The boy who beeps - from GE

GE has brought out an interesting video on a young boy who can talk to machines by a beep! What does this have to do with process safety? You figure it out in this video.


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Root causes - Unveil them to prevent future incidents

Often, I see incident reports where it mentions the root causes of the incident, but actually they are not the root causes.
I am taking the example of a case study put up on the OISD website called Fire Incident in Process Cooling Tower
in which it mentions the following as "Root Causes" for the incident: My comments are given in brackets.

ROOT CAUSE

1. The reason for explosion and major fire is gushing out of entrapped hydrocarbon from the cooling water return header to new cell, which got ignited since hot jobs were being carried out in close vicinity. The ingress of hydrocarbon was from leakage of hydrocarbon in cooler/condenser in connected process units. (This is the direct cause of the incident)


2. Not adhering to the practice of stopping all work (especially hot work) and prohibiting all unrelated contractor and company personnel at site, before commissioning a new system/ facility. Also, carrying out hazard analysis/ risk assessment would have probably indicated that there could be trapped HC gas, and prompted commissioning/ operation team to vent out entrapped gases. (Why was the work not stopped before commissioning of a new facility? Why was hazard analysis/risk assessment not carried out?)

3. Failure to prevent commissioning activities, even though several jobs were unfinished:

· HC and H2S detectors were not installed.

· Instrument cabling, cooling fan jobs were still unfinished.

· Decision to go ahead with commissioning at fag end of the day.

· Improper coordination amongst Operation, Maintenance and Project  departments.

· Unable to ensure the gaps identified in internal safety audit & operation check-list are liquidated before commissioning

(Why was the commissioning done even though several jobs were unfinished?)


I am hoping the OISD will publish the detailed investigation report of the HPCL Visak cooling tower fire incident and the GAIL pipeline leak incident, just as they have put up the Mr MB Lall's committee report on the Jaipur oil depot fire on their website.

 
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Times of India: Nagaram blast: Probe nails GAIL, says it ignored disaster warnings

Times of India: Nagaram blast: Probe nails GAIL, says it ignored disaster warnings


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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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Explosion in chemical plant injures one

 News reports in the USA indicate an explosion occurred in a chemical plant, injuring one. "A broken process line produced a chemical reaction, causing a small explosion in the chemical production area" is the statement made by plant official in this link. 

 While I am not commenting about the cause of this incident which is under investigation, how good is your asset integrity program? A good asset integrity program should ensure that you do not have failures like broken lines etc.

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Contamination in pipelines can cause disasters

In 2009, a commercial jet liner had to declare an emergency and land at Hong Kong airport after its engines lost thrust due to contaminated fuel. The reasons for the contamination was because of salt water in the fuel which was loaded in the previous airport. The underground fueling system at that airport was being extended. During the commissioning, salt water in a new pipe entered the main fuel lines as the clearing procedures were inadequate. This caused the thrust problems in the engines. In our chemical process industry, we often line up equipment after repair/hydrotest. Any remnants of water could cause a catastrophic incident later. Make sure your commissioning and start up procedures address this.


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People, Processes And Problems: Better Understanding The Three P’s Of Manufacturing

People, Processes And Problems: Better Understanding The Three P’s Of Manufacturing

Thanks to Balachander Rao, my chemical engineering classmate for sending this insightful article.

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GAIL officials’ negligence led to pipeline blast: expert - The Hindu

GAIL officials’ negligence led to pipeline blast: expert - The Hindu

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Deadly reaction of lime sulphur with NPK solution

An incident where a farm worker was exposed to Hydrogen Sulphide due to mixing of Lime sulphur (mixture of calcium polysulfides formed by reacting calcium hydroxide with sulphur) with NPK solution is highlighted in this link.

MSDS of lime sulphur is given in this link where it mentions acidic materials or dilution with water will cause the release of hydrogen sulfide.



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Article on flange leaks

Even though this article is 9 years old, the causes of flange leaks remain the same. Worth reading in this link.
PS: This is for information only.

