May 1, 2015

Process safety and jugaad!

During my trips to Uttar Pradesh, I often see a "Jugaad" modification that highlights the innovativeness of India.  A people transporter, fitted with a agriculture pump set engine powers the vehicle. I was commenting about the vehicle to my driver, when he asked me a question "Do you know what is the brake fluid they use in that vehicle?". Then he told me that it was sachets of one rupee shampoo!!
I marvelled at the inventors ingenuity. Which brings me back to PSM and management of change. India should not loose its sense of innovation, while at the same time, it should manage the changes in a technically right way.....




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April 27, 2015

Hydrochloric acid handbook

Occidental Chemical Corporation (Oxychem), as part of their Responsible Care initiative have brought out a good handbook on hydrochloric acid including design and safety aspects. You can read it in this link. 

Link has been updated now.

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April 24, 2015

Chlorine gas leak incident in 1991

 A FEMA report about a chlorine gas release in 1991 (70 Mt of chlorine escaped) mentions the following:
"Chlorine release caused by leak of brine from heat exchanger mixing with liquefied gas. Mixture created corrosive acid which ate through pipes when product was transferred from storage tank.Leak increased as acid ate larger hole in pipe.
Plant employees believed they could contain the leak. Fire department notified by passer-by who was unsure of source. Response delayed until second call provided additional information. Further delay caused by long response distance and several possible sources to check for hazardous materials (Hazmat) release.
Firefighters and plant personnel overcome when chlorine cloud moved in unexpected direction.Command post had to be relocated three times to avoid moving cloud. Some residents exposed during evacuation; over 200 examined at hospitals; 30 admitted."


 Read about the incident in this link.

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April 18, 2015

April 16, 2015

New eyewash shower and stations standard

 The International Safety equipment association has published a standard for eyewash showers and stations. It is a useful document. Read it by logging in this link

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April 10, 2015

Safety features at Kudankulam nuclear power plant by NPCIL

A good presentataion of the safety features at Kudankulam nuclear power plant by NPCIL  is available in this link 

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April 7, 2015

Blast in China Chemical Factory

Blast in China Chemical Factory -RT.com

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Another pump accident

'On Monday, January 28, 2002, a clean coal filter drain pump exploded due to steam build up within the pump, inflicting fatal injuries to the fine coal operator at a preparation plant of an underground mine. The victim was standing approximately 8 feet away at the on/off switch when the pump cover struck him. The pump overheated after almost all liquids had been pumped from the filter drain tank causing the remaining fines to solidify, thus preventing flow. The inlet and discharge lines then became clogged with coal fines causing the pump to become a closed pressure vessel".Read about the accident in this link.



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April 1, 2015

Incomaptibile chemicals cost you!

A radiation leak from a drum containing radioactive waste at an underground nuclear waste dump in New Mexico was caused by “chemically incompatible” contents, including cat litter, that reacted inside a barrel of waste and caused it to rupture. It is reported that cat litter containing silicates is purposely used as a stabilizing agent in nuclear storage for stabilizing radioactive nitrate salts. A scientist inadvertently used an organic brand of cat litter which does not contain silicates. After some days, the nitrate salts in the barrel heated up, releasing hot gases, pressurised the drum and ruptured it.
 The damage caused a  radiation leak that will cost approx. USD 240 million to clean up!
Read the report in the Telegraph in this link


This is not an April Fools day joke!!!!!

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March 28, 2015

Access and Accidents

The German wings plane that crashed in the Alps on Tuesday killing all onboard is being attributed to the co pilot intentionally crashing the plane, when the pilot went out of the cockpit. The pilot was not able to regain access to the cockpit as the copilot is alleged to have locked the door from inside. There is an interesting video from popular science about how the cockpit door locking arrangement works.

Coming back to our industry, more and more electronic access systems are being installed in chemical plant control rooms and hazardous chemical storages to prevent unauthorized access. But have you thought about everything including emergency response or evacuation requirements in case of malfunction of these access control systems?

See the video about how the cockpit door locking arrangement works in this link.

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March 27, 2015

March 22, 2015

Could a Texas City blast happen again? Read the investigation at HoustonChronicle.com

Ten years after a Texas City refinery blast killed 15 and rattled a community, workers keep dying. The Houston Chronicle and The Texas Tribune investigate.
 http://www.houstonchronicle.com/texascity



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March 21, 2015

March 13, 2015

Golden Rules of Total

 Total, the oil and gas multinational has Golden rules for safety in its website which can be accessed in this link

 
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March 10, 2015

Confined space fatality in chemical tanker - lessons to learn

A confined space fatality incident in a chemical tanker highlights the dangers when we take safety precautions and permits lightly. This can happen to even the most experienced persons. Discuss this incident with your personnel and the lessons learnt. The incident case study is in this link.

