Pneumatic test fatality

Read the case study about a fatality during a pneumatic test in this link.

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CSB Chairperson Moure-Eraso Warns About Danger of Hot Work on Tanks Containing Biological or Organic Material - General News - News | the U.S. Chemical Safety Board

CSB Chairperson Moure-Eraso Warns About Danger of Hot Work on Tanks Containing Biological or Organic Material - General News - News | the U.S. Chemical Safety Board



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Near miss, near hit: Don't let the terminology bog you down| Plant Services

There is often confusion among people about what is a "near miss" . See the link below for an explanation:

Compliance | Near miss, near hit: Don't let the terminology bog you down — Whether called near misses, near hits, close calls or something else, the key is to make sure organizations track and investigate them | Plant Services



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Automation and the human

An incident with a plane when it descended  5000 feet without the knowledge of the pilots is reported in newspapers. The commander of the aircraft was under "controlled rest" , (naps allowed by rules) while the co pilot was reported to be busy with the flight data on her ipad. The ATC in Ankara, over which the plane was flying,noticed the flight dropping from its assigned altitude and radioed an emergency alert to the co pilot. The flight was then brought back to its designated altitude.  This incident is being investigated and the results of the investigation will be interesting to see. With so much automation, how did the plane drop 5000 feet without the co pilot noticing it?
In chemical plants, also, an alert and trained operator is the best defence against an incident. Automation is only an enabler and cannot replace the human. Focus on competency development program for your operators and shift crew. Establish a fatigue management program for your shift crew. When I was working in shifts in the Middle East in 1990's the management gave a lot of importance to fatigue management. In fact a near miss incident was reported when a maintenance worker was working on overtime on a critical equipment.


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Negligence caused fire at GAIL pipeline in Andhra: OilMin | Business Line

Negligence caused fire at GAIL pipeline in Andhra: OilMin | Business Line



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Design and robustness

 How GE designs its jet engines

The above link is worth watching and it is interesting to see how strict mandates for aviation design are!
Of late, in India, I see a deterioration in design aspects in chemical plants., mainly because of cost cutting pressures and severe competition in the EPC space. This leads to some dilution in design. Let me give you an example. There were two EPC contractors bidding to build a new ammonia storage tank. One of them who was the lowest bidder got the assignment. Tank was erected, commissioned and everything went off well. As time went by, corrosion started affecting the tanks and only then it was noticed that the designer had scrounged on the number of root isolation valves to cut costs. This meant that if there was a leak in an instrument manifold tapping coming from the top of the tank to the bottom, the leak could not be isolated. You might argue that a HAZOP study should have spotted this, but the quality of HAZOP studies has nosedived!

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Temporary change and asset integrity

This case study from OISD highlights the importance of asset integrity and managing temporary changes. Share it with all your operation and maintenance crew.

 

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Video of fire in service station

Leak + ignition source = fire. See the leak of a flammable fuel then catching fire from an ignition source (vehicle) in this link

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Fatality due to fall in molten iron bucket

News reports indicate that an employee of a major steel company has died after falling into a molten iron bucket which was at 1600 deg C. The investigation will reveal the cause of the tragic incident.

I want to share an incident in another company I heard about few years back, where an engineer fell into a shredding machine that was operating. The fall was due to an open manhole, left open by maintenance. The engineer did not see the open manhole and fell into it. The maintenance crew had taken a break and left without barricading or closing the manhole cover.

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CSB Emphasizes Existing Resources Available on Hot Work Safety

CSB Emphasizes Existing Resources Available on Hot Work Safety - General News - News | the U.S. Chemical Safety Board

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Basic safety guidelines while using gas cylinder

Air products has brought out a simple and effective safety bulletin on gas cylinders.
Read it in this link

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Taiwan gas pipeline blast

Close on the heels of the GAIL pipeline blast in Andhra Pradesh recently, comes news of a similar blast in an underground gas pipeline in Taiwans second largest city. The pipeline was passing through a busy road. See the video and 10 photos of the blast in this link. (Courtesy of Time magazine)


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Lessons from an air crash

The NTSB's investigation of an air crash at San Francisco airport during landing last year mentions that

"The board’s acting chairman, Chris Hart, warned that the accident underscores a problem that has long troubled aviation regulators around the globe — that increasingly complicated automated aircraft controls designed to improve safety are also creating new opportunities for error. 

The Asiana flight crew ‘‘over-relied on automated systems that they did not fully understand,’’ Hart said. 

‘‘In their efforts to compensate for the unreliability of human performance, the designers of automated control systems have unwittingly created opportunities for new error types that can be even more serious than those they were seeking to avoid,’’ he said. "

Read the article in this link. 

I am a firm believer of keeping it simple. Just because that vendors try to sell you a piece of "latest" technology, do not buy it unless you are convinced it will be useful for you. If the argument is that we need more automation systems as competency is going down, I would answer by saying, keep your systems simple so that your training programs become more effective!


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Operational Safety and Maintenance: Fear Ad Hoc Fixes | Chemical Processing

Operational Safety and Maintenance: Fear Ad Hoc Fixes | Chemical Processing



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We are like this only........

Recently I was travelling on a highway which is notorious for accidents. The company car which had picked me up had 4 other employees in it. Only the driver and me (sitting in the rear seat) were wearing the seat belts. I finished my work in the company (which has many plants at various locations) and was travelling back with the corporate safety head of the company along with me. He was not wearing his seat belt!! The driver was rash but none objected till I told him to drive safely. Guess you know where the problem is!!
Why are we like this??

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Pneumatic test accident

The dangers of pneumatic testing is highlighted in this fatal accident.


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PROCESS SAFETY TRAINING SERVICES BROCHURE

To all my readers, please find the process safety training brochure listing out the various topics I provide training in this link. 

 
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Major fire in chemical factory in AP

A major fire in a chemical factory in Nalgonda in Andhra Pradesh has been reported. The fire apparently began due to methanol catching fire. Read and see the video at NDTV in this link 



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Bypassing overrides and the metro incident

The recent incident in the Delhi metro where the train travelled some distance with the doors open has a parallel to process safety. Apparently, problems were observed by the driver with the door closing system and he requested permission to override it and operate it manually. After getting the permission, he apparently did operate the doors manually in a few stations, but forgot to do so at one.

When you authorise trip or override bypasses due to a malfunction, the sense of vulnerability must increase ten fold with close supervision to prevent human error remember WHERE HUMAN, THERE ERROR!

Read the article mentioning the incident in this link. 


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Controlling a chemical plant by thought

 Engineers are perfecting the art of flying a plane just by using a pilots thoughts. This research has progressed rapidly and the article in this link explains the status.
Is it possible that a few years down the line, we may be controlling plants through the DCS operator thoughts? If they perfect the art of flying a plane just by thoughts, then I am sure the technology will filter down.


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