July 31, 2013

Lessons from Hazira fire

With reference to my previous post about a fire in a refinery, a fire had occurred in January 2013 in a oil depot of IOC at Hazira.that Killed 5 workers. The investigation report of that incident mentions that  the root cause of the incident was ignition of flammable vapours inside a floating roof tank pontoon.It appears that the pontoon was earlier repaired with old corroded plates that led to the leak. The cause of ignition was most likely a spark generated due to a falling object.


Read the report in this link.

See a video of the fire in this link. 


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July 29, 2013

Operator dies in flare KO drum area fire

A fire in a flare KO drum area has killed an operator in an IOC refinery in Koyali.  The incident occurred on 16th July and the operator succumbed to his burns on 25th July. While the reasons for the incident are being investigated, please remember that Flare systems are emergency safety systems and that we need to pay them great attention. Often fires get reported due to water seals blowing, overflows from flare stacks, and inadequate maintenance. Are you giving your flare systems the same importance as a single stream rotating equipment?

Read the news article about the incident in this link. 

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July 25, 2013

MOC survey results

Thank you to the participants of the MOC survey
Results are given below:



Total participants: 45
What do you feel is the weakest link in your MOC program?
Lack of commitment by top management                              21.7%   
Too elaborate and complicated                                               29.7%   
Lack of time                                                                            48.6%
Do you have adequate time to conduct a PSSR?
Yes                                                                                          64.9%
No                                                                                            35.1%
Do you feel the PHA conducted as part of MOC is really bringing out all process hazards?
Yes                                                                                         48.6%
No                                                                                           51.4%
What is the greatest challenge to your MOC program?
Majority answered that it is lack of proper engineering documentation



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July 21, 2013

3D virtual simulator for chemical plants

Now this is one technology driven change that sure is going to benefit process safety! The Department of Energy is running a program with West Virginia University to test 3D virtual simulators for training process plant simulators. Read an article about this in this link.

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July 18, 2013

Accident in urea plant in 1992 - Are you taking precautions?

 In 1992, while doing maintenance work on an ammonia feed pump in a urea plant in India, 11 persons died due to sudden ingress of ammonia reportedly due to a failed suction valve bush.What precautions are you taking when handing over equipment for maintenance to prevent such incidents?
Read the incident in this link.

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July 15, 2013

A balloon causes a refinery outage!

A news report indicates that a refinery in the US experienced a "momentary power problem that prompted a plant restart". Apparently, the problem was caused by a Mylar balloon that got caught in power lines supplying the refinery. Read the article in this link.

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July 12, 2013

Explosion in solvent tank

An explosion took place in a solvent tank that was part of a process that was being started up for the first time. It is reported that the explosion took place even though there was a nitrogen blanketing system of the tank. When you start a plant for the first time or after any modifications, be very careful. Humans make mistakes and especially during the time pressures for commissioning.


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July 11, 2013

Management of Change survey

Dear Readers,
Kindly take a few minutes to complete a Management of Change survey (6 questions, multiple choice) in this link.

Date of closing of survey is 24.7.13. Results will be published in blog. Thank you for your participation.


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July 8, 2013

Operating discipline!

For those of you folks who are practicing behavior based safety in your organisation to improve safety culture, see this very educational video in this link. 


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July 4, 2013

An organisations take on Safety Culture

In an article in Power Magazine, I read about a company called NV Energy who have developed a very good safety culture and it shows in their accident stats. You may argue that they are a small organization but I believe what they are doing is also applicable to big organizations.

 Read the article in this link.


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July 1, 2013

3d printed chemical reactor achieved

Further to my last post, "Scientists in the UK have used reactors made on a 3D printer to complete a three stage organic synthesis. The reagents, catalyst and purification step for the synthesis are completely integrated into the chambers of the sealed reactor. When the reactor is rotated, gravity pulls reactants through the different chambers to complete the synthesis".

Read the article in this link.
The next step in process safety may well be micro reactors and micro plants.......stay tuned!! 

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June 28, 2013

3d printing and process safety

The news has been full of reports of how a company put their plan for 3D printing of a plastic gun on the net and how one person was even able to fire a bullet from it. It appears right now that the printer prints using plastic material. The advantages claimed are accuracy, less wastage. An article by Bloomberg  "Your future will be made by 3D printers" is interesting to read.

In the future, maybe 3D printing will improve process safety by eliminating manufacturing defects!!