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March 4, 2015

Chemical Safety Board Under Fire

Chemical Safety Board Under Fire



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Thermal expansion accident

Thermal expansion inside a valve caused the bonnet of the valve to fail. The safety alert mentions the following:

Pressure build-up occurs in the gate valve cavity from thermal expansion of fluids. Extreme pressure build-up from fluid expansion can occur if the valve body is completely full of fluids (e.g., a grease/oil/water mixture) and heated to elevated temperatures. Such pressure can exceed the rated working pressure of the valve.

A valve with the ability to isolate the body cavity from the flow line may be at risk.
Presence of grease or compounds designed to enhance sealing ability may exacerbate the condition.
Grease or a grease/oil/water mixture when heated in a sealed enclosure can exceed 7000 psi (48.5 MPa) at 250 °F (121 °C).
Gate valve body cavities that are not 100% full of fluids do not experience excessive pressure as the vessel was heated. Trapped air or gas allows room for thermal expansion.

Read the safety alert in this link. 

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February 27, 2015

Depending on ROV's for isolation is bad design

An accident in a refinery in 2007 that killed 4 contract workers highlights the dangers of depending only on ROV's (remotely operated valves) for isolation. A maintenance job was being carried out on a hot oil line. Operators closed a ROV in the line and issued the permit to remove a blind on the downstream flange of the ROV. Instrument air to the ROV was left open. (ROV is a fail to close valve) When the maintenance workers were fixing the chain block to remove the blind, it inadvertently hit the switch on the ROV control field panel and opened the valve, causing hot pressurised oil to spray, ignite and kill the 4 workers.  

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February 24, 2015

Blast in Hyderabad-two-die-13-hurt- Times of India

Blast in Hyderabad, two die, 13 hurt - Times of India

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Lessons from Fukushima

Read the lessosn learnt from Fukushima in this link  http://nas-sites.org/fukushima/files/2012/10/Kitazawa.pdf

It applies to us in the CPI, too!


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February 22, 2015

Management decision during crisis

Continuing with Fukushima, a very interesting read on Fukushima and management decisions!
http://www.nikkeibp.co.jp/rebuild/en/article_09/index_03.shtml

 
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February 16, 2015

Don't Normalise deviations!

 In 1994, a fatality caused by exposure to hydrogen sulfide occurred at a refinery. The accident  occurred while draining of a fuel gas knockout drum in a hydro treating unit. Normal work procedures included periodically opening a valve that carried a water-gas mixture to a separator which removed and vented hydrocarbon gases to a flare. During the preceding winter, the piping to the separator froze, and the drum was temporarily drained to the sewer. This deviation went unnoticed and the temporary practice of draining to the sewer continued. On the day of the incident, the operator opened the valve to the sewer believing it to be part of the draining procedure, resulting in the release of toxic amounts of hydrogen sulfide that killed the operator.

Source: osha.gov

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February 12, 2015

February 11, 2015

Explosion in pyrolysis plant

 Read case study of explosion in pyrolysis plant


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February 5, 2015

Explosion in Catalyst Vessel

 On June 3,2014, an explosion tool place at a plant June 3, in a catalyst vessel in a plant in Netherlands. The catalyst, it is reported, was being cleaned with warm, liquid methylbenzene. According to the investigation report, while the cleaning process was taking place, the temperature and pressure in the reactor rose quickly, which caused the explosion
Read about it in

 http://www.nltimes.nl/2014/09/18/explosion-shell-moerdijk-caused-excess-pressure-report/

 See a video of the explosion in:
 http://www.liveleak.com/view?i=404_1401831796

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February 4, 2015

PSV outlet pipe size reduction causes fireball incident

An incident where a PSV outlet pipe size was reduced from 4" to 3" caused an incident when the PSV popped. The resulting rupture caused a fireball. The personnel were protected as they were wearing fire retardant clothing. Read about this incident in this link

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February 1, 2015

NTSB findings on gas pipeline incidents

The NTSB has published a study report on the integrity management of gas transmission pipelines in high consequence areas. Their findings are:

1.There has been a gradual increasing trend in the gas transmission significant incident ratebetween 1994-2004 and this trend has leveled off since the implementation of the integrity management program in 2004.

2.From 2010–2013, gas transmission pipeline incidents were overrepresented on high consequence area pipelines compared to non high consequence area pipelines.

