CSB Draft report on DuPont accidents - lessons to learn

The CSB has released a draft report of the three accidents at DuPont facilities. The report mentions the following: "CSB Chairman Rafael Moure-Eraso said the three accidents particularly concerned CSB personnel given DuPont’s longstanding reputation for a commitment to safety. Noting the company started as a gunpowder manufacturer in 1802, and became a major chemical producer within 100 years, Dr. Moure-Eraso said, “DuPont has had a stated focus on accident prevention since its early days. Over the years, DuPont management worked to drive the injury rate down to zero through improved safety practices.” Dr. Moure-Eraso continued, “DuPont became recognized across industry as a safety innovator and leader. We at the CSB were therefore quite surprised and alarmed to learn that DuPont had not just one but three accidents that occurred over a 33-hour period in January 2010.
CSB board member and former chairman John Bresland also spoke at the news conference: “These kinds of findings would cause us great concern in any chemical plant – but particularly in DuPont with its historically strong work and safety culture. In light of this, I would hope that DuPont officials are examining the safety culture company-wide.”
Member Bresland noted the CSB finding that the phosgene hose that burst in front of a worker was supposed to be changed out at least once a month. But the hose that failed had been in service for seven months. Furthermore, the CSB found the type of hose involved in the accident was susceptible to corrosion from phosgene. Team Lead Johnnie Banks said, “Documents obtained during the CSB investigation showed that as far back as 1987 DuPont officials realized the hazards of using the braided stainless steel hoses lined with Teflon, or PTFE. An expert employed at DuPont recommended the use of hoses lined with Monel, a strong metal alloy used in highly corrosive conditions. The DuPont official stated: ‘Admittedly, the Monel hose will cost more than its stainless counterpart. However, with proper construction and design so that stresses are minimized…useful life should be much greater than 3 months. Costs will be less in the long run and safety will also be improved.’”In fact, the Monel hose was never used. Internal DuPont documents released with the CSB draft report indicate that in the 1980’s, company officials considered increasing the safety of the area of the plant where phosgene is handled by enclosing the area and venting the enclosure through a scrubber system to destroy any toxic phosgene gas before it entered the atmosphere. However, the documents show the company calculated the benefit ratio of potential lives saved compared to the cost and decided not to make the safety improvements. A DuPont employee wrote in 1988, “It may be that in the present circumstances the business can afford $2 million for an enclosure; however, in the long run can we afford to take such action which has such a small impact on safety and yet sets a precedent for all highly toxic material activities?”
The need for an enclosure was reiterated in a 2004 process hazard analysis conducted by DuPont, but four extensions were granted by DuPont management between 2004 and 2009, and at the time of the January 2010 release, no safety enclosure or scrubber system had been constructed. CSB investigators concluded that an enclosure, scrubber system, and routine requirement for protective breathing equipment before personnel entered the enclosure would have prevented any personnel exposures or injuries.
The CSB investigation found common deficiencies in DuPont Belle plant management systems springing from all three accidents: Maintenance and inspections, alarm recognition and management, accident investigation, emergency response and communications, and hazard recognition.
CSB Team Lead Banks said, “The CSB found that each incident was preceded by an event or multiple events that triggered internal incident investigations by DuPont, which then issued recommendations and corrective actions. But this activity was not sufficient to prevent the accidents from recurring.”
The CSB draft report recommends that the DuPont Belle facility revise its near-miss reporting and investigation policy to emphasize anonymous participation by all employees so that minor problems can be addressed before they become serious. The CSB report also recommends the Belle plant ensure that its computer systems will provide effective scheduling of preventive maintenance to require, for example, that phosgene hoses get replaced on time.
The CSB draft recommends that the DuPont Corporation require all phosgene production and storage areas company-wide have secondary enclosures, mechanical ventilation systems, emergency phosgene scrubbers, and automated audible alarms, which are at a minimum consistent with the standards of the National Fire Protection Code 55 for highly toxic gases.
Industry groups have established various good practices for the safe handling of phosgene and other highly toxic materials in compressed gas cylinders. The draft report concluded that the most comprehensive guidelines are those set forth by the National Fire Protection Association, or NFPA.
The draft report recommends that industry-organizations such as the Compressed Gas Association (CGA) and the American Chemistry Council (ACC) adopt the more stringent guidelines of the NFPA for the safe handling of phosgene and other highly toxic gases.
The report recommends the Occupational Safety and Health Administration (OSHA) update its compressed gas safety standard to include modern safeguards for toxic gases such as phosgene. These improved safeguards include: Secondary enclosures for units using phosgene, mechanical ventilation systems, emergency phosgene scrubbers, and automated audible alarms".
See the press release in this link 
See a video of the animation of the phosgene incident in this link.

