Inherent safety considerations

The National Science Academy has published an interesting article on inherent safety. The article mentions "The use of hazardous chemicals such as methyl isocyanate can be a significant concern to the residents of communities adjacent to chemical facilities, but is often an integral, necessary part of the chemical manufacturing process. In order to ensure that chemical manufacturing takes place in a manner that is safe for workers, members of the local community, and the environment, the philosophy of inherently safer processing can be used to identify opportunities
to eliminate or reduce the hazards associated with chemical processing. However, the concepts of inherently safer process analysis have not yet been adopted in all chemical manufacturing plants. This report presents a possible framework to help plant managers choose between alternative processing options—considering factors such as environmental impact and product yield as well as safety—to develop a chemical manufacturing system.
Read the report in this link.


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Fatal accident in DAP plant

A fatal accident in a DAP manufacturing complex in the US is reportedly due to a  steam turbine explosion. The plant had experienced another fatality a few days prior to this incident. Read and see the video in this link.
Second industrial accident death at Mississippi Phosphates - WLOX.com - The News for South Mississippi


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"Get serious about safety"

An article in the Bangkok Post highlights lack of seriousness about safety. The article has similarities to what is happening in India. The recent train accident in Andhra Pradesh has the routine court of inquiry instituted but we never know the outcome of the inquiry! Read the nice article in this link.

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Risk management - Financial Vs Process safety

An article about the recent financial issue in a leading company mentions that a shareholder group warned the management that risk management was not up to the mark. The group also mentioned that there was no person with adequate financial expertise in the risk management committee. Chemical manufacturing companies also need to have persons with expertise in manufacturing and process safety in their risk management committees. Risk cannot be managed unless it is understood. Read the article in this link.

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Prevention of corrosion

Tata Steel (Corus) has brought out a good primer on "The Prevention of corrosion on structural steelwork". It succinctly explains the basics and helps to preserve asset integrity. Download it from this link.
 
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Steam reforming disasters

John R Brightling, Peter V Broadhurst and Mike P Roberts of Johnson Matthey Catalysts have written a good article called "Catalyst catastrophes in hydrogen plants". It is good reading for all those who operate steam reformers. Time and again, I see the same mistakes being repeated - lack of flow through tubes, bypassing of furnace high pressure trips, lack of close monitoring of the reformer during start up and deviations from SOP.
Read the article in this link.
  
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Sulphuric acid safety

NorFalco have published a good guide to sulphuric acid manufacture, handling and storage. Many explosions have recently taken place in sulphuric acid tanks due to generation of hydrogen. The guide mentions the following:
"Storage tanks for sulfuric acid in strengths of 93% through 99% are usually fabricated from carbon steel. At normal temperatures there is usually some gradual corrosion on carbon steel that results in the evolution of hydrogen gas and the formation of an iron sulfate precipitate, most of which settles to the bottom of the tank. Wall thickness should be carefully calculated to provide corrosion allowances and for the high specific gravity of the acid. Smaller storage tanks (under 10,000 gallons) are sometimes constructed from stainless steel or a type of HDPE (High Density Polyethylene) made especially for sulfuric acid service. Such materials reduce or eliminate hydrogen and iron-sulfate generation. Regardless of the material your tank is constructed from, always ensure that it has been designed and manufactured specifically for sulfuric acid. Many storage tanks use anodic protection systems to minimize corrosion. Storage tank cleaning and inspection procedures are available on request from NorFalco .
HYDROGEN GAS: Hydrogen gas is potentially explosive and special care must be taken when working near tanks or performing maintenance on tanks. A hydrogen meter and spark proof tools and lights should be used, and open flames and welding should be avoided. 
CORROSION, INSPECTION AND CLEANING: A program of routine internal inspection should be established to ensure early detection of excessive corrosion. It is necessary to clean out the tanks at regular intervals to allow for inspection. A suggested minimum frequency is every 3 years for tanks containing hot acid and every 5 years for tanks containing cold acid".
Read the complete guide in this link.
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Innovative solution for changing flange bolts online

I came across an article that mentions an innovative solution to replace flange bolts online.
The article mentions that "Stork’s technology hydraulically clamps pressurised bolted pipeline flanges together so that corroded stud bolts can be safely removed without exerting additional force to the gaskets. Once all of the bolts have been replaced, the hot bolt clamps are de-pressurised and removed. Change out of the bolts is achieved without taking the flanges out of operation, disruption to the standard line pressure or danger of hydrocarbon release".

I am not endorsing the product but you can read more about it in this link.