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Responsible Care - reinforcing public opinion

The Indian Chemical Council is promoting Responsible Care and trying to motivate organisations into obtaining the RC logo it awards. This is a good initiative but the public needs to have faith in the process. The public are always sceptical of any self regulation by an industry body as they feel that it will be compromised. I have a few suggestions to the ICC to help to make RC more acceptable by the public:

1. The logo should be awarded with the condition that it will be withdrawn if a fatal or reportable accident occurs after awarding the logo. The company then has to go through the whole process for obtaining the logo. ICC must not only publicise the list of companies that have been awarded the logo, but also publicise the names of companies for which the logo has been withdrawn.
2. The best practices of every company that has been awarded the logo should be publicly displayed in ICC website for anyone to emulate.
3. One of the conditions of awarding the logo should be contribution to a fund to improve safety in the SME sector of chemical industries, including fireworks industries. The contribution could be fixed as a percentage of turnover.The improvement of safety in the SME sector of chemical industries should be taken up by ICC themselves and this must be publicised.


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Hydrogen safety in the sulphuric acid industry

Good article - hydrogen safety in the sulphuric acid industry

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A simple slogan

 Yesterday, while driving behind a car, I saw a sticker on  its rear window which said
" WEAR YOUR SEAT BELT - YOU PAID FOR IT"
 A simple yet effective slogan!

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Technology is not a complete substitute

The saga of the missing Malaysian airlines MH370 flight highlights the fact that technology is an enabler but it cannot override the human. The way in which vendors are hard selling process safety technology these days worries me. A typical case is SIL rated instrumented systems. While the statistics and numbers sound very good, no vendor is gong to tell you about the life cycle needs and cost of maintaining these systems.

Nowadays, I also see many cases of the operation staff  left out of the design loop. The net result is that the operator gets a system which leads to work overload during emergencies. Then the vendor hard sells "alarm management software"!!
Somewhere in our journey of process safety management we have forgotten Dr Trevor Kletz's inherent safety philosophy of "keeping it simple".
I often see complicated PSM systems in many "World Class" companies. These systems are "managed" by separate PSM cells.....have we forgotten that the owner of PSM is operations? I often see the systems getting more complicated because the PSM cell needs to justify their existence! (My due apologies if I have hurt anyone).

Having had the fortune to learn about process safety when the word was not in "fashion" , I pray the post bhopal generation of chemical engineers realise that managing process safety is not only about technology........design it for humans who make mistakes.....keep it simple and easy to understand.


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Visakhapatnam pharma unit blast: Condition of three critical - The Hindu

Visakhapatnam pharma unit blast: Condition of three critical - The Hindu

Thanks to Mr Subbu for sending news about the blast.
Ammonia and high temperature are dangerous due to the thermal expansion coefficient of liquid ammonia.

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Update on GAIL pipeline blast

The Hindu: GAIL pipeline blast in AP


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Pipeline fire kills 14 in AP

News filtering in of a GAIL pipeline blast in Andhra Pradesh which has reportedly killed 14 people. Read the story in this link


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Blast, fire in Bathinda refinery, none hurt - The Hindu

Blast, fire in Bathinda refinery, none hurt - The Hindu

You can see the photo of the fire in above link.


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Major fire at Bathinda refinery, no casualties reported - Hindustan Times

Major fire at Bathinda refinery, no casualties reported - Hindustan Times

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Don't neglect pressure gauges -chemical processing

Don't neglect pressure gauges -chemical processing

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2 die in steel plant accident

Thanks to Mr Subbu for sending news about Two engineers who were killed at a steel plant when they entered a container laboratory and were apparently asphyxiated by some gas.
Read about the accident in this link

When you enter analyser houses in chemical plants, ensure that the gas alarms are working and that there is no alarm before entering the confined space. As there will be tubing and other places from where gas from cylinders outside can leak, be careful.

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Major fire in Russian refinery

Major fire in Russian Refinery courtesy rt.com
See photos and videos in above link.

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The dangers of evaporating liquid nitrogen

A case study where a post graduate student died due to nitrogen inhalation is given in this link . The student was using liquid nitrogen. The accident highlights again the dangers of nitrogen.