Thermal expansion of crude oil causes an incident

A HSE press release mentions that an incident had occurred in a crude oil pipeline due to thermal expansion of the crude oil. The report mentions that the company had recognized the risk of thermal expansion of crude oil and subsequent pressure increase but had depended on a manual system of draining the pipeline instead of installing engineering controls.
Beware of thermal expansion of liquids trapped in pipelines! Read the press release in this link.

Chemical dosing and storage systems

In many plants that I visit, I observe that many operators of chemical storage tanks and dosing systems do not follow certain basic precautions for avoiding incidents. Greg Humm of West Yost associates has a good presentation on the basic safety requirements for chemical storage and dosing systems.This is applicable for all industries including water treatment. See the presentation in this link. (PDF file - be patient!)

Managing risk in the chemical industry

With strategies of chemical companies always evolving to changing circumstances, I often find that "de-risking" strategies are often applied from a purely financial point of view rather than a combination of financial and process safety risks. In chemical industries, process safety risks need to be carefully studied and evaluated, as a single process incident could wipe out all the gains that you had obtained by de-risking purely from a financial point of view. Similarly, during mergers and acquisitions of chemical companies, process safety risks need to be carefully evaluated. It may cost you more if you do not heed process safety risks.
See BASF's approach to managing process safety risks in this link.

Operational excellence - an example

Chevron's tenets of operation is an excellent example of what process safety management should be! Their tenets, which I am quoting from this link in their website are

1. "Always operate within design and environmental limits.
2. Always operate in a safe and controlled condition.
3. Always ensure safety devices are in place and functioning.
4. Always follow safe work practices and procedures.
5. Always meet or exceed customers’ requirements.
6. Always maintain integrity of dedicated systems.
7. Always comply with all applicable rules and regulations.
8. Always address abnormal conditions.
9. Always follow written procedures for high-risk or unusual situations.
10. Always involve the right people in decisions that affect procedures and equipment".

I specially like the  last tenet. I see many companies NOT involving the right people in decisions that affect procedures and equipment.

Emergency headcounts

During a trip to Singapore, I saw an interesting LCD display outside a very large shop with many entrances and exits. This signage is posted at all entries. It warns  visitors that it is unsafe to enter when monitor turns red! (Approved load is 431).

Emergency scrubbing systems

It is very important to design your emergency scrubbing systems properly. If not, they will fail you when you need them the most. Croll Reynolds has a case history of "a relatively uncomplicated but effective method for handling large runaway emissions of TDI and solvent vapours. "
Read it in this link.

OSHA proposes fines

A news article mentions the following : OSHA has proposed fining a company $119,000/=  for 17 serious safety violations. These include "allowing cylinders to be exposed to physical damage; having inaccurate field verifications on tanks and values; using equipment that was not in compliance with recognized and generally accepted good engineering practices; failing to have clear written operating instructions for processes such as unloading hydrogen fluoride into storage tanks and switching storage tanks; failing to address human factors in relation to remote operating valves on the hydrogen fluoride storage tanks; failing to document and resolve issues addressed by the process hazard analysis team; failing to establish written procedures to maintain the integrity of process equipment; failing to implement written emergency operating procedures for emptying hydrogen fluoride tanks; failing to perform appropriate checks and inspections to ensure equipment was properly installed; and failing to establish and implement written procedures to manage changes to process chemicals, equipment and procedures. The company also was cited for a deficient incident report that did not include factors contributing to the vapor release and the recommendation resulting from the internal investigation. "
Read the article in this link.