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June 25, 2013

Drones for flare tip inspection

While we read about drones being used for military purposes, here is another use for them -a refinery has used a drone fitted with a camera for inspection of the flare tip while refinery was in operation. Now this is what I call as innovative usage of technology! Read the article in this link. 

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June 21, 2013

A confined space fatality

Three years ago, a experienced person (17 years experience) lost his life when he entered a space inside a ship that was inerted with nitrogen. This, through he was trained and experienced.
 Read the accident report in this link.

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June 17, 2013

Another hot work tank explosion

A refinery in China experienced a hot work accident that killed two workers. Apparently the tank in which the accident took place was decommissioned. Ensure you take all precautions when doing hot work on tanks.
Read the news articles in these links:
Tank explosion 1
Tank explosion 2

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June 15, 2013

Vessel blast kills one

In a fertilizer manufacturing facility very close to the Louisana unit, one person was killed when a vessel ruptured when it was being pressurized with nitrogen.
Read about the incident in this link.

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Photos of the fire in chemical plant

See photos of the fire in the chemical plant in Louisana in this link

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June 14, 2013

Explosion in chemical plant

An explosion in a chemical plant (manufacturing ethylene/propylene) in Louisana has killed one person and injured several. We have to wait for the CSB to investigate and report the findings.
Read about the incident in this link
Watch the video in this link.

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June 11, 2013

Rescuers die in a confined space rescue

A tragic accident where two rescuers lost their lives trying to rescue two persons who had lost consciousness inside a chimney is reported in a bio gas plant under construction in Thailand. This incident stresses the need for training would be rescuers. World over, many deaths continue to occur as rescuers enter confined space without proper protection and loose their lives. Read the incident in this link. 

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June 8, 2013

Process safety leadership survey results

A total of 55 readers undertook the survey and I thank them for their participation. The results are given below:
 

1. How much do you think are your top management really committed to process safety?
Very much                                                         39.2 %   
Sometimes                                                        25.9%   
Needs improvement
(they say something and do something else)  34.9%   

2. In times of production problems, do you think process safety gets bypassed according to the urgency?
 Yes                    22.9%   
Sometimes        60.4%   
Never                 16.7%   

3. Do your PSM audit findings receive adequate follow up from top management?
 Yes                                                46.8%   
Needs improvement                      53.2%   

4. Do your inspection departments findings get overruled by top management to maintain production?
 Yes, but with a technical basis     47.9%   
Yes, without a technical basis       25.0%   
No, never                                       27.1%   

5. Do you get contradicting signals from top management regarding process safety?
 No, never              41.7%  
Yes, sometimes    56.3%   
Yes, always           2.0%     

6. Do you feel the root cause analysis of process incidents and near misses really bring out the root causes?
Yes                       72.9%   
No                         27.1%   

                             
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June 1, 2013

Lessons from the near miss at Heathrow airport

Last week, a plane had to make an emergency landing at Heathrow airport soon after take off as one of the engines failed. No one was injured. Preliminary investigations have revealed that the engine cowls (covers) on both the engines were left unlocked and came off during take off, damaging the engine and other parts.
The air accident investigation board's report indicates that there had been 32 previously reported fan cowl door detachment events, 80% of which had occurred during the takeoff phase of flight!

Read the report in this link. 



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May 28, 2013

Survey on Process Safety leadership

Dear Readers,
Request you to participate in a survey I have created for process safety leadership. There are seven multiple choice questions and would take very less time to fill it. Your responses will be anonymous.
Survey results will be published on the blog. Survey closing date is 6.6.13. Thank you!

Take the survey in this link. 



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May 24, 2013

Fire in HPCL refinery

A fire that lasted about 6 hours has been reported in a refinery at Visakhapatnam. No casulaties were reported. Read about the incident by Indian Express in these links

Major fire at HPCL Visakha refinery

Fire: Emergency systems saved HPCL


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May 21, 2013

May 18, 2013

Process Safety for fresh engineers

I often get fresh engineers sending me e-mails about a career in process safety. I tell them that they must have a minimum of 10 years in operational experience to really think about a career in process safety. Process Safety cannot be learnt only from textbooks - it needs a deeper understanding on how organisations work and the human issues involving process safety. ASME has brought out a video about process safety for fresh engineers in this link.

