Explosion in boiler due to acid cleaning

Two people were killed when an explosion occurred in a acid cleaned boiler. The explosion occurred when a an ordinary halogen lamp was inserted inside. The investigation report mentions the following:
"The most likely cause of the accident was the ignition of hydrogen gas that built up in the starboard boiler steam drum. The hydrogen accumulation occurred because of inadequate ventilation arrangements to release the gas to atmosphere, as it evolved during the chemical cleaning procedure. As the steam drum door was opened, air was drawn in and combined with the hydrogen gas to produce a mixture between the hydrogen’s Lower Explosive and Upper Explosive Limits. This potentially explosive gas was not ventilated to atmosphere, nor was the confined space of the steam drum tested for toxic or flammable gases in accordance with normal practice. As the non-intrinsically safe, halogen lamp was passed into the steam drum, either the high temperature of the halogen bulb or lens glass, or an electrical spark from the lamp, ignited the gas and caused the explosion
Southampton University’s report at Annex O clearly explains how hydrogen gas can evolve when using sulphamic acid to clean steel structures such as boilers. A conservative estimate was made of the amount of hydrogen gas that was likely to have evolved through contact with the steel in the starboard boiler. This estimate, which did not consider the interaction of other possible contaminants, was based on the assumption that there was no effective ventilation and the inhibitor was 95% efficient. The report determined that, at the point of opening the steam drum, there would have been about 2.7m3 of hydrogen present, giving a hydrogen air/mix of about 55%. This is well within the hydrogen LEL and UEL range of 4 -75%, i.e. an explosive mixture existed in the steam drum"
Often heat exchangers and new equipment are acid cleaned using sulphamic acid, in chemical industries. Ensure that your personnel as well as the contractor personnel who are doing the job are aware of the hazard of hydrogen generation in the process of acid cleaning. I would like to know from readers whether they have experienced any similar incident and what are the precautions you follow.

Read the detailed incident report in this link.
 
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Molasses tank leak

A news item mentions that a molasses tank in a sugar factory in Odisha had developed a crack and molasses entered the " staff quarters" and killed three persons.
Read the article in this link.
 
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Horrible confined space incident

Two metalworkers were "cooked" inside an oven after a worker mistakenly switched it on. The news report mentions "Detectives investigating the horrific deaths in the massive oven say the pair had tried to rip the insulation off the wall of the oven and clawed at the door in a desperate bid to get free".
Ensure you follow all your confined space entry procedures, including lock out, tag out and try procedures.
Read about the incident in this link.
 
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Major gas leak from oil rig

A major gas leak from an oil rig in the North sea has been reported. The gas has not caught fire yet. The rig and surrounding ones were evacuated. The flare on the rig continued to burn but the wind direction was blowing the gas away from the flare. Read/ see the videos in these links:
Link 1
Link 2

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Fatality due to fall through removed grating

Thanks to Senthilkumar for sharing news of a fatal accident due to fall through a removed grating:
"At the filtration section of a Phosphoric Acid Plant plant maintenance personnel were lifting a 3 meter filter cloth through a removed grating at the filtration floor at 12 m height. The filter cloth was being removed every four weeks. To lift the filter cloth, the gratings are removed and fixed back every time after lifting/replacement of the filter cloth. Unfortunately the same operator who was watching the lifting activity stepped in to the open hole (of the removed grating) while talking in a radio. He died because of the fall from from 12 m height to ground level".
Removed gratings are very dangerous. During erection or maintenance stages, ensure you have proper control over them. 

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Confined space and gas detectors

Thanks to S.Selvam for sending news about an incident where the gas detector used for confined space tests was out of calibration.Read about the incident in this link.
 Another article by Concept Controls mentions the following:
'There has never been a consensus among manufacturers regarding how frequently confined space gas detectors need to be calibrated. However, manufacturers do agree that the safest and most conservative approach is to verify the
performance of the instrument by exposing it to known concentration test gas before each day’s use. This functional “bump test” is very simple and takes only a few seconds to accomplish. It is not necessary to make a calibration adjustment unless the readings are found to be inaccurate. The regulatory standards that govern confined space entry
procedures are in agreement with this approach'.
Read the article in this link.