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1 employee injured after fire, explosion at Moore distillery; blast blamed on ethanol flash

1 employee injured after fire, explosion at Moore distillery; blast blamed on ethanol flash



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Improving road safety in India

Please take some time off to sign this petition. It affects all of us......

Petition to improve road safety in India


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Gas leak in Chhattisgarh’s Bhilai steel plant, 6 killed, 40 injured

A tragic accident where 6 people lost their lives when a water line to scrubber ruptured and gas leaked out: (two DGM's among those killed)

Times of India Gas leak in Chhattisgarh’s Bhilai steel plant, 6 killed, 40 injured
http://timesofindia.indiatimes.com/india/Gas-leak-in-Chhattisgarhs-Bhilai-steel-plant-6-killed-40-injured/articleshow/36450920.cms

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How secure are your redundant systems?

An article in the Guardian highlights the importance of functional testing of your redundant systems. In the incidents mentioned, two helicopters of identical make faced a main lubrication oil system failure while airborne. Though the back up system came on line, an alarm indicated that it was not working properly, so the crew had to make emergency landings in the sea. Later it was found out that the back up system was indeed working fine, but the alarm was wrongly configured.
Read the article in this link. 


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Fire in Refinery

A news article mentions about a fire in a Chinese refinery in the sulphur recovery section. Interestingly, it mentions that the fire reignited a few hours after it was put off due to "chemical reaction of combustible material in an oil tank with fire extinguishing foam".

Read the article in this link. 

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Basics of flammability

A good basic primer on flammability, explosion protection and flammable gas detectors can be found in this link. 
PS: I am not endorsing any product - this is for information only.


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Ammonia leak hospitalises 54

An ammonia leak due to an apparent pipe burst in a fish processing plant in Tamilnadu has sent 54 of the workers to hospital. The reason is under investigation.
The ammonia leak incidents at the users end as well as incidents related with fireworks are on the increase in India. This is a good case for Large chemical manufacturing companies to take up the education and safety precautions for the small scale industries which handle hazardous chemicals.

Read about the incident in this link.


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Massive fire in Dutch plant

Explosion and fire at Dutch Chemical plant - BBC news


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Proposed changes after oil rig accident

The Coast Guard issued a Federal Register Notice of recommended interim voluntary guidelines concerning mobile offshore drilling units, or MODUs, and manned fixed and floating offshore facilities engaged in activities on the U.S. Outer Continental Shelf. This is part of the Coast Guard’s continuing response to the explosion, fire and sinking of the MODU DEEPWATER HORIZON in the Gulf of Mexico on April 20, 2010.

- See more at: http://mariners.coastguard.dodlive.mil/2014/05/02/522014-federal-register-notice-of-outer-continental-shelf-units-fire-and-explosion-analyses/#sthash.zFvYwSqf.dpuf

The Report highlighted the following considerations as areas not specifically addressed by current regulations:
Minimum values are needed for explosion design loads for use in calculating the required blast resistance of structures;
Explosion risk analysis of the design and layout of each facility should be performed to identify high risk situations;
H-60 rated fire boundaries between the drilling area and adjacent accommodation spaces and spaces housing vital safety equipment may be necessary dependent on the arrangement of the facility;
Uniform guidelines for performing engineering evaluations to ensure adequate protection of bulkheads and decks separating hazardous areas from adjacent structures and escape routes for likely drill floor fire scenarios are necessary;
Performance-based fire risk analysis should be used to supplement the prescriptive requirements in the MODU Code; such analysis should use defined heat flux loads to calculate necessary levels of protection for structures, equipment, and vital systems that could be affected by fires on the drill floor;
Maximum allowable radiant heat exposure limits for personnel at the muster stations and lifesaving appliance launching stations in anticipated evacuation scenarios should be implemented.

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Tanker explosion

An oil tanker after unloading its cargo of oil has exploded off the coasts of Japan. Apparently, a grinder was being used to clear paint from the walls of the ship when the explosion occurred. Do not underestimate the dangers of hot work even in a so called empty tank. The force of the explosion has ripped open thick metal sheets as you can see in the video in this link. 