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May 14, 2013

Wireless and explosion proof instruments

 Read a good article on wireless instruments and how they can be made explosion proof or intrinsically safe in this link.
PS: The article is for information only and I am not recommending any product.
 
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May 10, 2013

Flash fire in plastics unit in USA

On May 2nd, a flash fire occurred at a major plastics producer in the USA.This site had experienced a major fire in 2005 which the CSB had investigated. In the current fire it was reported that few workers were burned.
See a video and news article in this link

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May 8, 2013

Behaviour Based Safety - Take it with a pinch of salt!

I am always of the view that if behavior based safety has to succeed, the behavior of top management should be corrected first. For example, in an organization if top management keep saying safety is important and do not support their actions with visible and cost committed actions, nothing will change. The Indian culture follows the rule "the boss is always right". So in most Indian organisations, it is something short of blasphemy to observe and report top managements behaviour!
When I was working as a Plant manager 25 years ago, the bosses right up to the top were always displaying the correct behaviour mainly because they were technocrats and had command over the other non technocrats in the organization. The United Steel Workers union in USA has a take on behavior based safety which is worth reading from this link. (large file...be patient).

 Do you have a BBS program going on in your facility? I would like to seek feedback from you about your experience.

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May 6, 2013

Welder killed in sulphuric acid tank accident

News reports indicate a welder was killed yesterday at a Chemical manufacturing plant in South India when the lid of a sulphuric acid tank burst "when he was trying to open it". Further details are not known.
Time and again we are seeing repeats of sulphuric acid tank explosions. Train your operators about the hazards of sulphuric acid tanks and hydrogen generation in the tanks due to corrosion of carbon steel.

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Chemical freight Train accident in Belgium

A news article mentions a freight train accident in Belgium. The train was reportedly carrying acrylonitrile. One person reported dead and 49 injured. Read the article in this link.

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May 3, 2013

Another reason to ban mobiles in chemical plants

In 2011, a medical evacuation helicopter crashed in the USA killing all four occupants including a patient. The NTSB has concluded that constant texting by the pilot on his mobile was a contributing cause of the accident. He ran out of fuel. A news article mentions that "It was the first fatal commercial aircraft accident investigated by the National Transportation Safety Board in which texting has been implicated. And it underscored the board's worries that distractions from electronic devices are a growing factor in incidents across all modes of transportation — planes, trains, cars, trucks and even ships."
Now this is another reason to ban mobiles in chemical plants!

Read more: http://www.foxnews.com/us/2013/04/10/pilot-texting-contributed-to-copter-crash-ntsb-says/#ixzz2RONCSQmc


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May 1, 2013

Ammonia tanker accident

An ammonia tanker incident on the Pune Solapur road that killed two persons has been reported in the newspapers. Apparently the driver dozed off.
In India as well as around the world, there are a large number of accidents involving ammonia being used in refrigeration systems in dairies etc. All the ammonia manufacturers must get together to adopt a drive to educate end users about the hazards of ammonia and its safe handling and transportation

Read about the road tanker accident in this link.


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April 27, 2013

A contrarian view to Process Safety Management

 For those of you who have been around in the chemical industry for a long time, you will recall that prior to the nineties, process safety was managed in most companies by people who had vast experience and knowledge. Today, I see a dangerous trend - we are drowning in complex PSM systems that takes time to understand and given the high attrition rates, accidents continue to happen. I believe for a PSM system to succeed, there can never be a replacement for strong technical competency right up to the top of a company and that PSM systems must be simple, easy to understand and execute. It is not the number of elements you have in your PSM system or the Safety Integrity level that counts but the capacity to comprehend what the system is telling you.....!

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WEST FERTILISER PLANT EXPLOSION UPDATE-5

 A reader has pointed out the following:
'As I understand it, this facility was a storage and retail operation selling directly to farmers. Thus the facility would receive ammonium nitrate in bulk by rail, store it and then sell it to farmers for soil application. I do not believe there was any "manufacturing" of ammonium nitrate on the premises. While the fire may have started in another area of the facility and spread to the ammonium nitrate storage area, these facts are not known at this time. Rather than speculate using incomplete information, lets wait for the fire cause and allow folks to do their job".

I agree with him!
 