Contribute to the surviving victims of Bhopal by buying my book "Practical Process Safety Management"

Lessons to learn from safety report of Railways

The Indian railways high powered committee on rail safety has published its report. There are two recommendations in the report which also apply to process safety management in India. I am quoting from the report: "There is no practice of independent safety regulation by an independent agency separate from operations. The Railway Board has the unique distinction of being the rule maker, operator and the regulator, all wrapped into one. Commissioners of Railway Safety though considered to be the safety watchdogs have negligible role at the operational level. Compliance of safety standards set by Railways for themselves are often flouted for operational exigencies. The Committee has recommended a statutory Railway Safety Authority (RSA) and a safety architecture which is powerful enough to have a safety oversight on the operational mode of Indian Railways without detaching safety with the railway operations. The Committee has also recommended measures to strengthen the present Railway Safety Commission to undertake meaningful regulatory inspections" IR suffers from ‘IMPLEMENTATION BUG’. Implementation of accepted recommendations of the previous safety committees has been a major issue. The Committee has recommended an empowered group of officers in Railway Board to pilot the implementation of the recommendations in a time bound manner with full funding. The Committee has also recommended the review of implementation of recommendations by the new statutory outfit of Railway Safety Authority under Government of India. In India, we need to make PSM mandatory and bring an independant investigating authority like the CSB. Also, the recommendations of safety audits need to be followed up. Read the full report in this link.

Capacitor failure incident

An interesting incident of a capacitor failure aboard a ship is reported.
Chemical plants use capacitor banks to improve power factor and there are lessons to learn from this incident.
Read about the incident in this link.

Fire in Chemical Tanker

A fire has been reported in a chemical tanker in Mumbai. It appears that toluene was unloaded and "stripping" operations were on when the fire occurred.
Read about it in this link.
UPDATE: An explosion has occurred in the same vessel reportedly injuring 7 petrsonnel, one critically. Read about it in this link.

Contribute to the surviving victims of Bhopal by buying my book "Practical Process Safety Management"

Murphy's technology laws

I came across some interesting technology laws from Murphy! The best I liked were:

1. "The degree of technical competence is inversely proportional to the level of management.
2. Logic is a systematic method of coming to the wrong conclusion with confidence.
3. Technology is dominated by those who manage what they do not understand". 

No harm intended to anyone......but it is of relevance to PSM today!!!!

Read many good ones in this link

Modifications and HAZOP's

The Management of change element of PSM requires that a PHA be carried out when carrying out modifications. The problem I see in many companies is the lack of continuity of a PHA team due to resignations and retirements. However many checklists and procedure we write, a good PHA depends on the skills of the team leader. With people moving in and out as the PHA chair, the PHA study suffers. No PHA software can replace the skills of a trained PHA facilitator. Whenever a PHA facilitator is changed, go through your facilities management of organizational change procedures and ensure that the requirements of a PHA facilitator are met.

Update on China pesticide factory explosion

Further to my earlier post on an explosion in a pesticide factory in China, a newspaper report indicates the following:
"The investigation found that a heat transfer oil spill under one of the three chemical reactors inside the factory caused a fire that heated the ammonium nitrate and guanidine nitrate in the reactor. Both compounds are used to make explosives and explode at high temperatures.
This caused one reactor to explode, triggering a second, massively destructive blast in the plant. "The blast revealed severe problems with the production processes at the Keeper Chemical factory," according to the investigation statement.
The factory was poorly equipped, had low safety standards, and most procedures require human labor, according to the statement. Further, the factory altered the raw materials and the heat transfer oil system without assessing the risk. In addition, the workers were unqualified. Most of them, including the head of the workshop, were middle school graduates without education in chemical production. "The workers had low qualifications for dealing with emergencies and did not meet the requirements for chemical factory production," the statement said".