Reactor Blast kills two

A reactor blast at a unit in Ankleshwar has killed two persons. Times Of India reports that "R S Ninama, additional district magistrate of Bharuch, said, "Preliminary investigations have found that the blast was caused by overheating of the reactor. The industrial safety department will investigate the accident and find out if safety has been compromised".
While I am not speculating on the cause of the incident, ensure that you are aware of the following:
Reactive chemical incidents are on the increase. Reasons are attributed to:
1. Lack of knowledge on process chemistry
2. Lack of knowledge on designing relief and vent systems
More and more companies are relying on in house R & D to develop new products. Unless you have a good system of ensuring that process safety is taken care of during the scale up from R & D to pilot plant and manufacturing plant, a disaster is waiting to happen.

Read the article about the incident in this link.

Electric heaters + Flammable material = Fire!

A court in UK has imposed a fine of 1.24 million pounds for an explosion in a tank in a gas terminal. A press release from HSE UK mentions the following:

"Investigators traced the cause of the explosion to a leak of highly flammable hydrocarbon liquid into a part of the plant responsible for treating waste water before discharging it into the sea.The leak was caused by the failure of a corroded metal separator vessel, which allowed water contaminated with the highly flammable condensate to enter a concrete storage tank where it was heated by an electric heater. The heater's elements were exposed within the tank, raising the surface temperature significantly causing the explosion and fire"
Read the press release in this link

Global warming and process safety

Just like the scare caused by the Y2K bug, today, chemical industries need to factor in the changes in weather due to global warming. The CSB narrated an incident where there was a propane release due to water freezing in a piping dead leg due to unusually cold weather. When the ice formed, the pipe expanded, cracked and later, when ambient temperature increased, propane came out of the crack and caused a major fire.
A news article reports another incident where a chlorine release occurred due to the freezing of a regulator due to cold weather. Though in India, we do not face such low temperatures, chemical operators must make themselves familiar with the pour points of liquids. Maybe in the not so distant future, we will be having snow and ice in India too!
Read the incident in this link

P2S5 accident

Dr Michael Fox has narrated an incident where a worker apparently inhaled P2S5 dust. he mentions that "When P2S5 enters the lungs it reacts with the moisture in the lungs and forms H2S. Only a very small particle of P2S5 is needed to produce a toxic concentration of H2S once inside the lungs. "
Read the incident in this link.
There are other incidents also which can be viewed from the above link.

Hypochlorite + urea explosion

For my friends in the fertilizer industry, Dr Michael Fox has narrated an interesting incident where an explosion killed one person. The explosion occurred when 12.5% sodium hypochlorite was being unloaded into a tank that previously contained a liquid fertilizer consisting of 78% urea and sulfuric acid (1:1 ratio). His investigation found out that when "liquid fertilizer was added to an excess of sodium hypochlorite, an extremely vigorous reaction plus significant heat was generated. One possible explanation seemed that when there is excess of alkaline sodium hypochlorite, the sulfuric acid is neutralized and what remains is sodium hypochlorite and urea, a mixture said to produce explosive nitrogen trichloride "
Read about the incident in this link.

Explosion proof and intrinsically safe fork lifts

The Hunstman Corporation has reported that it has recently completed an upgrade of their forklifts used in their Chinese facility to meet Chinese standards. The article mentions the following:
"The firm originally imported all of its explosion proof equipment from Europe to comply with EU standard (EN1755:200), American standard (UL NEC500/505) and International standard (IEC). However China only accepts its own in-house standard when accrediting explosion proof equipment.
As a result of this all equipment had to go through system upgrade to ensure that it was up to the Chinese “General Principles for Explosion Proof Industrial Trucks in Explosive Atmospheres” (GB19854-2005). A representative for Huntsman and the factory said:
“The aim was to conduct an overall system upgrade on the European converted explosion proof trucks to meet the Chinese national standard.”
The importance of using explosion and intrinsically safe equipment in potentially unsafe environments is vital, especially when transporting raw materials as is the case in the Guangzhou plant. On vehicles such as forklift trucks components such as the ignition must be adapted to prevent any spark or heat that could cause safety concerns when in the working environment.
The representative added: All the requirements of explosion protection safety management and safety supervision were considered, including, for example, the design and installation of Exd batteries and Exd lights, rewiring of Exd enclosures and changing the start-up battery on the diesel trucks.”
 Read the article in this link