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April 25, 2013

WEST FERTILISER PLANT EXPLOSION UPDATE 4

A news report  mentions that investigators say that the explosion did not involve the ammonia tanks. Read the report  in this link

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April 24, 2013

Fire in refinery during maintenance work

A major refinery in USA experienced a fire during maintenance work in a heat exchanger in a catalytic hydro desulphurisation unit. 12 contract workers were reportedly injured. Read about the incident in this link

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April 23, 2013

WEST FERTILIZER PLANT EXPLOSION - UPDATE 3

A news article mentions that the residences and other complexes were built over the years surrounding the fertilizer plant that was started in 1962. While this needs to be investigated, we, In India need to enforce facility siting rules to prevent the unauthorized development around a chemical plant.

Read the article in this link.

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April 21, 2013

WEST FERTILIZER PLANT EXPLOSION UPDATE 3

While not jumping to conclusion about the reason for the explosion, the photos before and after the explosion indicate that ammonium nitrate that was stored exploded after an initial fire in some other section of the plant, that spread to the area where ammonium nitrate was stored.
Compare the photos of the plant before the explosion (Courtesy: Google Earth) and after the explosion, courtesy AP:
Before the explosion:
After the explosion:

From the photos, it appears that the fire first started in the manufacturing area for ammonium nitrate ( read this link from Wikipedia about the process) and then spread to the storage area of ammonium nitrate.

There are a number of pictures in this link of the plant after the explosion and looks like the bullets and ammonia trailers were spared the wrath of the explosion.


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WEST FERTILIZER PLANT EXPLOSION UPDATE 2


The NY daily news has reported that "the fertilizer plant that exploded had 1350 times the amount of ammonium nitrate that would have raised red flags.The factory in West, Texas, did not report its massive amount of the potentially explosive fertilizer to the Department of Homeland Security, a source familiar with DHS operations said. At least 14 people died and more than 200 were injured following the blast on Wednesday".

By the way, the ammonia synthesis industry has completed 100 years of operations. Read an interesting update on this event by BASF in this link. 



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April 18, 2013

UPDATE ON TEXAS FERTILISER PLANT EXPLOSION

News reports indicate that the Fertilizer plant that exploded held an estimated 54,000 pounds of anhydrous ammonia to produce ammonium nitrate, a fertilizer.


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HUGE EXPLOSION IN TEXAS FERTILISER PLANT

Thanks to Abhay Gujjar and Ravi Varma for sending details of a huge explosion in a fertilizer plant in Texas. Reportedly there have been many casualties.  Read the news report and graphic video of the explosion in this link.

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Fukushima - status

Thanks to Sanjeevi for sending this article on the status of the Fukushima disaster clean up. It is scary! Read it in this link.

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April 15, 2013

Regulatory oversight of PSM

There may be regulations and regulations but regulatory oversight (checking of implementation by legal authorities involved) need to be strong to enforce the regulations - this is one of the lessons learnt from the refinery fire in California. In India, too there are many good regulations but the problem comes when enough manpower and competency is not available with the regulatory authorities.
Read the article on the lessons learnt from a regulatory point of view from the refinery incident in California in this link.        http://www.mercurynews.com/top-stories/ci_22966315/federal-officials-say-regulatory-system-needs-overhaul-wake


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April 13, 2013

Accident in a refrigeration plant

Thanks to Satya Subrahmanyam for sending details about an accident in  a diary that killed three people, where according to Deccan Chronicle,  "An oil separator exploded due to reported electro-mechanical failure and the entire refrigeration unit caught fire. The blast occurred an hour after work started in the morning".
Read the article in this link. 
Read another associated article in this link 


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April 12, 2013

Ammonia leak in Urea plant

An ammonia leak in an urea plant in North India has affected 8 workers according to a news report. The shift in charge and a DGM were arrested and later released on bail. Read the news article in this link.


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April 11, 2013

CSB statement on Chevron refinery fire

The CSB has posted their statement about the Chevron refinery fire.An important statement is given below:
"The CSB also has identified deficient management of change reviews conducted by Chevron where more corrosion resistant metallurgy such as 9CR was identified as needed for crude unit high temperature service that could have addressed the piping circuit that failed. However, this more corrosion resistant metallurgy was not implemented more broadly in crude unit high temperature service. Under the current regulatory system Chevron cannot be cited for conducting “ineffective” MOC’s – they are only required to simply conduct them and implement agreed upon actions. Too many of the elements of the PSM regulation simply require paper procedures or activities,rather than concrete measures toreduce risk at every opportunity"
Read the CSB statement in this link.
.