Read the report in this link.

More confined space accidents

"A plumber was attempting to warm a confined space in which he intended to work. He placed his lighted cutting torch in the vaulted area and closed the opening. When he returned to the vault, he noticed that the torch was no longer lit and, after entering the vault, attempted to relight the torch. The torch had used up the available oxygen in the space, causing it to extinguish, and filled the space with acetylene. When the plumber reopened the space, oxygen was again introduced and the ignition caused the acetylene vapors to ignite. The plumber was blown out the opening and burned over 65% of his body. He died about a week later."
Read about this accident and 11 other confined space accidents in this link

Accidents in batch processes

See this link for few accidents connected with static electricity and reactivity in batch processes. There are lessons to learn.

Rupture of a rubber lined vessel

A rubber lined vessel was taken out of service to replace the rubber lining. The vessel was taken to the rubber lining works and it was heated with external propane torches after blanking off all openings. Workers heard a whistling noise and ran way. A few moments later the vessel exploded. Heating the vessel externally caused the vessel to over pressurize and rupture. Read the case study in this link.

On line leak sealing

Sorry, the previous post on online leak sealing had a bad link....
Recently, I had met a senior colleague of mine called Mr S.Raghavachari after a gap of 20 years. While reminiscing about the "good old days", I remembered that he had written about online leak sealing. I mentioned about my blog and he promptly sent his article on the subject to share with readers.I thank him for sending the article.
Online leak sealing is effective if all hazards are evaluated. There have been numerous accidents during on line leak sealing, mainly due to the mushrooming of fly by night operators. Be careful while choosing your on line leak sealing contractor. Ensure he has the proper technical background and support.
 You can read Mr Raghavachari's article in this link.

Deadly explosion in pesticides factory

An explosion has taken place in a pesticide factory in China. A news article mentions that "According to the preliminary investigation, the major substance that caused the blast was guanidine nitrate, a combustion-supporting chemical that can irritate the eyes, skin and upper respiratory system. The specific cause of the accident is still under investigation"
Read about the accident and see photo of the blast zone in this link.

Don't make a mockery of a mock drill

The recent unfortunate death of a young woman  volunteer in a mock drill at Bangalore, speaks volumes of the state of emergency preparedness. In many chemical plants, mock drills are conducted by informing everyone about the timing of the drill. What is the purpose of this if you want to test your real emergency preparedness? In 1995 I attended an advanced firefighters and rescue training at Dubai where not only were we made to fight live natural gas fires generated in a natural gas skid mounted mock plant ( we had to isolate the supply of natural gas) but also made to search for victims inside buildings. Smoke bombs were placed inside the buildings to disorient us, along with strobe lights that were flashing ( also to disorient us). The instructors place a lot of emphasis on the safety of the firefighters and rescue team. Recently I read an article about a new training tool for firefighters in this link.
Always be prepared and don't make a mockery of a mock drill.

Silo collapse in fertilizer factory

A silo structure collapse in a fertiliser factory has led to injuries to 15 people.The cause of the incident is under investigation. Ensure that all structures (both civil and structural) are inspected and maintained properly. Sometimes, I have observed fertiliser material covering many structures. What you don't see cannot be inspected. Another article Mentions that police have registered criminal cases against the management.
See the video of the collapsed structure in this link
Read the article in this link.

Meetings and Process Safety

Nowadays meetings are the order of the day. Either the plant manager is coming from a meeting or going to one! Net result - plant visits by the plant manager are rare. Process safety needs to be managed by look,listen and feel technique - look at the plant, listen to your shift crew and feel the pulse of what is going on at the plant level! A newspaper report suggests that attending meetings makes one brain dead. Plant Managers - Beware!!!
Read the news article in this link

Plane accidents and process safety

"06/23/1967 Mohawk Airlines
BAC-111-204AF Blossburg, Pennsylvania The airplane crashed after an in-flight fire destroyed the pitch control systems. All 34 people aboard were killed. A malfunctioning nonreturn valve allowed hot engine bleed air to flow back through an open air delivery valve, through the APU and into an acoustic blanket lined section of the fuselage. This caused flexible hoses with hydraulic fluid to ignite and lead to an uncontrollable fire". Beware of check valves!!

