure numerous environmental factors, including air pressure and density, for data to calculate airspeed, altitude and attitude. Because of the faulty readings, the flight computers determined inaccurate airspeed readings and incorrectly indicated a downward angle for the aircraft, which contributed to an early rotation and an un-commanded 30-degree pitch up and left yaw, resulting in the stall"
Whatever advanced process control systems you may have, it ultimately depends on the measurement reading that the system receives. Focus on the integrity of your primary measuring devices.
Read the article about the crash in this link.

Bayer stops MIC production

A news article mentions the following:
"In a surprise move in U.S. District Court in Charleston, attorneys for Bayer CropScience announced they were dropping plans to resume production of the chemical, commonly called MIC, and would begin dismantling the unit.
That ends the key part of the latest lawsuit in a nearly three-decade battle.But Bayer's decision erases a threat that loomed over the people of Institute for a generation.
The company will no doubt replace MIC, which is used to make a pesticide, with some other chemical, but nothing could be as bad, said Oden, a retired biology professor at West Virginia State University who still lives next to the plant."Chemicals don't have to kill," she said.
"There were so many questions that weren't answered," she said. "And I know there' no such thing as foolproof, because look at the situation in Japan. There's no safe, foolproof ways for doing most of what we do."
A 2008 accident that killed two workers and sent projectiles dangerously close to an aboveground MIC storage tank brought new scrutiny from Congress and the U.S. Chemical Safety Board.
The explosion also showed larger, more affluent communities in the Kanawha Valley that they too could be in danger — towns that the folks in Institute can't help but notice are whiter. In all, some 300,000 people live in the 25-mile MIC "vulnerability zone," which includes the state capital.
MIC is a colorless chemical used to make pesticides, polyurethane foam and plastics. It attacks the respiratory system, and at low levels, can irritate the eyes and throat. High concentrations can cause serious lung damage, hemorrhaging and death.
Several companies manufacture it, but the Institute plant is the only one in the nation that still stores it in large quantities.
Bayer has said it spent $36 million to improve safety and upgrade equipment, and that it slashed its MIC stockpile by 80 percent and eliminated all aboveground storage. How long it will take to exhaust the remaining supply and rid Institute of MIC entirely was not immediately clear.
Less than two years after Bhopal, Congress passed the federal Right-to-Know Act, to help the thousands of people around the country who live in the shadow of industry know what chemicals are made and stored in their neighborhoods. But that openness began to diminish after the terrorist attacks of 2001. Chemical plants became viewed as potential targets. Reports on the toxic inventory of industries were no longer as readily available to the public.

Read the full article in this link

"A Fail safe fails"

A news item in the The Wall street Journal reports the following:
"BP PLC came within 1.4 inches or less of preventing the worst offshore oil spill in U.S. history, say engineers studying the safety device that failed in last year's Gulf of Mexico disaster.
The device, known as a blowout preventer, was a massive set of valves that sat on the sea floor nearly a mile beneath the Deepwater Horizon drilling rig, which floated on the surface. It was equipped with powerful shears designed to cut through pipe and seal off the well in an emergency. Why the device failed has been one of the central mysteries of last year's disaster.
In a report released Wednesday, engineers hired by U.S. investigators say they have solved it: The force of the blowout bent the drill pipe, knocking it off-center and jamming the shears. Rather than seal the well, the blades got stuck 1.4 inches or less apart, leaving plenty of space for 4.9 million barrels of oil to leak out.
The investigators concluded the blowout preventer failed as a result of a design flaw, not because of misuse by BP or any of the other companies involved, and not because of poor maintenance. The fail-safe device, the last line of defense against a disaster, wasn't designed to handle a real-world blowout, according to investigators, who called for further study of the devices.
The report doesn't address what caused the blowout itself. That has been the subject of several other major inquiries, which all have found that a series of decisions by BP and its contractors set the disaster in motion.
Even if the device had worked, it wouldn't have saved the lives of the 11 rig workers killed in the accident. That's because no one even tried to activate the shears until after massive explosions killed the men and crippled the rig. But the device could have mostly prevented the oil spill that began when the Deepwater Horizon sank two days after the initial explosion".
How sure are you that your fail safe devices will work as intended? Today there are systems available to conduct a online partial stroke test of critical valves. But the test is done during normal operating conditions. In the case of a major upset or incident, conditions may prevent the fail safe devices from working. 
Read the article in this link.