3. While the Pipeline and Hazardous Materials Safety Administration’s gas integrity management requirements have kept the rate of corrosion failures and material failures of pipe or welds low, there is no evidence that the overall occurrence of gas transmission pipeline incidents in high consequence area pipelines has declined.

4.Despite the intention of the gas integrity management regulations to reduce the risk of all identified threats, high consequence area incidents attributed to causes other than corrosion and material defects in pipe or weld increased from 2010–2013.

5.Despite the emphasis of integrity management programs on time dependent threats, such as corrosion, gas transmission pipeline incidents associated with corrosion failure continue to disproportionately occur on pipelines installed before 1970.

6.From 2010–2013, the intrastate gas transmission pipeline high consequence area incident rate was 27 percent higher than that of the interstate gas transmission pipeline high consequence area incident rate.

7.Approaches used during integrity management inspections of gas transmission pipelines conducted instate inspections vary among states and whether this variability affects the effectiveness of integrity management inspections

has not been evaluated.

8.The Pipeline and Hazardous Materials Safety Administration (PHMSA)’s resources on integrity management inspections for state inspectors, including existing inspection protocol guidance, mentorship opportunities, and the availability of PHMSA’s inspection subject matter experts for consultation, are inadequate.

9.Federal to state and state tostate coordination between inspectors of gas transmission pipelines is limited.

10.The lack of high consequence area identification in the National Pipeline Mapping System limits the effectiveness of pre-inspection preparations for both federal and state inspectors of gas transmission pipelines.

11.There is a considerable difference in positional accuracy between interstate and intrastate gas trans

mission pipelines in the National Pipeline Mapping System, and this discrepancy, combined with the lack of detailed attributes, may reduce state and federal inspectors’ ability to properly prepare for integrity management inspections.

12.The discrepancies between the Pipeline and Hazardous Materials Safety Administration’s National Pipeline Mapping System, annual report database, and incident database may result in state and federal inspectors’ use of inaccurate information during pre-inspection preparations.

13.The lack of published standards for geospatial data commonly used by pipeline operators limits operators’ ability to determine technically sound buffers to increase the safety margin and also hinders integrity management inspectors from evaluating the buffer’s technical validity.

14.The lack of a repository of authoritative sources of geospatial data for identified sites may contribute to operators’ inaccurate high consequence area identification.

15.Inappropriate elimination of threats by pipeline operators can result in undetected pipeline defects.

16.The prevalence of inappropriate threat elimination as a factor in gas transmission pipeline incidents cannot be determined because the Pipeline and Hazardous Materials Safety Administration does not collect threat identification data in pipeline incident reports.

17.The inadequate evaluation of interactive threats is a frequently cited shortcoming of integrity management programs, which may lead to underestimating the true magnitude of risks to a pipeline.

18.The prevalence of interactive threats in gas transmission pipeline incidents cannot be determined because the Pipeline and Hazardous Materials Safety Administration does not allow operators to select multiple, interacting root causes when reporting pipeline incidents.

19.Inspectors lack training to effectively verify the validity of an operator’s risk assessment.

20.Many pipeline operators do not have sufficient data to successfully implement probabilistic risk models.

21.A lack of incident data regarding the risk assessment approach(es) used by pipeline operators limits the knowledge of the strengths and limitations of each risk assessment approach.

22.Whether the four approved risk assessment approaches produce a comparable safety benefit is unknown.

23.Sufficient guidance is not available to pipeline operators and inspectors regarding the safety performance of the four types of risk assessment approaches allowed by regulation, including the effects of weighting factors, calculation of consequences, and risk aggregation methods.

24.Professional qualification criteria for pipeline operator personnel performing integrity management functions are inadequate.

25.The use of inline inspection as an integrity assessment method for intrastate pipelines is considerably lower than for interstate pipelines (68percent compared to 96percent) in part due to the operational and configuration differences.

26.A much higher proportion of integrity assessments is conducted by direct assessment for intrastate pipelines than for interstate pipelines partly due to operational and configuration differences.

27.Of the four integrity assessment methods, inline inspection yields the highest per mile discovery of anomalies that have the potential to lead to failure if undetected.

28.In line inspection is able to inspect the integrity of the pipeline segments susceptible to multiple threats.

29.Improvements in in-line inspection tools allow for the inspection of gas transmission pipelines that were previously uninspectable by in-line inspection.

30.Operators may limit the use of in-line inspections due to operational complications.

31.There are many limitations to direct assessment, including that (1) it is limited to the detection of defects attributed to corrosion threats, (2) it only covers very short sub-segments of the pipeline, (3) it relies on the operator’s selection of specific locations for excavation and direct examination, and (4) it yields far fewer identifications of anomalies

compared to in-line inspection.