Incidents with relevance to process safety also

Two recent incidents have a relevance to process safety also. In the first, a patient reportedly went into a coma after she was administered NO2 instead of oxygen. The doctors involved in the incident have reportedly been suspended but their contention is that nitrous oxide was filled by mistake in the oxygen cylinder. Ensure your gas cylinders are properly colour coded and you buy it from authorized dealers. Many plant accidents have happened when a wrong gas cylinder was connected and caused an inadvertent reaction.

The second incident, sent by Mr P.Vijayaraghavan, mentions that a housewife was killed due to burns when she sprayed insect repellant near a gas stove that was burning. Insect repellants are propelled by flammable gases. So are some hair sprays. Pressurised spray cans are also used in industry for dye checking etc. Ensure that people read the warning signs written on the cans before they use the can.
Please spread this message. It may save a life.

Process Safety Violations and fines

OSHA has cited a chemical plant for 18 violations, 16 of them considered serious and one labeled "willful."
The news article mentions the following:
"A willful violation is one committed with knowledge of and disregard for the law, or with indifference to worker safety.
OSHA's serious violations included failure to provide a proper hydrogen gas detection system, over-pressure protection, emergency egress, personal protective equipment and hazard communication training. It also cited AL Solutions for failing to safely store flammable materials and ensure the safe use of forklifts.
A minor violation was for failing to keep proper injury and illness records.
OSHA said AL Solutions is now in its Severe Violators Enforcement Program, designed to focus on "recalcitrant employers that endanger workers by committing willful, repeat or failure-to-abate violations."
Read the article in this link.

Submersible pumps and safe work practices

A friend was mentioning about an incident in his plant where a submersible pump was removed for maintenance. The tank contained a molten chemical. The opening where the submersible pump was fixed, was covered with a thin plywood cover. A trainee who was interested to know what was going on, accidentally stepped on the plywood cover which did not hold his weight. The cover gave way and opening was just sufficient for him to slip inside upto his armpits. Luckily other operators were around and lifted him up.
Do your job hazard analysis properly when you issue a permit. It is always better to custom make proper metal covers which are bolted down in place when submersible pumps are removed.

Cooling water treatment without chemicals

I came across an article in which mentions the elimination of chemicals and their associated handling hazards in the treatment of cooling water. The article mentions the following:
"To resolve many of the issues associated with chemical treatment, technologies using non-chemical treatment have been evolving. Non-chemical devices (NCDs) use many different technologies to achieve biological and corrosion control. Over 30 suppliers are known to provide commercially available products that can be grouped into four basic classes or methodologies: magnetic devices; induced electric field devices; ultrasonic devices, and mechanical energy devices.
How CHC Works
The CHC unit consists of a pressure equalizing chamber and a cavitation chamber. Inside the cavitation chamber, two pairs of nozzles are positioned opposite each other at specific distances, lengths, and angles. Water is first pumped into the pressure equalizing chamber at a pump pressure of ~70 PSI. From the equalizing chamber, water is channeled into the cavitation chamber, where water is forced to rotate with high velocities. The rotation of water streams creates a high vacuum, typically greater than -30 inch Hg. This high vacuum condition causes micro-sized bubbles to form in the water streams. These bubbles are filled with a mixture of vapor and dissolved gases. The water streams in two nozzles rotate in opposite directions. Meanwhile, the water streams travel forward at accelerating speeds. Upon exiting from the nozzle, the opposite water streams collide at the mid-point of the cavitation chamber. At this point, pressure increases spontaneously, causing the sudden implosion of micro-sized bubbles. At the moment of collapse, hydrodynamic cavitation generates intensive shocking waves and produces extremely high temperatures. Under these conditions, chemical reactions such as conversion of dissolved calcium and bicarbonate ions into calcium carbonate (CaCO3) and oxidation of organic compounds can occur. In addition, the bacteria in the water are ruptured by mechanical, physical and chemical forces".
Read the article and see the images in this link.