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Take care of your structures

Are you maintaining your structures properly? As plants age, corrosion seeps in and is a deadly killer. Do not ignore corrosion. It can cause catastrophic failures.
A safety bulletin by the Minerals and Energy department of Australia mentions " In January 1998 a wharf walkway structure failed due to extensive corrosion when 6 men were walking on the structure. All men fell with the failed walkway structure 8 metres to the ocean, some suffering serious injuries. An investigation identified that corrosion of the failed walkway truss was severe and some cross bracings in the truss had completely corroded through. It was further reported that in 1991 and 1993 structural engineering reports had been commissioned and these reports recommended that repairs be carried out to corroded members on several walkway structures including the structure which collapsed. At the time of the collapse, none of the rectification work identified in those reports for this walkway structure had been attempted. The investigation report concluded “the walkway truss failed as a result of the mine operators inadequately actioning reported recommendations by consultant engineers.” Treatment plants may also be very corrosive environments and there have been several incidents where steel floors have collapsed. Where corrosion in structural steelwork is more than merely a surface feature or where the corrosion may have diminished the original strength of the structure, a structural design engineer should be employed to assess the safety of the structure. If remedial work is recommended then such work should be carried out immediately, or in accordance with the priority timeframe identified in the consultant’s report. Furthermore, employees should be encouraged to report cases of structural steelwork corrosion they identify. Periodic plate and weld thickness tests should be performed on all bins, silos and hoppers to ensure their structural integrity has not been affectedby corrosion".
Read the safety bulletin in this link.

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The causes of fires and explosions - 75 years later

75 years ago, this month, the worst airship disaster took place when the hydrogen filled Hindenburg air ship caught fire and exploded as it was completing its 35th trip across the Atlantic, killing 35 people. Till date there are many theories about the incident. The Smithsonian magazine has published an article that mentions "Realistic alternatives for the cause of the explosion include a buildup of static electricity, a bolt of lightning or a backfiring engine, but at this point it’s impossible to determine what exactly caused the spark".
Today, static electricity. lightning and backfiring engines are still causes of fires, though there has been a lot of development in each of these fields to avoid fires. The BP Texas refinery disaster was started when the vapour cloud ignited due to a back firing engine. There are numerous cases of fires due to static electricity and lightning. Though technology has improved, man continues to commit the same mistakes!

Read the interesting article in the Smithsonian mag in this link. 
 

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PVC plant explosion

 An explosion at a PVC plant few weeks ago in US has been reported.The accident forced area residents and plant workers to shelter in place for several hours. Read and see the video of the fires in this link.

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Using GIS for emergency planning and response

A news item mentions that "The latest version of the web-based Geographic Information System (GIS) emergency planning and response system, developed by the National Informatics Centre (NIC), is all set for operations in factories in Mahbubnagar, Krishna and Nalgonda districts. Introducing the fourth phase of the technology here on Friday, NIC deputy director general Sanjay Singh Gehlot said, “the latest version aims to minimize damages during explosion or chemical accidents in industries.” The first phase the technology was launched some eight years ago".
Read the news item in this link.

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Discharge of bleaching agent causes illness

An incident in Thailand has been reported where many workers were sent to hospital after an abrupt discharge of a bleaching agent. The accident took place about 6.30pm when workers smelled a strong chlorine-like odour at the plant. The article mentions that the odour probably came from sodium hypochlorite, which was discharged from the plant during an emergency shutdown.
Read the article in this link.

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Blast in chemical factory

The Hindustan Times has reported a blast at a chemical factory near Chandigarh that killed 4 personnel.
"Initial reports suggested that the first blast was caused by a "static charge". However, according to sources linked with the probe, a safety valve of the reactor may have malfunctioned'.
Read the article in this link.

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Commissioning new plants - hazards

In a new plant that was being commissioned, Hot Oil, used as a heating medium, leaked from a flange. The leak was on the second floor and the temperature of the medium was about 300 deg C. The leaking hot oil, caused major fires and a section of the new plant was destroyed. Ensure that commissioning is done in a planned way and that checklists are followed.

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Chemical plant cited for safety violations

A chemical plant in the US has been cited for safety violations by OSHA. These violations include insufficient ventilation, an inadequate sprinkler system, inadequate worker training and failure to conduct hazard assessments at the plant.Read the article in this link.

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Hazards in tanks and vessels

WorkSafe , Alberta has published a safety bulletin titled "Controlling explosion hazards in vessels, tanks and piping systems. The following is mentioned:

"Two workers were welding an overflow pipe on top of a tank truck that contained residual flammable materials. Welding sparks ignited the materials, the tank exploded and the workers were killed. The explosive atmosphere in the tank had not been tested prior to the workers beginning their work. The tank previously contained produced water.