32.The selection of direct assessment by the pipeline operator as the sole integrity assessment method must be subject to strict scrutiny by the inspectors due to its numerous limitations.

33.Pipeline operators view geographic information systems as the preferred tool for effective data integration, as it can be used as a system of records and a source of authoritative data.


Read the full report with recommendations in this link.

 
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January 27, 2015

Walking the talk - the most effective way to sustain safety culture

I always say that if the behaviour of top management is right, the behaviour of the others will follow. This is beautifully articulated in an article by Don Ritz titled "Walking the talk on courageous safety leadership". This is worth reading by all senior management. I have been lucky to work in the Middle East where this was practiced in letter and in spirit. One day, when I was working in the plant, me and an operator were up on the compressor deck. The Vice President, Operations, was walking into the plant and he could not see us, as we were at second floor level. There was nobody else around. As we observed him, he paused by the lube oil console at the ground floor. The console floor was dirty. He took a service water hose, cleaned the area with the water hose and rolled back the hose on to its stand and carried on his walk. It made a big impact on both of us. Developing a good safety culture does not need consultants. It is simple and it needs deep rooted commitment.

Read the article by Don Ritz in this link.


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January 23, 2015

Case study of fire incident in VGO-HDT unit by OISD

Read the case study of fire incident in VGO-HDT unit by the Oil Industry Safety Directorate in this link


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January 22, 2015

Process safety incident investigation board - white paper by AIChE

Good paper on Process Safety Incident Investigation Boards by AIChE. India needs one like this.
 http://www.aiche.org/sites/default/files/docs/org-entity/process_safety_investigation_boards.pdf

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Wagon fire tamed, oil depot saved

Wagon fire tamed, oil depot saved


The incident again highlights the importance of facility siting.



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January 17, 2015

After string of jet crashes, a struggle to re-train pilots - Reuters

 After string of jet crashes, a struggle to re-train pilots
http://www.reuters.com/article/2015/01/09/us-indonesia-airplane-training-insight-idUSKBN0KI2B520150109

Shared from News on Flipboard, your personal magazine.
Get it for free to keep up with the news you care about.

 

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January 13, 2015

Rules for process incident investigation

The most important thing in communication is hearing what isn't said." -- Peter Drucker, Austrian-American writer and management consultant
Adapting the above to process incident investigation, I came up with this:
"The most important thing in process incident investigation is hearing what isn't said and seeing what isn't seen."
I have investigated a number of fatal accidents in the CPI and this is true in all cases!

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January 12, 2015

Nitrogen claims two more lives

Nitrogen has again claimed two more victims. This accident occurred at a TV Manufacturer in South Korea. Do not take any chance with nitrogen. It will not give you any warning.
Read about the incident in this link.

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January 11, 2015

Husky official says refinery fire under control | Dayton,OH News

 A major fire incident has taken place at a refinery in the USA. See the video and report in the following link:

Husky official says refinery fire under control | Dayton,OH News

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January 9, 2015

Elk River Chemical Spill incident investigation report

See the investigation report of the Elk River chemical spill in the following link. It is a classic case of ignoring multiple warnings


 http://www.ago.wv.gov/Documents/010815-ElkRiverChemicalSpill.PDF


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January 5, 2015

Refinery leak sealing incident investigation report

In November 2013, an accident during a leak sealing operation on a steam valve killed two technicians in a refinery in Europe. The lessons learnt from this incident are given  in this link
Share it will all relevant personnel. It may save a life.

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January 3, 2015

Online access to OISD standards

Recently, I was informed by a senior OISD official that the Oil Industry Safety Directorate has provided free online access to their standards and guidelines. To register for them, please go to oisd.gov.in and see "online access" under the OISD standards tab. Register yourself and after approval you will get online access.
Thanks to OISD for this initiative!

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New OSHA reporting requirements

 https://www.osha.gov/recordkeeping2014/OSHA3745.pdf

 
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January 2, 2015

Serious accident with a pump

An incident occurred in a slurry pump that has lessons for everyone. Treat ALL pumps with respect. Read about the incident in this link. 

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January 1, 2015

HAPPY NEW YEAR!

WISHING ALL MY READERS AND THEIR FAMILIES A VERY HAPPY, HEALTHY AND SAFE 2015!

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December 29, 2014

Quality of HAZOP studies

I had raised a question to a PSM group in LinkedIn about the deteriorating quality of HAZOP studies.
David Graham, a Process Safety Professional wrote this interesting and humorous comment
Slightly off-topic, but: Quite a few years ago I led a HAZOP on a new build unit for a refinery in the Middle East, on behalf of a large consultancy. One of the consultancy staff led a similar HAZOP on revamp of an existing unit. The staff employee took output from both studies and wrote the Management Report, major findings, etc. 
He included the following phrase in the report:
"It has to be understood that HAZOP will not reveal all the hazards to a project in operations and maintenance activities. It is therefore anticipated that any remaining hazards will be found during operations."
Boom!