Fire in refinery furnace injures operator

A fire in a furnace in a crude unit in a refinery in the USA has critically injured a worker. He apparently inhaled superheated air. I can imagine the terrible internal burns he must have received. The cause is being investigated.Read about the accident in this link.
OSHA has a good technical description of refinery processes and their safety hazards. Read it in this link.

Learning lessons

The investigation of the refinery tank explosion that killed 4 persons is underway. A BBC news item mentions the following:
"Maintenance work had been carried out on a 730 cubic metre storage tank which exploded on Thursday evening, damaging an adjacent vessel.Dr Ivan Vince, a safety, health and environmental specialist at ASK Consultants told BBC Radio Wales that the investigators will look at two types of causes.
"The first part of the investigation is narrowing it down to exactly what happened and what were the immediate causes," he said. It could be some time before the cause of the explosion is known."Then the route cause investigation looks at the bigger picture like the safety management systems, the adequacy of the training and procedures in general or deeper, the status of the safety culture, the working environment in general."I have never come across a situation where there have not been lessons to be learnt. The problem is lessons are learnt but then forgotten when personnel change."
The last statement is highly significant. Organisations should implement and sustain a process safety knowledge management system.Otherwise, as people change, their knowledge goes with them.
Read the article in this link

A piece of cloth causes chlorine release!

An interesting incident is mentioned by Stephen P. Andrew, T. Kim Parnell, Robert Caligiuri, Lawrence Eiselstein of Parnell Engineering and consulting:
"A process upset at a chlorine production facility resulted in a release that forced the partial evacuation of a nearby town. Investigations revealed that the events commenced with the failure of a shell and tube heat exchanger used to condense chlorine gas. Post-incident inspections revealed a cloth at the liquefier coolant inlet that accelerated the flow in that region, causing certain tubes to be breached. As a result, the water-based brine liquefier coolant was entrained in the chlorine process stream, forming a highly acidic oxidizing mixture. This corrosive mixture then flowed to the chlorine storage tanks destroying an elbow in the tank inlet piping and rendering the tank shut-off tank valve ineffective, thus allowing chlorine to vent into the atmosphere".
Read the detailed report in this link. 

Tank explosion in refinery

An incident in a refinery in the UK has reportedly killed 4 persons. The Telegraph reports the following:

"Four people were killed yesterday evening when a 730 cubic metre storage tank exploded in what appears to have been a tragic industrial accident.This is the first serious accident at the plant. Previous incidents include a small fire caused by a hydrogen leak in 2001 and two fires in 2003 in which no one was seriously injured.John Davies, leader of Pembrokeshire Council, praised the refinery's safety record saying: “I have known it all my life and this is first time as far as I am aware that a life has been lost in similar circumstances. It has an exceptional (safety) record.”

The refinery is one of the largest in western Europe, employing 1,400 people".
Read the article and see the video of the tank and spokespersons comments in this link  We have to wait for the investigation to see why this happened.
See some photos of the explosion in this link.

Understand the basics of chemical safety while managing change

The International Program on chemical safety has a good basic write up on chemical safety - corrosive materials, incompatibilities, materials of constructions, storage and effects of chemicals on concrete. Many times, we tend to forget the basics when managing change, that later results in an incident.
Read the article in this link.

Welder killed in accident

A regulator of a gas cylinder apparently malfunctioned and came out, killing a welder on the spot at an accident in a factory in Odisha. Times of India reports the following:
 "In the accident, Rawat`s leg flew 50 m away from the spot, while the palm of his left hand is still missing, Ponda sub-divisional fire officer Parab said. Quoting the factory officials, Parab said that the blast was the result of a broken knob of a gas cylinder with which Rawat was cutting metal sheets at the Kundaim-based iron plant. "As the cylinder's knob was broken, the force of the gas centered around the knob and moved out with a tremendous force that caused the blast," Parab said."
Treat your gas cylinders and their fittings with respect. I keep observing scant disregard for the handling and safe usage of gas cylinders at many sites. Read the article in this link.

