Lessons to learn from Hot work accident at DuPont

The CSB has published its report on the investigation of a hot work accident at a DuPont facility in the US.

Two contractors were performing welding atop a 10,000 gallon slurry tank when hot sparks ignited flammable vapors inside the tank, causing an explosion that killed one contractor and seriously injured another.
One of the root causes of the incident was failure to test the internal atmosphere of the tank prior to hot work outside the tank. DuPont is renowned for their safety practices and if can happen in DuPont, it can happen anywhere else.

While I am not commenting on the incident and its findings, I strongly feel that competency to understand process safety issues is dwindling in India. When I started my consultancy 10 years ago on process safety, I often got calls for a "safety audit". I had to explain that process safety is different from the regular occupational health and safety. What I see today is the alarming lack of process safety competency in leadership in many Indian Chemical Companies. You may have excellent process safety systems but the bottom line is that unless you have competent personnel to understand and use these systems, they cannot protect you.

Read the CSB report and watch the excellent video in this link.

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More confined space accidents

 NIOSH had published in 1986 case studies of confined space accidents. They observe that 60% of fatalities in confined space accidents are would be rescuers. Some of the accidents mentions are:

"A 54-year-old worker died inside a floating cover of a sewage digester while attempting to restart a propane heater that was being used to warm the outside of the sewage digester cover prior to painting it Workers had wired the safety valve open so that the flow of propane would be constant, even if the flame went out. The heater was located near an opening in the cover of the digester. When the worker attempted to restart the heater, an explosion occurred that vented through the opening. The worker crawled away from the heater into an area that was oxygen deficient and died. A co-worker attempted a rescue and also died". 
"A 20-year-old construction worker died while attempting to refuel a gasoline engine powered pump used to remove waste water from a 66 inch diameter sewer line that was under construction. The pump was approximately 3,000 feet from where the worker had entered the line. The worker was overcome by carbon monoxide. A co-worker, who had also entered the sewer line, escaped. A 28-year-old state inspector entered from another point along the sewer line and died in a rescue attempt. Both deaths were due to carbon monoxide intoxication. In addition to the fatalities, 30 firefighters and 8 construction workers were treated for carbon monoxide exposure".

Read the case studies of confined space accidents in this link

 
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Blast in German chemical plant

Thanks to Balu for sending information of an accident in a German chemical plant has reportedly killed two people. The plant was manufacturing  cyclododecatriene, an intermediate used to make nylon 12, flame retardants, flavors, and fragrances.The blast was apparently triggered in a tank in the cyclododecatriene plant.The cause of the blast is being investigated.
Read about the accident in this link.
 See blast pictures in this link

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Plant aging and process safety

Human beings age, but plant's dont! If you agree with this statement, you are in trouble! As plants age, corrosion spreads, material fatigue occurs, and your maintenance practices need to understand and take into consideration the residual life of your equipment.
In today's cost conscious world, very few look at the long term picture and think that you can get away with repairs. Not so. If you neglect the residual life assessment of your plants, be sure that you will end up spending more money than what you would have spent if you had a long term strategy in place. What is happening today is that instrumentation and control systems keep getting regularly upgraded mainly because the vendors do not support them more than 5 to 7 years! But mechanical equipment continue to be used often at much higher rates than they were originally designed for. Many world class organizations have reliability and obsolescence cells specifically for drawing out a long term asset replacement plan. Do you have one?

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Process safety and competency

In the next decade, the key process safety issue for India is going to be process safety competency. The average age of the Indian Workforce is today reported to be about 27 to 30 years and as experienced personnel leave the organisation, a huge process safety knowledge deficit is arising. The process safety competency gap is observed right at the top in some organizations to the bottom of the pyramid. Only those companies in the CPI who recognize that process safety competency is a a huge business risk will be able to safely manage their processes.
Read what one global organisation is doing about competency in this link.