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December 21, 2014

4 killed in confined space accident

A Newspaper report mentions the deaths of 4 workers working inside a storage tank in Assam , most probably due to lack of oxygen.

Read the Times of India newspaper report in this link.

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EDITORIAL: The chemistry we never want to think about needs thought

EDITORIAL: The chemistry we never want to think about needs thought

Thought provoking editorial!


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December 20, 2014

Lithium ion battery runaway reactions

 After the completion of investigation of the battery fires incidents in the 787 aircraft, the NTSB has concluded the following in its report available at http://www.ntsb.gov/doclib/reports/2014/AIR1401.pdf:
 
"The NTSB identified the following safety issues as a result of this incident investigation:
Cell internal short circuiting and the potential for thermal runaway of one or more battery cells, fire, explosion, and flammable electrolyte release.
This incident involved an uncontrollable increase in temperature and pressure (thermal  runaway) of a single APU battery cell as a result of an internal short circuit and the cascading thermal runaway of the other seven cells within the battery. This type of  failure was not expected based on the testing and analysis of the main and APU battery that Boeing performed as part of the 787 certification program.
However, GS Yuasa did not test the battery under the most severe conditions possible in service, and the test battery was different than the final battery design certified for installation on the airplane. Also, Boeing’s analysis of the main and APU battery did not consider the possibility that cascading thermal runaway of the battery could occur
as a result of a cell internal short circuit.

Cell manufacturing defects and oversight of cell manufacturing processes.
After the incident, the NTSB visited GS Yuasa’s production facility to observe the cell manufacturing process. During the visit, the NTSB identified several concerns, including foreign object debris (FOD) generation during cell welding operations
and a postassembly inspection process that could not reliably detect manufacturing defects, such as FOD and perturbations (wrinkles) in the cell windings, which could lead to internal short circuiting. In addition, the FAA’s oversight of Boeing,
Boeing’s oversight of Thales, and Thales’ oversight of GS Yuasa did not ensure that the cell manufacturing process was consistent with established industry practices

Thermal management of large format lithium ion batteries
Testing performed during the investigation showed that localized heat generated inside a 787 main and APU battery during maximum current discharging exposed a cell to high temperature conditions. Such conditions could lead to an internal short circuit and cell thermal runaway. As a result, thermal protections incorporated in large format lithium ion battery designs need to account for all sources of heating in the battery during the most extreme charge and discharge current conditions. Thermal protections include (1)recording and monitoring cell level temperatures and voltages to ensure that exceedances resulting from localized or other sources of heating can be detected and addressed before cell damage occurs and (2) establishing thermal safety limits for cells to ensure that self heating does not occur at a temperature that is less than the battery’s maximum operating temperature.

Insufficient guidance for manufacturers to use in determining and justifying key assumptions in safety assessments.
Boeing’s EPS safety assessment for the 787 main and APU battery included an underlying assumption that the effect of an internal short circuit within a cell would be limited to venting of only that cell without fire. However, the assessment did not explicitly discuss this key assumption or provide the engineering rationale and justifications to support the assumption. Also,as demonstrated by the circumstances of this incident, Boeing’s assumption was incorrect, and Boeing’s assessment did not consider the consequences if the assumption were incorrect or incorporate design mitigations to limit the safety effects that could result in such a case. Boeing indicated in certification documents that it used a version of FAA Advisory Circular (AC) 25.1309, “System Design and Analysis” (referred to as the Arsenal draft), as guidance during the 787certification program. However, the analysis that Boeing presented in its EPS safety assessment did not appear to be consistent with the guidance in the AC. In addition, Boeing and FAA reviews of the EPS safety assessment did not reveal that the assessment had not (1) considered the most severe effects of a cell internal short circuit and (2) included requirements to mitigate related risks.

Insufficient guidance for FAA certification engineers to use during the type certification process to ensure compliance with applicable requirements.
During the 787 certification process, the FAA did not recognize that cascading thermal runaway of the battery could occur as a result of a cell internal short circuit . As a result, FAA certification engineers did not require a thermal runaway test as part of the compliance demonstration (with applicable airworthiness regulations and lithium ion battery special conditions) for certification of the main and APU battery. Guidance to FAA certification staff at the time that Boeing submitted its application for the 787 type certificate, including FAA Order 8110.4, “Type Certification,”did not clearly indicate how individual special conditions should be traced to compliance deliverables (such as test procedures, test reports, and safety assessments) in a certification plan.