Process safety and metrics - don't get lulled into a false sense of security!

There has been a lot of discussion on how to make process safety management work and new initiatives like risk based PSM and others have been suggested. These include metrics for tracking of process safety performance. The old adage " what cannot be measured cannot be managed" is true for process safety, too. However, I observe a stark difference between metrics for measuring PSM performance and UNDERSTANDING that measurement. In many of today's chemical companies, the board of directors often do not have a person competent to analyze the PSM metric that is being displayed. With the net result that the number being displayed is just that - a number. For example, if a metric that is being displayed to the board is the pending items from a process safety audit, the actual number may be less but its severity may be very high. What is the solution? There is only one answer - the board of directors of chemical manufacturing companies should ensure that there is someone competent to analyse the PSM metrics for them.

Air and cyanide - a potent combination!!

An incident that occured in a gold treatment plant in Australia has lessons to be learnt for all of us in the chemical industry. In this incident, a cyanide line was being cleared of a choke using plant air. The hose was left connected to the system after the choke was cleared. As the blockage was not totally cleared, cyanide pressure went up more than the air pressure and cyanide entered the air system. Two employees were treated for cyanide poisoning.
Read about the incident in this link. .

Transportation of hazardous cargo - How ready are you?

As India's highways develop rapidly, more and more transportation of hazardous chemicals take place on our highways. Many of you will agree that there is still a lot more to do to improve the safety while transporting hazardous cargo. 35 years ago, in the US, there was an accident involving a road tanker carrying liquid ammonia, which reportedly killed 7 persons. The cause of the accident was reported to be speeding, sloshing of the partially filled tanker, and inadequately designed guard rails. The lessons learnt from that accident are still valid today. A blog post mentions the following about the reasons for the accident:

• "The truck was driving at or near 53.6 mph when it took the curve taking it from the Loop to the Southwest Freeway. We’ll probably never know why Schmidt was speeding when he exited the Loop.
• Back then, barrier systems on routes that carry hazardous materials were not capable of redirecting vehicles that transport dangerous materials. The bridge rail at that stretch of road was more equipped to contain automobiles than trucks carrying hazardous cargo.
• The ramp where the crash occurred opened in 1963.
• Schmidt, who had been employed by Transportation Co. of Texas since 1975, had driven commercial vehicles since 1969. He had left Corpus Christi between 5 and 5:30 a.m. for the Tenneco plant and had made at least 10 trips to Houston carrying liquid loads.
• It’s said that this crash led to restrictions on the transportation of hazardous cargo through Houston, but that’s not necessarily the case. According to the NTSB report, the city had been using Loop 610 as a hazardous materials route since 1970."

Read about it in this link.

Blast in storage of raw materials for explosives

Times of India has reported a blast in a stores containing raw material for manufacturing explosives, in Nagpur. The reason is being investigated.. According to the article, "The blast that obliterated at AMA Industries' store in Bazargaon on Thursday morning and caused a tremor in the city, also left those in this business confused. The structure housed raw materials for making commercial explosives and did not have finished products. Experts say the thumb rule is raw materials usually would not explode unless bound into a single explosive even in case of a fire. They can burn resulting in a massive fire but not cause a blast, said industry players on condition of anonymity. "Various chemicals like ammonium nitrate, aluminium powder, sulphur when mixed in specific proportions make an explosive. However, all such chemicals stored at different places even in a single premises do not explode under normal fire. A safe distance has to be maintained for storing each of them," said an explosive maker. Aluminium powder is known to catch fire if water is sprayed on it but still a blast is not heard of, he added".
Read the article in this link 
Read another article on the effect of the blast wave in this link. 

Mechanical seals and flushing/cooling systems

(Diagram Courtesy Flowserve) Mechanical seals need to be understood by plant operators for their proper operation. Many times, the operations and maintenance personnel are at loggerheads because many of the operation personnel do not fully understand the principles of seal flushing/cooling systems. Flowserve has a very good mechanical seal piping plan document in this link which clearly explains the functioning for various types.