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Explosion in 3 D printing firm

New technologies but old hazards - A 3-D printing company, was cited by OSHA after an explosion and fire , which inflicted third-degree burns to an employee. The company was using combustible metal powders like titanium and aluminium alloys in the 3D printing process. There were no Class D metal fire extinguishers on-site during the explosion and fire.

"Establishments that use metal powders in this new technology need to scrutinize their processes and take steps to prevent and protect their employees from fire and explosion hazards that arise with these materials," said Robert Hooper, OSHA's acting regional administrator.

Read the details in this link.

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Short cuts are wrong cuts - death by H2S

I came across a powerful youtube video about an accident involving hydrogen sulphide in 2008 in the Middle East where 3 people died. The accident occurred in a pit which was open to atmosphere but contained hydrogen sulphide in the bottom.The reason was taking shortcuts and not obtaining a permit. There are lessons to be learnt from this video, my thanks to whoever has shared this on you tube , as it can save many many lives. Ensure all your employees see this video......in this link.

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Reactive chemical incident due to human error

In 2012, a tragic accident in a pharma plant in Ireland claimed the lives of two employees. Apparently, the cause was due to human error in a batch reactor, when the reactants were charged without charging solvent first. The rapid reaction took place without the solvent in place to absorb the heat. This caused the reactor to explode. A news article mentions that one of the ambulances that took one victim was later found so contaminated with chemicals that it was decommissioned.
When you know that certain reactions can dangerously overheat if the operator forgets a step, proper engineering controls should be implemented.
Read the details of the accident in this link.

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One killed, six injured in NLC steam pipeline burst - The Hindu

One killed, six injured in NLC steam pipeline burst - The Hindu

It appears that the unit in which the accident occurred was over 50 years old and that residual life assessment studies were carried out. Will have to wait for the investigation to understand what happened.



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Williams Cos. reeling from four explosions at facilities in less than year - Tulsa World: Business

Williams Cos. reeling from four explosions at facilities in less than year - Tulsa World: Business

The article explains how a series of accidents have occurred at a company which had a good safety record.



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Accident at nuclear power plant - learn lessons

The accident at the newly commissioned Kudankulam power plant highlights the importance of line breaking permits. It appears that while maintenance crew were at work on the shutdown reactor, hot water at about 70 deg C came out of a valve, injuring the workers. While handing over equipment for maintenance, be careful about pockets of trapped hazardous material. Look for any dead legs, which could store them.

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Fatal accident during demolition of tank

When you are demolishing a tank or vessel, take adequate care. Conduct a hazard and risk assessment with the demolishing team to make sure the correct method is used. An incident occurred when a  tank being pulled down by an excavator collapsed on the cab of the excavator. Read about it in this link.
 
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Fatal accident due to pipe explosion

A good case study on the importance of ensuring proper positive isolation and ensuring the line is gas freed before any hot work is done is given in this link.


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Refinery attack In Algeria - Lessons Learnt

On 16 January 2013, terrorists attacked a convoy of gas refinery workers as they departed the housing area of a Refinery in eastern Algeria. The incident led to a four-day siege resulting in the deaths of 38 hostages.
 Read the article of how the emergency was declared by a security guard, (who later died) in this link

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Big is beautiful

Shell is building the Worlds first FLNG (Floating LNG production facility) called the Prelude. Watch the youtube video of the launch of the structure from the dry docks in this link. 
Worth watching is the mesmerising work of the tugboats as they steer the Prelude into the sea. The facility is planned to go into operation in 2017.

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Micro reactors and process safety

Researchers at Fraunhofer (Europe’s largest application-oriented research organization) have demonstrated how mcro reactors can be used to safely produce even explosives. Read the interesting article in this link.

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Hydrogen from CO2 and sunlight

An interesting article in the Times of India mentions the experiment of producing hydrogen using carbon dioxide and sunlight. Worth a read in this link.