Stale flight data and poor quality audio recording of the 787 enhanced airborne flight recorder (EAFR).
The incident airplane was equipped with forward and aft EAFRs, which recorded cockpit audio data and flight parametric data. The EAFRs recorded stale flight data for some parameters (that is, data that appeared to be valid and continued to be recorded after a parameter source stopped providing valid data), which delayed the NTSB’s complete understanding of the recorded data. In addition, the audio recordings from both EAFRs during the airborne portion of the flight were poor quality. The signal levels of the three radio/hot microphone channels were very low, and the recording from the cockpit area microphone channel was completely obscured by the ambient cockpit noise. These issues did not impact the NTSB’s investigation because the conversations and sounds related to the circumstances of the incident occurred after the airplane arrived at the gate and the engines were shut down, at which point the quality of the audio recordings was excellent.

The NTSB determines that the probable cause of this incident was an internal short  circuit within a cell of the APU lithium ion battery, which led to thermal runaway that cascaded to adjacent cells, resulting in the release of smoke and fire.The incident resulted from Boeing’s failure to incorporate design requirements to mitigate the most severe effects of an internal short circuit within an APU battery cell and the FAA’s failure to identify this design deficiency during the type design certification processes."


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December 19, 2014

Repost - Process Safety in the 21st Century

I had originally posted this in 2010. Four years later, some of my predictions are coming true!!! Guess I should become an astrologer...

Process safety in the 21st Century(ORIGINALLY POSTED ON NOVEMBER 11th, 2010)

Having spent 30 years in the chemical industry, I am trying to hazard a guess on the direction of process safety in the 21st century:
1.The human being will become more and more the focus in process safety. Technical competency of individuals is fast decreasing and job hopping means that process safety knowledge is fragmented in an organisation.
2.Plants are becoming more and more hi tech with control systems and instruments with wireless technology and “smart” technology while the human being is becoming “unsmarter”.
3.As organisation become larger and larger, the management of process safety is getting lost somewhere in between the layers of communication. While leading process safety indicators are good in highlighting problem areas, the focus on these indicators is also human dependent and with directors on boards of companies changing, this focus gets shifted from time to time.
4.There will be Low frequency High Potential accidents happening in large organisations. The BP case is just a teaser. Even in organisations that manage their process safety closely, one slip is enough.Managing to avoid this “slip” will become tougher and tougher in this “flat world”.
5.Fortunately or unfortunately we are in an age of rapid technology change. Plant operators should be careful to select the technologies they need and more importantly to “deselect” the technologies they do not need. One mans bread may be the other man’s burnt toast!
6.To become more and more competitive, organizations are cutting costs. While there is nothing wrong in cutting costs, I see a drastic decrease in in-house competency to assess the technical issues while cutting costs.
7.There will be a number of security issues with chemical plants as control technologies change.
8.Competency of people is becoming a major issue. Simulator training of plant operators may become a legal requirement soon in many countries!

I do not want to bore you with this monologue, but how do we avoid this? Top management must continually have a feel of what is going on at the ground level. There is no better solution that the old fashioned way of walking the talk by periodically meeting people at ground zero and observing what their problems are! I’m signing off…..!

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December 12, 2014

Update on Dupont incident

Excerpt from Written Testimony Submitted by U.S. Chemical Safety Board Chairman Rafael Moure-Eraso to the Joint Committee: Senate Committee on Environment and Public Works and the Senate Committee on Health, Education, Labor, and Pensions hearing entitled, "Oversight of the Implementation of the President’s Executive Order on Improving Chemical Facility Safety and Security”:
 