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Speech by Judith Hackitt CBE,HSE Chair

I have highlighted some important points made by Judith Hackitt, HSE Chair in a speech tilted "Applying effective leadership and enhancing competency improvement in hazardous industries:
"Everywhere I go there seems to be a growing level of interest and stated commitment to process safety, but sadly this does not always translate into consistent measurable improvement in performance. For example, in Great Britain where we require major hazards industries to report loss of containment to HSE, in the last year alone there have been over 100 loss of containment incidents, more than half of which were considered to be precursor events for a potential major accident. That equates to an average of two loss of containment incidents every week, one of which had the clear potential to develop into a major catastrophe. I use these statistics to illustrate the magnitude of the problem which we all face, I am not suggesting that there is a greater problem in Great Britain than elsewhere but it does highlight why we should all be concerned. Sooner or later one of those "potential" catastrophes will become a real one, somewhere. Our luck is going to run out.

 Automation and process control has brought many benefits but has also increased the remoteness of the process itself and the hardware from the vast majority of people. Process operators now monitor and control processes via computer screens and increasingly complex process control systems which run the process much more steadily and reliably also can create a false sense that the computer wouldn't let things go wrong.

• Smoother running can also have an impact upon the level of attention which is afforded to engineering knowledge and concerns. Pressures to deliver reduced costs and better returns have placed requests for inspection and maintenance in the "problem" box. Shutting down a process to carry out inspection is resisted and schedules are pushed out. In many cases the value of preventive maintenance which we all learned a long time ago when Kaizen and Total Quality Management were very high on everyone's agendas has been replaced by a drift back to "If it isn't broke then we don't need to stop to fix it". And even when it is broke - let's just patch it up.
• Economic variations can also lead to assumptions being made which turn out to be wide of the mark. In the case of the UK's North Sea oil and gas operations, back in the 1990s with oil prices at a low level it was widely assumed that assets were coming to the end of their operating life and maintenance was therefore cut back, but those neglected assets are now being called on to operate again at high levels and well into the foreseeable future. Catching up on poorly maintained assets is by no means easy – it is costly and it takes a long time to rebuild integrity - and confidence.
• Failure to understand the true role of those who are charged with managing safety can also be a factor, especially by senior managers and leaders. Those whose job title is "safety management" are there to ensure that everyone else is playing their part in managing safety as an integral part of every person's job. It is not to do it for them and most certainly it is not possible for senior managers to delegate the leadership of safety to one director or individual. Acting as the conscience or the champion of safety within an organisation is one thing, fragmentation of functions to the extent that senior managers believe that safety responsibility belongs with someone else is another.
• Change in ownership and contractorisation or outsourcing of activities has been a widespread feature of many parts of the process industries for some years now. Contractorisation leads to the potential for further diffusion and possible confusion about who is responsible for what, including safety. Change of ownership is an increasing cause for concern, in that it is unclear what documentation and knowledge about critical issues such as basic design principles are passed on when assets change hands.
• Advances in technology.  I have already mentioned that modern plant that incorporates state of the art equipment has brought with it great benefits in terms of increased reliability, less excursions from normal operating conditions and so on. But the trade off to this can be a growing sense of complacency that the sorts of problems which had happened in the past could not happen again and that they have been fixed. Over time the corporate memory of what can go wrong and the consequences of things going wrong and how important it is to avoid such catastrophic events can fade  for everyone – senior managers and operators - resulting in a growing lack of understanding and appreciation of the importance of process safety, especially at the most senior levels. Ultimately, this can lead to a situation where the right questions are not being asked by the leaders of an organisation because they didn't even realise or understand what needs to be asked." 

 Read the complete speech in this link

 
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Risk management in CPI

A good article in the Business Standard highlights the importance of risk management. I know of a chemical industry where the Chief of safety has been designated as "Chief Risk Officer". For a chemical manufacturing facility, apart from the financial and other risks, the risk to reputation and business continuity if an incident occurs is much higher. The article in the Business Standard mentions the following:
'Even Mukesh Ambani in a way is striving to protect his revenue streams by diversifying into homeland security. “If you want a safe Jamnagar, or a safe Mumbai, you might as well offer the best security solutions to the nation’s top cities and its energy assets. It’s also linked to strategic energy security,” says a senior RIL executive, who did not wish to be quoted."
Read the article in this link.

 
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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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