"09/06/1971 Pan International
BAC-111 Hasloh, Germany The aircraft collided with a bridge, shearing off both wings, after a double engine failure occurred during takeoff. The water-injection system to cool the engines during takeoff was inadvertently filled with kerosene instead of water".

30 years ago, an operator in the plant I worked filled up antifoam liquid from a drum similar to an oil drum into the hydraulic governor of a large steam turbine. We found out when the governor started misbehaving!!

Source of plane accidents : http://planecrashinfo.com/unusual.htm

Fire in Pharma factory

Reports of a fire incident in a Pharma factory mention that hazardous waste stored for incineration caught fire. Are you safely storing hazardous waste as per the norms? Generally, what I have observed in other factories is that the incinerator area, being far away from the plant, sometimes gets a little less attention than it should be getting. Most of the work is also contracted out.Ensure that the contractor employees are trained in the norms of handling, storing and processing hazardous waste.
Read the article about the fire in these links:
Link 1
Link2

The importance of emergency stopping

How do you ensure that your emergency stop buttons will work when needed? The emergency stop is the last line of defense and a good article by Robin J Craver mentions the following:
"The nature and operation of the machine must be considered.
· Is it safe to have the emergency stop system cut the power to the machine drives and actuators? This may result in the hazard “free falling” leading to a more dangerous situation.
· Should the system actuate a brake or clamp?
· Would stopping the machine in position result in a worsening of an injury?
· Should the system allow the machine to continue on or reverse to a safe position?"
 Read the article in this link.

Process safety and nanotechnology

With nanotechnology, the process safety hazards will change. A whole new nano process safety approach may need to be taken to identify nano hazards. An article mentions the hazards of nano dust. It mentions that "nanomaterial dust could explode due to a spark with only 1/30th the energy needed to ignite sugar dust — the cause of the 2008 Portwentworth, Georgia, explosion that killed 13 people, injured 42 people and destroyed a factory".
Read the article in this link.

Fire in refinery

A fire in a major refinery in the US has been reported. Apparently, the fire was due to a flange leak.See the video of the fire in this link.

Pressure vessels and labs / R & D's

I have often seen that personnel in labs and R & D setups do not understand the hazards of a pressure vessel. Many times, pilot plants are built by buying equipment from the second hand market. Not having the specifications / data sheet for the vessel is dangerous. One such fatal incident in a NASA lab highlights the following:
"Vessel at least 33 years old
• Unknown prior service, no nameplate, no drawings
• No pressure or temperature rating information
• Most welds on hold down bolts were cracked before being put into this service
.Vessel design inappropriate for intended service
– Vacuum vessel put into service as a pressure vessel
• Vessel not pressure checked prior to full use
– And no restricted access during initial pressurization
• Critical welds on hold down bolts not inspected after 33+ years of existence
– Were not considered critical for a negative pressure (vacuum) application
• Bolt welds were cracked and cracks exhibited corrosion prior to this use
• Vessel failed (chamber lid separated from chamber body) when all hold down bolt welds broke simultaneously".

Read about the incident in this link.

Industrial accidents in India

As interesting article in Livemint.com highlights that statistics of industrial accidents in India are not accurate. It mentions that "Data supplied by two labour ministry agencies show that accident insurance benefits claimed by companies indicate a rate of accidents that far outweigh those that are reported".
Read the article in this link.

Ammonia gas leak incident

IBN Live has reported an ammonia gas leak at Paradeep where 3 workers were rendered unconscious.  The news item mentions that "Sources said some crew members inadvertently handled the gas tank of the ship carrying 13,000 metric tonnes (MT) of ammonia gas meant for the plant. The employees who came in contact with the gas fell unconscious. The unloading of gas through a pipeline to the plant had been completed by then". 
Read the news item in this link.