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Two lab analysts die

Further to my earlier post of an accident due to a naphtha fire in an ammonia plant , it is sad to note that two lab analysts who suffered 80% burns have died in a hospital in Chennai. This incident highlights the dangers which personnel face when dealing with hazardous chemicals. They do not give you a chance. The reason for the incident is being investigated. I had worked as a shift in charge at this plant 30 years back. The place where we used to collect naphtha samples regularly was at the hydrodesulfurisation sections ( primary and secondary) outlet.
Look at all you sample collection procedures and whether all hazards have been identified. Train lab personnel to recognize these hazards and report them to plant personnel.


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Simultaneous jobs and their dangers

Many times, during an annual shutdown of a chemical plant, many jobs will be taking place and there is pressure to complete the  jobs on time. Be careful during this period as there may be a tendency to overlook some of the hazards due to simultaneous jobs. Your regular HIRA (hazard identification and risk assessment) may not be adequate and some risks due to nearby jobs may be skipped. Before every turnaround ensure that a special training is given to the people who conduct HIRA on how to identify hazards from simultaneous jobs.


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Are you travelling in a confined space?

In a lighter vein........
I am sure many of you will be flying frequently on official visits. Though planes are designed to be evacuated very quickly during an emergency, I often compare them to flying in a confined space! I have tried to correlate the system in chemical industries used for confined space entry to that of flying in a plane:

Confined space entry permit = boarding pass
Man watch = flight stewards
24 V lighting = emergency escape path lighting
Air blower system for ventilation = cabin air pressurisation system
Oxygen monitoring = oxygen masks drop down when oxygen is less
Rescue plan = emergency exits and chutes
Chief emergency and rescue controller= pilot!


I am sure you will be more comfortable when u fly next!! All the best!


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Case study of a sulphuric acid tank repair

Read a presentation by Carl Matherne on Application of NACE Standards for Sulfuric Acid Storage and Delivery – Tanks and Piping

  
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Accident at chemical facility at Tarapur MIDC

Close on the heels of the accident at a chemical facility in Andhra Pradesh, news about a series of explosions in a chemical facility in MIDC, Tarapur has been reported. No causalities have been reported. Read about the incident in this link.
 
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Chemical factory blast kills two in Andhra Pradesh - The Hindu

Chemical factory blast kills two in Andhra Pradesh - The Hindu



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Fire in ammonia plant injures 7

I felt sad to read the news about a naphtha fire in the ammonia plant of Madras Fertilizers which injured two people seriously. A total of 7 people were reported injured. Read the news article in this link.

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Mists of flammable material can be dangerous

In my career as a process safety consultant, I have investigated some fires caused by fine spray of a flammable  liquid. The most common include pressurised lube oil leaking from a defective hose or hose joint and the fine mist catching fire.
Read a good reference of various fire incidents caused by mist fires in this link.


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Sulphuric acid spill/leak incidents

Sulphuric acid leak/spill incidents continue to occur. Read about two incidents in these links
Accident 1
Accident 2

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PSM internal audit survey results

My thanks to the 22 persons who participated in the survey. The survey results are as follows:

1.  Over 65% of repsondents say that their PSM internal audit is carried out once in 6 months
2. All respondents say that they audit all their elements at a time
3. 30% of respondents replied saying that they audit process safety culture also
4. 50% of respondents use a rating system for the PSM internal audits
5. 85% of respondents replied saying that they feel the PSM issues are coming out during the audits
6. 60% felt that management was not viewing the PSM internal audits seriously
7. 85% felt that technical competency for conducting PSM internal audits needs improvement
8. 50% of the respondents say they classify audit findings as per risk.

 
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LNG tank leak incident

An incident at a a large LNG storage facility in Washington state in USA when an explosion in a "processing vessel" sent sharpnels into an LNG storage tank, puncturing it,has lessons in Quantitative RIsk Assessment and assumptions made.
The graphic leak of LNG from the tank ( which is similar to liquified ammonia tanks) but stores LNG at a temperature of -160 Deg C is shown in the video in a news report. The tank also appears leaking at two different places on the outer shell. The wind direction has helped in not igniting the vapour leak.