"The most recent example is the tragic chemical accident at the major DuPont chemical plant in La Porte, Texas, just east of Houston.  On November 15, 2014, there was a release of methyl mercaptan, a highly toxic and volatile liquid, which DuPont itself has estimated at 23,000 pounds – a very significant quantity.  Odors of the chemical were reportedly discernible many miles from the plant.  Four workers – including operators and would-be rescuers – perished inside the methomyl-production building where the release originated.
DuPont is certainly no “outlier.”  In fact, DuPont has long been regarded as one of industry’s leading lights in safety, and it markets its safety programs to other companies.  What happened last month, however, was the fifth release incident at a DuPont facility that the CSB has investigated since 2010, and three of these had associated fatalities.  While the CSB investigation remains underway in La Porte, some preliminary facts are already emerging.
The incident occurred following an unplanned shutdown of the methomyl unit due to inadvertent water dilution of a chemical storage tank several days earlier.  Efforts were underway to restart the process, but problems occurred including plugged supply piping leading from the methyl mercaptan storage tank.  As efforts were underway to troubleshoot these problems, it is likely that methyl mercaptan (and possibly other toxic chemicals) inadvertently entered the interconnected process vent system inside the building.  The release occurred through a valve that was opened as part of a routine effort to drain liquid from the vent system in order to relieve pressure inside.  We found that this vent system had a history of periodic issues with unwanted liquid build-up, and the valve in question was typically drained directly into the work area inside the building, rather than into a closed system.  In addition, our investigators have found that the building’s ventilation fans were not in service, and that the company did not effectively implement good safety practices requiring personnel to wear appropriate personal protective equipment (PPE) that was present at the facility.  Appropriate PPE would include equipment, such as supplied air respirators, for workers performing potentially hazardous tasks inside the building.
In summary, this was a complex process-related accident with tragic results.  It gives rise to a number of design and organizational safety concerns.  Its occurrence – taken along with other major accidents afflicting large and small corporations – underscores the need for some systemic reforms.  It would be a serious and tragic mistake to consider each of these accidents as just another isolated event, reflecting only the limited practices of a small group of people operating outside regulatory scrutiny.  If it can happen at DuPont, I would submit it can happen anywhere."


Read the complete CSB written testimony to joint committee from which above excerpt was taken in this link

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December 6, 2014

Accident while working on control valve

OSHA has an incident about an employee loosing his end of a finger when performing calibration of a control valve. The incident teaches us the importance of hazard identification and risk assessment prior to performing a job.
Read about the incident in this link.

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December 3, 2014

30 years after Bhopal - lessons not learnt

30 years ago, on the night of December 2nd/3rd 1984, the Worlds worst industrial disaster took place.

In India and elsewhere around the World, catastrophic chemical plant incidents continue to occur. Memory is short. In the numerous incidents since Bhopal, many of the reasons are similar to those of the Bhopal disaster:
  • cost cutting without properly analysing the effects on process safety
  • poor competency
  • poor asset integrity
  • high attrition rate
  • inadequate emergency response and planning
  • inadequate implementation of facility siting
  • not paying heed to audit reports and past incidents etc.
What has changed between 1984 and 2014? It is technology. But can technology change behavior of people? In 2010, two fatal accidents occurred at two different sites of one of the World's best process safety managed organization. Why? Think about it!

Even if you have a 40 element PSM system, there is no guarantee that a catastrophic accident will not occur.  Is there a solution to this? One of the possible solutions is accountability at the highest level. By this I mean legal requirements that will make the entire board of chemical organizations accountable for a process incident that kills or maims people. This includes the Director, Finance and Director, HR too. The Sword of Damocles should surely work.

Our Prime Minister is doing a great job in encouraging "Make in India". I wish the slogan was "Make Safely in India" . We still do not have any PSM rule. We still do not have an independent incident investigating authority. The status of the chemical safety and security rating system whose draft was published last year is not known.

My thoughts are with the victims of Bhopal - dead and surviving...and I pray that another Bhopal does not occur.

Read my earlier posts on Bhopal:



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


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December 1, 2014

DuPont Says Plant Leaked 23,000 Pounds of Toxic Gas by Jim Malewitz, The Texas Tribune November 29, 2014

DuPont Says Plant Leaked 23,000 Pounds of Toxic Gas
 by Jim Malewitz, The Texas Tribune
 November 29, 2014

About 23,000 pounds of a flammable, foul-smelling toxic gas leaked from the DuPont chemical plant in La Porte where four workers died earlier this month, the company said Saturday.

That’s significantly more than the 100 pounds of methyl mercaptan that DuPont estimated had escaped the plant in its initial report, and was enough to asphyxiate the four workers and hospitalize another.

Companies are required to report all releases of at least 100 pounds of the gas to the Texas Commission on Environmental Quality. DuPont said it revised its initial estimate after determining how much gas was in the plant’s pipes and vessels before and after the tragedy.

“The release occurred inside a process building at the site’s Crop Protection unit and dissipated from openings in that structure over time,” the company said in a statement.

The U.S. Chemical Safety and Hazard Investigation Board is still investigating the incident.

Methyl mercaptan can cause nausea, vomiting and fluid buildup in the lungs. Its rotten-egg smell wafted over La Porte for at least 24 hours after the accident, but county health officials said the leak posed little risk to the community because the gas rapidly degrades once released into the air. Even trace amounts carry the smell.

The plant, about 30 miles southeast of Houston, makes products like alcohol resins and a popular insecticide called Lannate.