Vehicles and process safety

An incident where a car hit a chemical storage tote has been reported. Ensure you have identified all possible points of impact of vehicles. Piperacks, storage tanks, culverts, loading/unloading stations are all areas which you should study for a possible vehicle collision. I had been to a large refinery which had expanded in the space available. (There was a huge space deficit). Their staff bus had to cut across two units, along a narrow culvert carrying hydrocarbon pipelines. Its a disaster waiting to happen.
Read about the car accident in this link
 

Dispersion of chlorine and its containment

Thanks to Harbhajan Singh Seghal for sharing his article on " dispersion of chlorine and its containment". Read it in this link.

Management Integrity level (MIL) and Process Safety

There is a lot of talk about safety integrity level and the reliability of control and shutdown systems. While a reliable instrumented system is good for process safety, it is the integrity of management, what I call Management Integrity Level that is more important! By this what I mean is whether management is really interested in process safety by allocating resources, time and competencies. Even if we develop a MIL (Management Integrity Level) rating for management, the score has to be measured and monitored on a continuous basis!
Do not get carried away by SIL ratings and multi coloured QRA's and risk matrices. Look into your organisation and determine whether Management Integrity Levels are adequate! The answer lies within!

The dangers of pressure vessels

A good article - Accidents in Pressure Vessels: Hazard Awareness by Temilade Ladokun, Farhad Nabhan and Sara Zarei Mentions the following:  
The main causes of failure of a pressure vessel are as follows:
Faulty Design
Operator error or poor maintenance
Operation above max allowable working pressures
Change of service condition
Over temperature
Safety valve 
Improper installation
Corrosion
Cracking
Welding problems
Erosion
Fatigue
Stress
Improper selection of materials or defects
Low –water condition 
Improper repair of leakage 
Burner failure 
Improper installation

Read the article in this link.

New pipeline design concept

DNV has released details of a new concept in subsea pipelines called "X stream". The thickness of the pipe is reduced by using inverted HIPPS concept. It is an interesting read. Read it in this link.

Leak detection in sub sea pipelines

An article mentions the use of fiber optics to detect sub sea pipeline leaks based on Joule Thompson effect. Many sub sea pipelines transfer LNG, ammonia etc and any leak in these pipelines will have a catastrophic effect. The article mentions the following: "Fibre Optic Distributed Temperature Sensing (DTS) methods have been successfully applied to many processes in the oil & gas industry. This non-intrusive sensing system proves invaluable in the monitoring of LNG pipelines both for cool down at commissioning, for temperature profiling during operation and as a leak detection system. There is ongoing work in the use of fibre optic DTS systems in the development of smart cryogenic hoses for the transfer of LNG and storage and piping systems aboard floating LNG vessels. Developments in LNG pipes include multi-layer insulated piping systems. This contribution presents recent studies in the use of fibre optic distributed sensors for temperature profiling and leak detection in multi-layer insulated LNG pipes". Read the article in this link.

Are your SOP's clear?

There are lessons to learn from an aborted take off recently at Hong Kong airport. The aircraft commenced takeoff not on the assigned runway but parallel taxiway. The air traffic controller noticed the airplane accelerating on the taxiway and ordered the aircraft to stop. There was no other traffic on the taxiway at the time of the serious incident.A news report mentions the following:
"Hong Kong's Civil Aviation Department (CAD) released their final report concluding the probable causes of the incident were:
- A combination of sudden surge in cockpit workload and the difficulties experienced by both the Captain and the First Officer in stowing the EFB computers at a critical point of taxiing shortly before take-off had distracted their attention from the external environment that resulted in a momentary degradation of situation awareness.
- The SOP did not provide a sufficiently robust process for the verification of the departure runway before commencement of the take-off roll.
- The safety defence of having the First Officer and the Relief Pilot to support and monitor the Captain’s taxiing was not sufficiently effective as the Captain was the only person in the cockpit trained for ground taxi'.

Are your SOP's clear and are your operators trained to handle spurts in workload that occur during an emergency?