A vessel was purged with natural gas to remove hydrogen sulphide. The vessel was opened and a worker was washing the inside of the vessel with a water wand. A pyrophoric iron reaction on the demister pad started to release sparks inside the vessel. An explosion occurred and the worker was fatally injured.

Iron sulphide is a pyrophoric material. This means that it can spontaneously ignite when exposed to air. It is created when iron oxide (rust) is converted into iron sulphide in an oxygen-free atmosphere where hydrogen sulphide gas is present or where the concentration of hydrogen sulphide (H2S) exceeds that of oxygen.
When iron sulphide is subsequently exposed to air, it is oxidized back to iron oxide and either sulfur or sulfur dioxide gas is formed. This chemical reaction between iron sulphide and oxygen generates a considerable amount of heat. In fact, so much heat is released that individual particles of iron sulphide become incandescent and glow. This heat can ignite nearby flammable mixtures.
Most refineries experience spontaneous ignition of iron sulphide either on the ground or inside equipment. Pyrophoric iron fires most commonly occur during shutdowns when equipment and piping are opened for inspection or maintenance. Iron sulphide fires can be avoided by preventing the sulphide from contacting air. This can be achieved by maintaining a continuous layer of liquid or inert gas between the material and the air. Inerting vessels with nitrogen gas is one such method.

A vessel containing hydrogen sulphide was purged with propane. The workers then opened the vessel for clean-out. When the manway was opened, an explosion occurred resulting in the four workers receiving burns to their faces and hands. The possible source of ignition that caused the explosion was static discharge or metal-to-metal contact"
Read the Workplace health and safety bulletin in this link


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Enforcement of safety rules

An article in the Hindu newspaper reflects the lack of enforcement of fire safety rules in hospitals and other buildings. Chemical plant zoning rules are another area where the rules need to be strictly implemented to avoid the consequences of a catastrophic incident. Unfortunately there is still more to improve in this area. Let us not wait for another Bhopal type incident to wake up to the reality.
Read the article in the Hindu in this link.
  
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Explosion in glue factory in Japan

An explosion has been reported in a glue factory of Mitsui Chemicals in Japan. Read the article and see the photo of the explosion in this link.

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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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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.

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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.

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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!

Fatality at ammunition factory

A fatal accident at an ammunition factory has even experts "baffled". The article mentions "Mule, a permanent employee, was described as a highly skilled worker. The incident happened around 2.10 pm when he was about to go for lunch. AFK officials said there was a spark and suddenly Mule was on fire. Showing presence of mind, Mule sprinted towards a water tank and doused the fire. Otherwise, the fire could have spread causing much damage, said some of the employees". Maybe static electricity was the cause??
Read the article in this link
Read another article in this link

The dangers of aerosol cans

Yesterday I had been to the birthday party of my friend's eight year old daughter. The kids were playing with an aerosol can which generated foam thread, when pressed. None of the kids were aware of the hazards of the aerosol can and that the gas used as a propellant was flammable! What does this have to do with process safety? We also use aerosol cans for dye checking or lubricating/removing rust etc. Read the warnings on the can before you use them. Propane and butane are often used as propellants and the escaping gas can catch fire if a source of ignition is present. Also do not dispose empty aerosol cans in a fire. They can explode.
Thanks to R.Sriram for sending these tips on aerosol cans:

• Aerosols contain a product and a propellant that are packed under pressure.  
• Many people use aerosols without realizing some of the potential hazards associated with them. 
• Oven cleaners, tile cleaners, pesticides, disinfectants, hair sprays, room deodorizers, paints, and furniture polishes are examples of aerosol products. 
• When the nozzle of an aerosol is pressed, the product and propellant are released from the container in a fine mist. The actual product propelled by the aerosol, such as some oven cleaners, can be corrosive, flammable, or poisonous. Acute symptoms of aerosol exposure include headache, nausea, dizziness, shortness of breath, throat irritation, and skin rash. 
• A misdirected spray can cause eye injury and chemical burns. 
• Never leave or place an aerosol can near high heat sources, such as a heater, direct sunlight, or fire. 
• Keep aerosol cans away from children and pets. 
• Never puncture or subject an aerosol can to sharp impact; a sudden puncture may cause an explosion. 
• Dispose the Aerosols in a proper way.

A water tank kills

A supervisor was killed when he attempted to rescue his fellow worker who had collapsed after entering an empty water tank. Investigation is on to determine what was present inside the water tank. If a water tank can kill, just imagine the hazards you face when you enter a confined space in a chemical factory. Follow your company procedures strictly and don't take any confined space for granted. Read the article about the water tank fatality in this link.