Aviation safety and Chemical Process Safety- Different approaches!

I was reading a press release by the Press Information Bureau about the improvements made by the civil aviation minsitry one year after the fatal Mangalore air crash. The report mentions the following:
"A Civil Aviation Safety Advisory Council (CASAC) was formed on May 28, 2010 with the mandate to strengthen aviation safety environment through synergisation of available expertise in areas of airlines, airworthiness, operations, air navigation, aerodromes, aircraft engineering, human performance. Special invitees to the Council include FAA, ICAO Experts, IATA, Airbus, Boeing, Bombardier etc. This is an ongoing initiative under the Chairmanship of Secretary (Civil Aviation). The Council gets its technical inputs from working groups covering Operations (Fixed wing and helicopter sub-Groups), Aerodromes, Air Navigation Services, Airworthiness General Aviation and Helicopters. Based on the reassurance drive several issues in the three areas of aerodromes, operations and airworthiness came up. Immediate actions to address the deficiencies have been taken up during the past one year. Several safety related circulars have been issued and implementation ensured. These include presence of Cabin crew in cockpit in case of one pilot leaving the cockpit, Cabin Crew to interact with pilots on intercom during period of lean cockpit activity, in the event of incapacitation of PIC, copilot to take over control and in the event of PIC not responding to calls of copilot regarding ‘go around’, assertiveness by copilot to be encouraged. Regulatory provision for penal action for reporting for duty with alcohol consumption has been made. Pilots are being subjected to Breath Analyser test prior to flights. License are being suspended for three months in case of first BA positive and on second BA positive instance, the licence is cancelled.
In a move to step up the quality of training Captains, the period of Instructorship/ Examiner-ship has been restricted to 5 years with proficiency check every 2 years. Increased oversight for selection of trainers, quality of training imparted by trainers, integrity of simulator training have been introduced. Breath Analyser Test has been mandated for approval of Training Captains and Pilots with BA ‘positive’ report have been debarred from becoming Training Captains. Existing Training Captains if found BA ‘positive’ are debarred from training Captain list for three years.The process for approval of foreign pilots has been made stringent wherein background checks are being done to ensure that these pilots have accident free record. The experience requirements for the foreign pilots have been enhanced and the pilots are subjected to Proficiency Checks before approval is granted by DGCA. These pilots are being subjected to same medical standards as the Indian pilots."  Read the press release in this link
While appreciating the efforts taken by the Government in improving air safety, I could not help comparing the status of process safety management in India after the Bhopal disaster, when compared to developed nations. The PSM rule which is mandatory in USA since 1992 is still not mandatory in India......

Magnesium dust explosion?

An I pad manufacturing facility in China has experienced a possible magnesium dust explosion injuring 16 workers. The incident is being investigated. The news article mentions the following:
"Currently, little is known about the cause of the explosion. However, reports by the local Chinese media have stated that the explosion was caused by the ignition of magnesium dust. Magnesium is a highly flammable metal that is commonly used in industrial polishing processes. As reported by CNET, magnesium is also used in the manufacture of fireworks and flares. Faulty or deficient ventilation systems at the Chengdu plant may have allowed magnesium dust to accumulate in the atmosphere. If that was the case, even a small spark would have been enough to trigger an explosion". Read the news article in this link

Learn from these process incidents

The Industrial Disaster Management Information System of the Government of Gujarat has given information about 15 process incidents. Learn from these incidents as they seem to be occurring with alarming frequency in other places too. Read about the incidents in this link.

Are we prepared to tackle a major disaster?

A news item in the Hindu newspaper indicates that a mock drill that was held in Andhra Pradesh had shortcomings. The report mentions that

"During the exercise, it was found that except fire, police, revenue, medical, and civil supplies departments, the other departments did not respond to the expected level to the crisis. According to a senior official, there was zero response from the Greater Hyderabad Municipal Corporation (GHMC) stating that the accident area did not fall under their jurisdiction.