Read the news article in this link.

Chlorine tonner incident

Thanks to Mr Harbhajan Singh Seghal for sending this incident:
INCIDENT
In one of the chlorine consuming industry two persons were affected with chlorine while the operator disconnected the tonner from the process due to hard valve operation of the tonner.
DETAILS OF INCIDENT
· The consumer withdraws liquid chlorine from the chlorine tonner and consumes gas after evaporation.
· As per practice, the consumer keeps the tonner in line to withdraw maximum chlorine from the tonner.
· On the specific day of the incident, the operator tried to isolate the tonner at 1.0kg/cm2 pressure when about 40-50 kgs liquid chlorine was left in the tonner and there was ice formation at the bottom of the tonner.
· He could not close the valve fully. The spindle of the valve damaged due to excessive force.
· The operator decided to cut off the tonner by wearing SCBA.
· This action resulted in heavy gas leakage and affected two persons in the surrounding area.
ACTION TAKEN
· The tonner brought to the works.(of the chlorine supplier)
· It was depressurized and the valve was dismantled
· Iron chloride rust and greenish color sludge was observed in the threading of the valve.
· Damaged valve replaced with new valve.
ROOT CAUSE
· Liquid chlorine withdrawal rate is 180 kgs/hr. Maximum liquid chlorine is used up in 4-5 hrs operation at this rate. Some quantity (40-50) kgs remains in the tonner at the bottom.
· Some consumers try to recover this 40-50 kg liquid chlorine as gas by keeping the tonner in line for more time.
· The left over liquid chlorine evaporates at 5-6 kgs/hr as gas and lowers the temperature of the tonner/pipe lines due to fall in pressure till the remaining liquid chlorine is exhausted.
· 1.0 kg/cm2 pressure can lead to about -20 degree C and takes 8-10 hrs to completely empty the tonner.
· Normally chlorine in the tonner is dry. But under such conditions (-200) the same chlorine becomes wet.
· Water in the chlorine separates out and freezes in the spindle of the chlorine valve. It makes the valve hard to operate at that time.
· After attaining normal temperature, chlorine evaporates first and water later. This chlorinated water reacts with the sprindle and makes the chlorine spindle greenish.
· The evaporators which do not have backflow prevention system (from evaporator to chlorine tonner) results carry over of iron chloride rust to valve spindle and makes the valve hard in operation.
LESSONS LEARNT
· The tonners containing some quantity of liquid chlorine (40-50 Kg) are not to be cut off at 1.0kg/cm2. The tonner is to be depressurized by releasing the chlorine to neutralization system through header or evaporator.
· After depressurizing, check that no chlorine gas comes from the upper valve of the tonner, and also check that no ice formation appears on tonner or pipe lines before the tonner is disconnected.
· Chlorine header and evaporator must have chlorine release facility connected to neutralization system.
· Chlorine evaporator must have liquid chlorine flow control interlocked with temperature and outlet pressure to avoid the back flow of chlorine
· Evaporator should have emergency release system with rupture disc and safety valve.
· Temperature of evaporator should be maintained between 80-85 degree C to avoid formation of rust as Fecl3 in the evaporator.
· Dry air (-40 degree) dew point is to be utilized for evaporator maintenance.
· Glass wool filter is to be utilized in gas line to avoid carry over of Fecl3 to main products and choking in chlorine system.
· Tonners can be kept in tilted position forming 20-30 degree angle to withdraw maximum liquid chlorine from the tonner.
MOST IMPORTANT LESSONS
· No chance should be taken with liquid chlorine system. Help of the filler (chlorine supplier) must be taken in such cases. One volume of liquid chlorine expands to 460 times
· Chlorine neutralization system must be effective and checked from time to time.
· Single person should never take this type of emergency job.
· Always stand by person ready with safety equipments should be present during such operations.