Two killed in pharma factory fire near Hyderabad

A news article mentions that a fire in a pharma factory at Patancheru has killed two people. The article mentions that
"According to police, the fire engulfed the factory after a reactor exploded due to an electrical short-circuit. The fire broke out in the evening, and spread to neighboring factories. Fire-fighting personnel had to battle for five hours to control the flames.This is the second such accident in three days. Four workers of a chemical factory were killed in a reactor blast at Polepalli Special Economic Zone (SEZ) at Jadcherla in Mahabubnagar district near Hyderabad last Friday".
Read the article in this link
See a photo in this link.

The dangers of sewers

Two people were reportedly killed in a factory in Chennai when they entered a sewage tank that was not opened for a long time. Be careful of sewers in your factory and residential colonies. Entry should be done only with proper confined space entry permits

The dangers of water hammer

Many of you would have heard the "banging" noise that a water hammer produces inside a pipeline. We also do not expect a pipeline to be destroyed by water hammer. But it happens. An article by Gregg Basnight mentions the following:
"Contrary to old operating practices to drain and warm up steam lines, "Cracking Open" valves in lines to bleed condensate under steam pressure is NOT safe and has resulted in numerous reported water hammer fatalities.Before admitting steam to any line, the condensate must be removed. Condensate should be assumed to be in all low points and dead legs until proven otherwise by verification of drain or steam trap position and operation. Pressurized dead legs without functioning traps or periodic manual blowdowns will have condensate present. The affected section of piping should be isolated, depressurized and drained before restoring steam to the system".
Read the full article in this link.

Give importance to sight glasses

30 years ago, in the ammonia plant where I worked, the sight glass of a high pressure (200 Kg/cm2) ammonia separator leaked during start up. Luckily we managed to shut the plant down safely with no injury to anyone. The root cause was the wrong torquing procedure used. A good article about sight glasses mentions the following:

"Proper design, installation and maintenance of sight glasses are the keys to their safe and effective use....a sight glass almost always fails in tension rather than compression. This is similar to the case for concrete, because glass is not ductile and cannot stretch like metal. Therefore, tiny imperfections in a sight glass window can create stress concentrations, which are potential failure points. Just the touch of a finger on the window can reduce the tensile strength of a virgin glass element by three orders of magnitude from one million to 1000psi. Although design and manufacturing flaws are important, most sight glasses fail due to improper installation. Mechanical stress is a frequent cause, arising from the over-tightening or uneven torquing of bolts that generate bending loads on the glass. When an existing sight glass window is replaced, trapped debris may become a problem if old gaskets have baked onto the flanges. While this may seem trivial, it is actually very dangerous. Even small contaminant particles or build-up might be enough to scratch, pit or bend the new glass during installation".

Read more: http://www.articlesnatch.com/Article/Sight-Glass-Safety-A-Major-Process-Plant-Concern/1604779#ixzz1gkkBXVxV
Under Creative Commons License: Attribution No Derivatives

Laser scanning - a tool for Management of change and Asset Integrity

The most difficult elements to implement in a PSM program are management of change and asset integrity simply because of the large quantity of data involved and less time available. I was reading an interesting concept of laser scanning in an article in Power magazine. It mentions the following:
"Laser scanning also provides a dimensionally accurate representation of the plant and all its equipment as well as a photographic quality visual representation. The laser scan database can be integrated with a variety of plant design applications to provide comprehensive facility management support".
The concept will be very useful for PHA teams who are analysing changes/modifications as they can virtually "see" the proposed modification. It is also an useful tool for managing your asset integrity as another article mentions.
Read the article on laser scanning in this link
Read the article on Virtual asset integrity management in this link.

US Unions briefing on Process Safety

The USW union of the US has briefed the US Congress about health and safety problems in the oil industry. As per a news article,"USW Health and Safety Specialist Kim Nibarger outlined five fatal flaws at the briefing on where the oil industry needs to improve its health and safety record: process safety, mechanical integrity, management of change, incident investigation and control room alarms and instrumentation. “When things go bad in a refinery, they go really bad and people die,” he told the briefing. “Focusing on personal safety—the wearing of hard hats and safety glasses, slips, trips and falls—says nothing about how safe a refinery is for workers and the surrounding community. BP had a low personal injury rate at its refineries, but the 2005 explosion and fire at its Texas City plant showed it failed miserably in terms of process safety. Fifteen people were killed and 170 were injured in the 2005 accident as a result of this failure. “The oil companies are playing Russian roulette with their equipment,” Nibarger said. “They are doing quick, stopgap fixes, like placing clamps on pipes instead of replacing the pipe. They’re extending the time between unit shutdowns when all the equipment is checked. When there is a shutdown they’re not always repairing or replacing critical equipment. When they do repair equipment they’re not bringing it up to current RAGAGEP (Recognized and Generally Accepted Good Engineering Practices) standards.”
If the above sound familiar to you, take a hard look at your PSM program!
Read the full article in this link.