In the past five years, the TCEQ has cited it at least two dozen times for violating state law. The plant has failed to perform routine safety inspections, keep equipment in proper working order and prevent unauthorized pollution leaks, according to violation notices issued by the agency. In a few instances, the agency demanded fines of a few thousand dollars from DuPont for more serious lapses.

But the unauthorized leaks of toxic chemicals are common in Texas. Thousands — and even millions — of pounds of toxic chemicals beyond what permits allow have spewed from the state's facilities, as The Texas Tribune has reported. Though many of those events were close calls that prompted evacuations at worst, some triggered deadly explosions that, in turn, caused even more gas to be released.

Since 2009, Texas chemical manufacturers have reported at least 19 other unauthorized releases of methyl mercaptan, according to state data. DuPont’s was the only methyl mercaptan release that killed or injured workers during that period.

This article originally appeared in The Texas Tribune at http://www.texastribune.org/2014/11/29/dupont-says-plant-leaked-23000-pounds-toxic-gas/.

November 28, 2014

USB sticks and security issues

In 2012, two power plants in the USA were affected by malware attacks, brought in by USB sticks. Read the article in this link.
Have you banned USB sticks in your plant?
 
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November 18, 2014

Snake in the control room

 In 1984, when I was shift in charge in an ammonia plant, the control room was ordinary building with three aluminium doors. Two doors were in front of the building and one at the back. The door at the back was near to a locker room. One day as an operator was changing his dress, he spotted a snake in the room. Immediately he raised an alarm (Basically he screamed his lungs out!!) and we managed to isolate the snake inside the room till help came and the snake was taken out. Imagine the plight if the snake had entered the main control room which was just a few feet away. Are you prepared for "snakes" in your control room? By this I mean are you ready with a plan in case the control room becomes uninhabitable due to some emergency? The emergency could be a fire, toxic gas ingress or anything else. Don't think it will not happen. Instead, be prepared.


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November 15, 2014

Planning for mock drills


Mayday! Mayday! The distress calls from Mukesh Ambani's plane that shook ATC - Times of India

The above article from Times of India shows how preparation for mock drills could cause an incident.
  
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November 13, 2014

News article from BBC

 Thanks to Sanjeevi for sending this news article from BBC http://www.bbc.com/news/business-29997074


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El Al crew briefly 'lost control' of plane in August incident, investigation shows - National Israel News | Haaretz

El Al crew briefly 'lost control' of plane in August incident, investigation shows - National Israel News | Haaretz

The incident highlights the need for a human being to take control during emergencies. Automation will not solve all problems.

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November 12, 2014

Fire in turbine in power plant

A leak in an oil pipeline of a steam turbine has caused a fire which has stopped power production in a Chennai power plant. Though no persons were injured, it highlights the dangers of lube oil leaks.
Read an article on Controlling the risks of lubrication oil fires - from Machinery Lubrication.

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November 9, 2014

Firefighter killed in ammonia leak in Israel

On 6.11.14, according to news reports, a firefighter was killed and hundreds of people living around an industrial area in Israel were asked to take shelter in their homes after an ammonia leak from a pressurised 60 MT ammonia  vessel. As per news reports, an initial investigation found that maintenance workers at the factory accidentally hit a pipe from the vessel, causing a crack to develop.The firefighter who died was responding to the emergency and trying to locate the leak when he became separated from his team due to the heavy cloud of ammonia vapors, and eventually ran out of air.
He was found unconscious shortly before midnight, but despite the efforts of medical teams, was pronounced dead at the scene.






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November 4, 2014

Case study on unusual failures in hydrogen production

A good case study on unusual failures in hydrogen production can be read in this link


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November 2, 2014

Learn lessons from this confined space incident

 LINK HAS BEEN UPDATED

An investigation of the marine accident investigation board of a confined space incident involving three fatalities indicates how careful you must be.
In this incident, three people died when they entered a ships hold.  You can also read about the rescue attempt and how the rescue contributed to the number of fatalities.
Read the report in this link.


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November 1, 2014

Learn lessons from this confined space incident

An investigation of the marine accident investigation board of a confined space incident involving three fatalities indicates how careful you must be.
In this incident, three people died when they entered a ships hold.  You can also read about the rescue attempt and how the rescue contributed to the number of fatalities.
Read the report in this link.

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

Pesticide reacts with moisture and overpressurises container

 An employee at a company was injured when the top of a seven gallon metal container top burst open and hit his arm.
The built up pressure was caused by a pesticide packet that due to a defect, was not entirely closed and activated with moisture from the air and began releasing the small amount of chemicals it held, pressurizing the container.

Read about the incident in this link
  

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