Link 1 - video
Link 2- news report


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The GM recall - what are the lessons in process safety culture?

You must be reading the news about the recall of 2.6 million cars GM made due to a problem in the ignition switch which could shut off the car while driving, disable the airbag, power steering and anti lock brakes. However it is reported that GM took 10 years from the time the problem was discovered and recalling the cars to fix the problem. Meanwhile 13 deaths have been attributed to this.
 In the ongoing Senate hearing, the recently appointed CEO of GM Ms Barra told the subcommittee, "that the new GM is more "focused on the customer" compared to a "cost culture" years ago at the automaker."

What is the commonality between a giant automotive maker and PSM? The answer is "cost culture". Beware of the cost virus in your organisation's PSM system.It can cause deadly accidents.
  
Read about the problem and recall in this link
Read about the testimony of GM Chief in this link

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Uzbek fertiliser plant acid spill investigation

In late February 2014, a sulphuric acid spill from a storage facility in a fertiliser plant in Uzbek was reported. Now the investigation reveals that it was a seam failure of the tank. Read the article in this link

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Role of HR in Safety

Mr M.K.Rao, Executive Director of India Glycols Limited has written a good article on "Role of HR in Safety". You can read the article in this link.  My thanks to him.

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Seven dead as tanker overturns - The Hindu

Seven dead as tanker overturns - The Hindu



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Process safety management internal audit survey

I would appreciate if, for those who are running PSM systems, you answer this survey (8 questions). Results will be published in the blog later.
Take the survey in this link.


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Fire in chemical unit

A fire in a  chemical unit in Udaipur has gutted the unit. In the pictures in the news report in this link, you can see remnants of barrels that have caught fire. Often, plants store chemicals in barrels on roads due to lack of space. This practice is a waiting time bomb. Barrels exposed to heat from a fire can explode violently and  spread the fire rapidly. 

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Confined space accident kills 7

 The Hindu Business Line has reported a confined space accident in a textile mill in Erode where 7 workers lost their lives. Apparently, the accident took place when maintenance work was taking place in a sunken pit in a ETP, when a valve broke and released poisonous fumes. The would be rescuers ( 6 of them) entered the  pit one by one to rescue the others and died. Please emphasize in your training the importance of rescuers NOT to enter any space for rescue unless they are adequately protected. This incident  is a tragic loss of life
Read about the incident in this link.


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When the back up fails........

 When I was working in Saudi Arabia, the 3000MTD gas based methanol plant was operated with state of the art DCS systems. Just before a planned turnaround, instrument personnel were working with some control room underfloor cables when, by mistake, all power to the DCS displays were lost. It was restored after 30 minutes. The plant parameters were maintained throughout the upset without any safety issue as the controllers in auto were doing their job. However a case study presented in 2012 by Shri KC Tripathy and others of NTPC shows how safety hazards cropped up during "complete and simultaneous DCS failure in two 500MW units"
The case study mentions among other useful learnings, the following:
"All processors (active and redundant) abruptly rebooted at once. Thereby both redundant network & redundant processor concepts of DCS design were defeated".

 Read the case study in this link.



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Common causes of flange leaks

Often flanges are a source of leaks, causing release of hazardous chemicals that may result in a fire or toxic chemical exposure. Read a good article on the basic causes of such leaks in this link.
 

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Process safety - voluntary or regulatory?

I read an interesting editorial in the "Record" about the above subject. Worth reading in this link.


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Lessons from NASA astronaut "water in helmet" incident

In July 2013, during a spacewalk outside the International space station, an astronaut reported water entry into his helmet. He was asked to get back only after he made three calls saying the water didn’t appear to be from a drinking bag. Later it was found out that the drinking bag was not the problem and a choked filter was the cause of the leak. The NASA investigation report mentions some of the reasons for the incident as inadequate training, the crew members and ground misunderstanding the severity of the situation, and a (false) perception that any water leak is likely due to a problem with the drinking bag. Do not normalize deviations!
Read more: http://www.universetoday.com/109814/as-astronauts-helmet-filled-with-water-he-told-nasa-three-times-it-wasnt-from-the-drinking-bag/#ixzz2uuMFin1Z

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A Century of Controversy, Accidents in West Virginia’s Chemical Valley in Lead-up to Spill

A Century of Controversy, Accidents in West Virginia’s Chemical Valley in Lead-up to Spill

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Moving scaffolding near HT cables

In 2012, there was an electrocution incident in China, when painters moving mobile scaffolding contacted a 10000 V electrical line. The CCTV video in this link illustrates the dangers of high voltages. It is graphic and not for the faint hearted. See the video in this link.