Adding too much chemical causes an incident

A news report mentions an incident where an orange gas cloud leaked from a manufacturing facility for making ferric sulphate. Apparently, too much nitric acid was added to a batch, resulting in a violent reaction that produced excess amounts of nitrogen dioxide that escaped from the reactor into the air.Nitrogen dioxide is a reddish brown gas and is highly toxic if inhaled and is also corrosive.
Ensure that you have proper controls over addition of chemicals, especially if adding an excess of one chemical can trigger something unwanted. Engineering controls are the best to avoid such mishaps. Depending only on an SOP in such situations may cause an an incident to happen.
Read the article in this link.

Boiler burst kills 4

A boiler of a dyeing unit  burst on Tuesday, killing four persons and injuring 20 others on Tuesday. Inquiries are on to find out the reason for the blast. An official said that the safety valve failed release in time, leading to pressure building up inside the boiler.Read about it in this link.

A change in piping material may overlook something else!

A plant decided to change its sulphuric acid piping from Cast Iron to SS. However, they decided to conduct piping design analysis as per code requirement.The analysis found out that design did not adequately consider the difference in cross-sectional thickness between Cast Iron and SS (Cast iron is very thick compared to stainless steel). Also, the heat transfer rates of CI and SS differ. The piping expert redesigned the piping system to account for the thinner cross-section and thermal expansion properties of stainless steel and thus avoided premature failure. 
Read the article in this link.

Explosion in sulphuric acid tank

An explosion in a sulphuric acid tank has injured four personnel in Japan. There is the danger of presence of hydrogen in sulphuric acid tanks and when you do hot work be aware of the simple precautions like gas testing etc.
Read about the accident in this link. The Chemical Safety Board had earlier brought out a safety bulletin on the Dangers of Hot work, which is worth reading for every plant operation, maintenance and safety personnel. Read it in this link.

Fire in Pharma Plant

A fire in the vacuum dryer area of a pharma plant has reportedly seriously injured three people. As per Company press release, it states "There was a fire incident in a powder processing area at early hours on Nov 28,2011, at unit 11 which is located at Pydibhimavaram, Srikakulam near Vizag, A.P. Three persons were injured and they were taken to the hospital. The powder processing area is isolated from the intermediate block. There was no impact to the operations as well as to the assets".
Another news report indicates that the fire was caused by an explosion due to high pressure in the vacuum dryer.
Read the news reports in these links
Link 1
Link 2
Link 3

Remembering Bhopal............

Please spend December 2nd/3rd as “Process Safety Day” in your organisation. Educate your personnel on the Bhopal Gas tragedy and its lessons. 27 years ago, on the night on December 2nd/3rd, 1984, on a wintry night in Bhopal, thousands of men, women and children died an excruciating death when MIC leaked from the Union Carbide factory. The survivors and the next generation children born to those exposed to the gas still are suffering from the effects of the gas. Bhopal is an ongoing tragedy and should never be forgotten. The Bhopal gas disaster comprises actually of three disasters - the first was the actual incident, the second was the inadequate compensation received and the third is the ongoing legacy of genetic defects and effects of the hazardous waste that has seeped into the ground water. Every plant operating, maintenance and safety personnel must never forget the lessons of Bhopal. They are still relevant today:
1. Do not cut costs without looking at the effects on process safety
2. Maintain all your layers of defense including asset integrity
3. Continually ensure that competency of personnel operating and maintaining plants are updated and current
4. Be prepared for the worst case scenario.
5. Understand the risks and measures to eliminate / reduce or control them
6. Learn from your past incidents. Those who do not learn are condemned to repeat the incidents.
7. Pay heed to your process safety management system audit reports

As you are aware, this blog is also dedicated to the surviving victims of Bhopal and for my regular subscribers, I appeal to you to buy my book "Practical Process Safety Management", the proceeds from which are donated to the surviving victims of Bhopal.Contact me at bkprism@gmail.com for buying the book.

See a presentation on the Bhopal Gas Tragedy by Vijita S Aggarwal, Associate Professor, University School of Management Studies,GGS Indraprastha University,Delhi, India in this link.
Read my older post comparing the Bhopal and the BP incident of 2005 in this link
Read the then Police Chief’s account of the tragedy in this link.