Process safety - Seeing and managing

A typical day for today's plant manager is like this: Punch in....login......read emails and answer......collect data for the meetings scheduled......firefight today's issues.......go back home late in the evening! I was just comparing the daily routine i used to do many years ago in the same position: Punch in....go around the plant for at least one hour.......read the log book.....write relevant instructions in the instruction book.....attend the daily plant meeting for discussing and resolving issues....discuss and take instructions from my boss....communicate these instructions to the plant......go back home peacefully, on time! Note: There were no ISO9000,ISO14000,OHSAS18001,PSM,TQM,Six sigma etc in those days! Managing process safety needs management by seeing, hearing and understanding. Unfortunately today's plant managers do not have the time to see the plant.....this is a dangerous trend. Also competency for managing process safety is lacking. Somewhere we seem to have lost our way!

Awards and Accidents

Further to the refinery accident during hot work which I had mentioned in my previous blog entry, an article in the Hindu lists out other accidents that occurred in the same refinery in 2009. It also mentions that the refinery won safety awards in 2009 and 2010. There is a disconnect here! Read the article in this link.
While awards are a good way to motivate people, the onus lies on management to sustain and improve process safety performance.Long ago, I had audited an organization that had been granted a prestigious award by an international organization for their safety management system. I visited the plant 6 months after this award. Their safety management was in shambles and I had mentioned to them that the sword is now hanging over your heads.
If everyone goes back home safely everyday and this is maintained, then your process safety management system is working well! Period.

Worker killed in explosion during hot work

An accident at a SRU at a refinery has killed a worker. Read the article in this link. Please see my earlier posts under safe work practices. Hot work should be done with proper precautions and it is sad that repeated accidents are occuring. 

Process Safety and Risk management in the high speed age

A good article called "Black swans turn grey -The transformation of risk" by Price Waterhouse Coopers highlights the following:

1. The boards of big organisations do not fully understand the risks that they are running
2. In the Internet age, speed and prejudice are all
3. Checks and balances at board level are critical.
4. Leadership and culture shape an organisation’s attitude to risk.

I think in a chemical industry "operational risk" is of greater importance that financial and strategic risks. As long as there are human beings involved in making decisions, there is a possibility of a process safety incident that has serious implications for the business. That's why I agree totally with the Baker Panel report suggesting that a person competent to understand process safety be on the board of Directors for Chemical Industries.
Read the article by PWC in this link.

Oil rig catches fire

An oil rig in Nigeria has caught fire and it is reported that two workers were missing and two are hospitalised. Reason for the fire is not known. Read about the fire in this link.

Learning from Buncefield

The Buncefield incident in 2005 was a wake up call for the industry. A lot of assumptions that were in vogue till then in QRA were overturned. Henry Troth has made a good presentation of the incident mentioning the following:

• "Take a critical look at your Safeguards, your Prevention and Mitigation Layers – they may not be as effective as you need
• Tanks should have overfill lines from HHH down to ground level to reduce splashing and vaporizing overflowing fuelTank 
• Overfill Protection should be SIL rated and proven in use
• Retrofit water curtains on closely spaced tanks
• Fire Pump House should not be a source of ignition (classified area)
• Store portable fire fighting equipment and foam in a ‘safe’ place -stationary equipment usually gets knocked out.
• Remember – you must keep all Safeguards working as well as the SIS layer(s) – otherwise you are exposed
• Is a spill all you need to worry about (what could possibly go wrong)?
• Consider consequences carefully – What will you do if the unthinkable happens?"

Download the presentation from this link.

Investigating process incidents

"Aerodynamically, the bumble bee shouldn't be able to fly, but the bumble bee doesn't know it so it goes on flying anyway" - Mary Kay Ash, American Businesswoman
I like this saying as it is very relevant to process incident investigation. In the course of investigating many process incidents, I have come to the conclusion that you need to be like the bumblebee (keep your mind open, and avoid jumping to conclusion!) while investigating incidents. Many chemical process incidents may apparently not reveal the root causes immediately. I have used the event and causal factor analysis/barrier analysis and Man-Technology-Organization analysis to determine the root causes of many chemical incidents. Also, listen to the people who were present during the incident and observe the incident site. Equipment tell silent tales.