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Case study on fire incident in cooling tower

 Read and share this good case study from Oil Industry Safety Directorate. The recommendations, I think speak for themselves, where the issues were.

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Sulphuric acid leak in refinery injures two

A leak from a sulphuric acid pipe in a refinery in USA  has reportedly injured two employees. It appears that workers in the refinery were "afraid" as acid leaks continued to occur frequently. Incidentally, the company has not allowed CSB investigators to pursue their investigation. Read about the incident in this link.


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Pneumatic test accident

The dangers of pneumatic testing is again highlighted by an incident where a 335 litre vessel exploded during the test, causing a worker to loose his legs. Read about the incident in this link

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Misuse of expansion bellows as pipe supports leads to accident

An incident in a pharma company in the UK where bromine sprayed a worker causing severe injuries has been attributed to the bellows used to support pipe work and also corrosion of the bolts of the bellows. Read the incident and causes in this link


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Thumb rules for mechanical seals

Mechanical seal failures cause a hazardous chemical to come out with severe consequences. A very practical rules of thumb for mechanical seals written by Mc Nally (who has 35 years of experience) can be found in this link.


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Chemical plant fire -photos

See 27 photos of the fire in this link.
You can see the pool fire also. Worth noticing is the pressure of the water in the fire water monitors which help to keep surrounding equipment cool


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Pictures from Chingari Trust

As readers are aware, the proceeds from my book go to the Chingari Trust in Bhopal, who take care of the children affected by the Bhopal Gas Disaster. As humans we often react only when it happens to us. The legacy of Bhopal must never be forgotten. Please see some pictures about the activities sent by the trust

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High pressure water jet machine accident

An accident during a high pressure jet machine usage is given in this link

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Chlorine leak affects many

A news report mentions about an accident on NH 75  on the Jharkhand UP border caused a truck carrying chlorine tonners to turn turtle, resulting in the bursting of some tonners. More than 100 persons are reportedly affected.It appears that bad road conditions led to the truck overturning.
Read about the incident in this link.


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Sulphur dioxide leak incident

In 2001, a release of SO2 gas was triggered when a vehicle hit a power supply pole and caused a power outage. Read about the incident and it's causes in this link.

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Interesting incident from workshop

Am currently attending an Indo US workshop on Science and technology for preventing terrorism. A speaker from the US mentioned an incident involving human factors - a highly secure facility which had three layers of security was penetrated by a group of activists, who managed to penetrate all three layers without being noticed by guards. When the activists reached the  secure building, they tried throwing some stones to attract attention, but the security guards thought that carpenters were working late and ignored the noises. Finally they were detected and apprehended. The incident was captured by video. The speaker highlighted that the guards never anticipated a breach as they thought that the three layer security was foolproof. The guards let their guard down! When people do routine monotonous jobs, there is a tendency to ignore warning signs as they are not alert enough.
The same applies to operators who run complex chemical plants with layers of automation. It is a human tendency to think that automation will always do its job. Make sure your operators are trained in the hazards of over dependence of automation. (automation addiction).


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Confined space fatality

One person died when entry was made into a decommissioned submarine without proper atmospheric monitoring. Most probable cause of the accident was oxygen depletion due to rusting inside the decommissioned sub. Many times, we feel that a decommissioned equipment is safer than an equipment that is in service. We let our guard down and then a fatality occurs. Sometimes, new equipment are brought to the site before a turnaround and placed near the unit. They may be nitrogen blanketed and have to be treated just like any vessel in service. Make sure your maintenance personnel understand this.
Read about the accident in this link.

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