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.


Contribute to the surviving victims of Bhopal by buying my book "Practical process safety management"

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.

 
Contribute to the surviving victims of Bhopal by buying my book "Practical Process Safety Management"

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


Contribute to the surviving victims of Bhopal by buying my book "Practical Process Safety Management"

Pneumatic test fatality

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

Contribute to the surviving victims of Bhopal by buying my book "Practical Process Safety Management"incidents

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



Contribute to the surviving victims of Bhopal by buying my book "Practical Process Safety Management"

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



Contribute to the surviving victims of Bhopal by buying my book "Practical Process Safety Management"

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.


Contribute to the surviving victims of Bhopal by buying my book "Practical Process Safety Management"

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

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



Contribute to the surviving victims of Bhopal by buying my book "Practical Process Safety Management"

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!

Contribute to the surviving victims of Bhopal by buying my book "Practical Process Safety Management"

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.

 

Contribute to the surviving victims of Bhopal by buying my book "Practical Process Safety Management"

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

Contribute to the surviving victims of Bhopal by buying my book "Practical Process Safety Management"

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.

Contribute to the surviving victims of Bhopal by buying my book "Practical Process Safety Management"