Fire in Guwahati oil refinery

Read about it in this link.

Three killed in factory explosion in China

The hazards of thermal expansion

Many plant personnel do not give importance to thermal expansion safety valves. These are typically small valves and often, the isolation valves are kept closed as they pass. It is human tendency to ignore small things but in process safety it is the small things that cause big disasters!

The CSB had published a good case study on a fatality that occurred due to the bursting of a heat exchanger due to thermal expansion of trapped ammonia. It is worth reading and sharing with all your colleagues. Read it in this link.
The photo at the left is courtesy of the CSB.
Read another incident in this post. 
Read a third incident in this post

Cyber security for chemical plants

Dr Trevor Kletz has said "what you don't have cannot leak". This was with reference to hazardous chemicals. It makes sense then and makes sense now. But with the advent of Internet and remote operation of chemical plants, we often think that the best way to keep a plants intranet secure is not to connect it with the Internet. In other words, "when you are not connected , you cannot be hacked". Last year, the cyber attack on a nuclear development facility in Iran, caused centrifuges to speed up but the control room did not display the increased speed! It is a very interesting story and just imagine what could happen if a cyber take over of critical equipment in a chemical plant takes place? Ensure your systems are adequately protected and conduct cyber security drills along with your regular mock drills! Read the very interesting article about the centrifuge incident in this link.

Process Safety - Keep it simple

I often think that today we are complicating things too much in process safety, in an already complicated World! This generation of plant operators have been inundated with technology. While some of the technology is excellent, not all of them really help the plant operator. Information overload is the bane of today's PSM programs. When I was a shift in charge at an ammonia plant, we had pneumatic control system (no DCS), but it was so user friendly. I would sit in the center of the control room and at a glance I got to know the plant status. The control room had three operators - one for the front end of the plant, one for the back end and one senior guy looking after both. During emergencies, the senior guy would coordinate the actions very swiftly as he could see the complete plant status just at a glance. The whole ammonia plant had only about 200 alarms that were located on the panel. The critical ones were painted red. By experience we would know which alarm meant what! We never had a serious process safety incident!!I managed to get some pictures to illustrate what I am talking about. 

Our control room looked similar to the one at the left. The table at the center was a flat table. The shift engineer used to sit at this table.The control panel is just below the clock.The flowsheet of the entire plant (called a mimic) was depicted at the panel top

This was a field controller.  See how simple it is! The red arrow is the setpoint.

 This temperature recorder was similar to the one we used to record secondary reformer top temperature and methanator temperature.









The message I am trying to convey is try to keep it as simple as possible. Buy only what you want and not what you get! (This is especially true for DCS and electronic instrumentation)

PSM and PDCA cycle

The PDCA cycle is the core of any management system. I have seen a common trend from investigating root causes of many chemical plant process incidents - it appears that many of the root causes are due to following the PDCA cycle in a different way: DCA,no P -DO, CHECK, ACT and No PLAN! Fire fighting efforts take place to immediately attack an issue. Productivity, cost cutting and efficiency improvements often take place without undergoing the management of change process. This is why I feel that while certifications to OHSAS 18001, ISO 14001, Responsible Care etc are good, the sustainability of such certifications become questionable. This is evidenced by fatal accidents in companies that are certified. How do we solve this issue? I believe that the onus lies with the top management. If top management are clear about process safety and its implications, then you do not need any system at all! Unfortunately, there is a huge knowledge deficit about the technical aspects of running a chemical plant and the importance of PSM. Recently I had implemented PSM in a pesticide manufacturing unit where the head of the unit was a hardcore experienced chemical engineer. His understanding of the technical nitty gritties of PSM helped me greatly during the implementation. I will end my ranting by repeating two things that Dr Trevor Kletz has said and is highly relevant to Process safety management: 1.Walk the talk! 2.Keep it simple!

WISH YOU A HAPPY NEW YEAR!

To all my subscribers and readers,
Wish you and your family a very happy New Year!