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April 10, 2013

Accidents and gas releases at a smelter


Read the article in this link

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April 7, 2013

Beware of the alligator in a PSSR!!

A participant in a recent training session told me of an incident where a cross country pipeline was being welded in marshy territory. The job was completed for the day and the next morning when the welder approached the pipe to start his job, an alligator which had entered the pipe in the night caught him and fatally wounded him.
I am reminded of such "alligators"  when people do not conduct a PSSR properly. Hidden hazards ("Alligators") will be waiting for you and will kill you when you least expect it. Take PSSR's seriously!


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April 4, 2013

Another sight glass incident

A worker died at a refinery when he was exposed to propane and HF when a sight glass ruptured. Read about the accident in this link.

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April 1, 2013

Refinery tank fire - lessons learnt

In 1995 two petrol tanks caught fire in a refinery in Gujarat. See the presentation in this link and learn lessons from the incident.

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March 26, 2013

On line flare cleaning

I read about a online cleaning of a partially blocked flare header. I was wondering what change the refinery made for the flare header to get partially blocked in the first place. See the video and article in this link. PS: This is for information only.

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March 22, 2013

Slurry pump accident

Even a slurry pump when operated dead headed can cause a serious accident. When pumps are operated with their discharge valve closed and no recirculating, the energy will converted to heat. In this incident a slurry pump over pressurized due to superheating of the slurry. Read about the incident   in this link.

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March 17, 2013

Are your contingency plans in place?

A recent fire in the Chennai Airport air traffic control complex due to a battery explosion highlights the how good contingency planning and drills can bring a dangerous situation in control. A Times of India article mentions that "A battery of the uninterrupted power system, that was the third back up for the Advance Surface Movement Guidance and Control System (ASMGCS) or surface movement radar, had caught fire and exploded. The battery system that exploded was immediately isolated from other equipment to prevent damage to sensitive machines. Even as the fire fighting was taking place, a few air traffic controllers were sitting along with their colleagues on the second floor and communicating with pilots of overflying aircraft over high frequency communication system."

Read the full article in this link.



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March 14, 2013

Confined space entry precautions

Reading a 1987 document about the hazards of confined spaces indicates how relevant it is even today. Old is gold!
Read it in this link. 

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March 11, 2013

Ammonia leak from plant

An incident where a safety valve in an ammonia plant lifted and discharged ammonia to the atmosphere has been reported. Check where your ammonia safety valves discharge. Vent stacks which may have been built by the designer may not be the appropriate solution as the population around the plant may have increased. Read about the incident in this link.


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March 8, 2013

March 5, 2013

Three killed in Chemical leak at Ankleshwar

Thanks to Mr Sunil Chauhan for sharing news about an incident that has killed three people. Times of India reports that "A chemical process involving acrylonitrile and carbon tetra chloride was being carried out. "This process needs a proper temperature control. The persons responsible failed to control the high temperature that led to a reaction and subsequent leakage of the gas from a gasket of a reactor. We are investigating whether the company had installed proper gasket. Preliminary findings indicate that automatic temperature control valve was not installed," sources said."

Read the article in this link. 


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March 4, 2013

Global Chemicals outlook - UNEP

UNEP has published a very informative global chemicals outlook and has given recommendations for the sustainable growth of the industry. Indian chemical manufacturing is projected to grow 59% in the period 2012 to 2020. The sound management of Process safety will become more and more important as the industry faces high attrition rates and management succession gaps. Read the report in this link.

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CEO faces bonus cut due to incidents

A news article mentions that the CEO of a chemical giant faces cuts in his bonus due to major incidents under his tenure. Many organizations are now linking process safety performance as one of the items to calculate incentives.
Read the article in this link. 


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March 2, 2013

Blast in API unit - DGM production arrested

The Hindu (AP edition) today reports that the DGM production of an API manufacturing unit in Andhra Pradesh has been arrested for a blast that killed two persons in January.  The news item mentions that "after a magisterial enquiry, it was established that plastic pipes were used for pumping the chemicals instead of metal pipes. It was also said that sub standard pipes were used."

Read about the incident that happened in January in this link.

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March 1, 2013

PVC pipe explosion incident

A safety alert by MSHA indicates the dangers of PVC primer trapped in enclosed spaces that caused a PVC pipeline to explode. Read about the incident in this link.


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