“The officials concerned failed to respond even after information was passed on to Hyderabad. Will their reaction be the same if such an accident occurs in reality?” asked an official. He also admitted that many of the district officials failed to participate in the exercise and that there was a need to check their preparednes".

 If after 27 years after the Bhopal disaster, we are still not prepared, I wonder what the situation will be when an actual disaster strikes!

Read the article in this link

Design your scrubbing systems properly

Scrubbing systems are your last line of defence. Ensure that adequate redundancy is provided to ensure that the system will work properly when needed. In an incident the CSB investigated, excess chlorine vented to a scrubber where it completely depleted the active scrubbing material (caustic soda), over-chlorinating the scrubber. The resulting decomposition reaction vented chlorine vapors to the atmosphere. Hazardous emissions continued for about six hours and led to the medical evaluation of five residents and 11 police officers, and the evacuation of 1.5 square miles. Read the CSB recommendations in this link.

Failure of UPS leading to turbine bearing damage

BHEL India has a good presentation on the importance of maintaining your UPS supply. In some of the incidents mentioned, the turbine bearing temperature increased to 140 Deg C and got damaged due to failure of UPS and auxiliary oil pump not coming in line afterthe turbine tripped. All failure modes of your UPS must be studied and corrective actions implemented. A UPS is a silent watchdog and if it malfunctions when it is required, it can cause a serious process incident. See the presentation in this link.

Combustible dust hazards - the explosions continue

The CSB has concluded that combustible iron dust has caused and explosion that killed one worker. The CSB mention the following:
"The first incident occurred on January 31 as two maintenance mechanics on the overnight shift inspected a bucket elevator that had been reported to be malfunctioning due to a misaligned belt. The bucket elevator, located downstream of an annealing furnace, conveyed fine iron powder to storage bins. The two mechanics were standing alone on an elevated platform near the top of the bucket elevator, which had been shut down and was out of service until maintenance personnel could inspect it. When the bucket elevator was restarted the movement immediately lofted combustible iron dust into the air. The dust ignited and the flames engulfed the workers causing their injuries. A dust collector associated with the elevator was reported to have been out of service for the two days leading to the incident.
The second incident occurred less than two months later on March 29 when a plant engineer, who was replacing igniters on a furnace, was engulfed in combustible dust which ignited. In the course of the furnace work, he inadvertently dislodged iron dust which had accumulated on elevated surfaces near the furnace. He experienced serious burns and bruises as a result of this second event; a contractor witnessed the fireball but escaped without injury."
Read the news release in this link.

The importance of properly designed back ups

A very good article by Bela Liptak about the back up systems at Fukushima mentions the following:
"The earthquake destroyed the electric power supply of the plant (the connection to the grid) which by itself should not have been a serious problem, because backup diesel generators (18) were provided. It seems they failed because they were not elevated and the 18-ft waves of the tsunami reached and damaged them. The reason for their being installed at low elevation was probably both convenience and concern for their stability. The destruction of these generators could have occurred because water entered the diesel fuel tanks and sank to the bottom because water is heavier than the diesel fuel. As the engine takes its fuel supply from the bottom of the tanks, water instead of oil reached it. It is also possible that the air intakes of the engines were not elevated and ended up under water. If either or both of these conditions existed, the engine could not operate.
The secondary battery backup (19) was of no use either because it was drastically undersized. It provided only about eight hours worth of electricity, while about ten times that would have been needed to supply the electricity needed for a safe shutdown. (It should be noted here that of the 104 American reactors, 93 are provided with only four-hour battery backups). Another problem in the Fukushima plant was the lack of automatic battery recharging. This could have been provided because the plant was still generating steam at a rate of about 5% of full capacity and, therefore, some of the turbine-generators could have been kept in operation.
No other backup was provided at the Fukushima plant. This is unfortunate, because electricity itself is not essential to cool the reactors. For example, if emergency cooling water tanks were provided on the roof, would have made it possible to charge water just by gravity, and if those tanks were properly sized, the accident could have been prevented."
Read the full article in this link