October 19, 2015

Readers response to post

Mr M.K.Rao, Executive Director of India Glycols responded to my post "Of Mimic panels and Video walls - back to the past?"
His reply is as follows:

"The subject Blog item is interesting and highly relevant too.

When I entered the DMT control room (IPCL, Baroda) in the year 1981, the scene was similar. The space above the pneumatic controllers had a mimic panel that depicted the complete PFD. In addition, we had a model of the entire plant on a large table in the same control room at a corner. It made learning faster and we used to have a better feel of the process. It was easier to know what was going on at a glance.
 

Going by the best of Past & Present, I feel a combination of
  1. DCS work stations
  2. Mimic panel representing the complete/ continuous PFD like in the past (Instead of Video panels – which may appear broken)
  3. A model (physical) of the plant right in the control room would help"

I agree with his valid suggestions and thank him for responding..
 

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October 17, 2015

Hydrogen explosion incident

 Read about a hydrogen explosion in a compressor in this link.


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October 13, 2015

Dead leg incident

 Read an incident involving a piping dead leg in this link.

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October 12, 2015

Of Mimic panels and Video walls - back to the past??

 I just returned from a large modern refinery. When I visited the control room, with large video walls, my thoughts went back to 1979 when I was operating an ammonia plant with pneumatic controllers and no DCS. The wall above the controllers had a mimic panel that depicted the complete process flow diagrammatically. This depiction covered the whole control room wall between the controllers and the ceiling, so it was large and easy to see.  The motors and pumps had running lamp indications in the panel. For 300 control loops, we had about 200 hard wired alarms located between the controllers in sets of 20.

See a concocted image of a mimic panel located above pneumatic controllers similar to the one I had used below:





















The modern control room I visited looked similar to the one below, with large video walls:









I was recollecting the progress in instrumentation - from pneumatic control systems to electronic to DCS without video walls and now DCS with video walls. - back to the past!!!!
Technology can and will always be an enabler only and as long as human beings exist, human errors will continue...take for instance the modern day DCS. We have so many alarms that inundate the operator during plant upsets, that vendors now sell alarm suppression software! Why do we need that many alarms in the first place???

One important philosophy in Process Safety - KEEP IT SIMPLE AND DON'T FORGET THE PAST!!

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Fire in a laboratory of an industrial gas facility

Reports coming in of a fire in the laboratory of an industrial gas facility in Singapore. Reportedly one person was killed. Read about the incident and see the photos  in this link.

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October 10, 2015

A temporary change causes a fatality

Temporary changes are dangerous if not managed properly. Read about an incident involving a temporary change that causes a fatality. This incident highlights what Dr trevor Kletz used to say "We do not know what we do not know"
Read the incident in this link.

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October 7, 2015

Overheated air compressor causes fatality

 Read about an incident involving an overheated air compressor that caused a fatality in this link

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October 3, 2015

4 workers hurt in explosion at SunEdison's Texas plant : Business

 New coming in about a fire in a polysilicon plant in USA involving Silane. Read about it in this link:
  4 workers hurt in explosion at SunEdison's Texas plant : Business


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CO2 Gas Hazards in the Brewing Industry

Don't take CO2 for granted thinking it will not harm you. Read this article:
CO2 Gas Hazards in the Brewing Industry

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October 1, 2015

2 workers killed in Vizag pharma city unit blast | Business Line

2 workers killed in Vizag pharma city unit blast | Business Line



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Du Pont incident recommendations by CSB

The CSB has approved the draft recommendations in the DuPont incident last year at LaPorte, Texas that killed 4 employees. I observe many similar instances in batch processes in various manufacturing units in the pesticide industry during PSM audits. The CSB recommendations are given below:

"Pursuant to its authority under 42 U.S.C. §7412(r)(6)(C)(i) and (ii), and in the interest of promoting safer operations at US facilities handling chemicals and protecting workers and communities from hazards, the Board makes the following interim safety recommendations to the DuPont chemical manufacturing facility in La Porte, Texas and the International Chemical Workers Union Council of the United Food and Commercial Workers:
Inherently Safer Design Review
Prior to resuming Insecticide Business Unit (IBU) manufacturing operations, conduct a comprehensive engineering analysis of the manufacturing building and the discharge of pressure relief systems with toxic chemical scenarios to assess potential inherently safer design options. At a minimum, evaluate the use of an open building structure, and the direction of toxic chemical leaks and the discharge of pressure relief systems with toxic chemical scenarios to a destruction system. Implement inherently safer design principles to the greatest extent feasible and effectively apply the hierarchy of controls such that neither workers nor the public are harmed from potential highly toxic chemical releases. Detail the analysis, findings, and corrective actions in a written report and make this report available to DuPont La Porte employees, their representatives, and the CSB.
Ensure Manufacturing Building is Safe for Workers
Prior to resuming Insecticide Business Unit (IBU) manufacturing operations, conduct a robust engineering evaluation of the manufacturing building and the dilution air ventilation system that includes the implementation of corrective action(s) to the greatest extent feasible in order to ensure a safe environment for all workers. Develop a documented design basis for the manufacturing building and the air dilution ventilation system that identifies effective controls for highly toxic, asphyxiation, and flammability hazards and implement these controls to the greatest extent feasible. Address non routine operations and emergency response activities in the design basis. The design basis for the manufacturing building and the dilution air ventilation system must use the hierarchy of controls and inherently safer design principles to the greatest extent feasible.
Ensure Relief System Design is Safe for Workers and the Public
Prior to resuming manufacturing operations, ensure all Insecticides Business Unit (IBU) pressure relief systems are routed to a safe location and effectively apply the hierarchy of controls to protect workers and the public. Commission a pressure relief device analysis, consistent with API Standard 521 and the ASME Code, including a field review. Include an evaluation of relief system discharge location to ensure that relief systems are discharged to a safe location that will prevent toxic exposure, flammability, or asphyxiation hazards in order to ensure public and worker health and safety to the greatest extent feasible. Include an evaluation of relief scenarios consistent with API Standard 521.
Perform More Robust Process Hazard Analyses
Develop and implement an expedited schedule to perform more robust process hazard analyses (PHAs) consistent with R1, R2, and R3 for all units within the Insecticides Business Unit (IBU). At a minimum, the PHAs must effectively identify and control the hazards referenced in this document utilizing the hierarchy of controls. The PHA schedule must be prioritized based on anticipated risks to the public and workers in order to ensure that the highest risk areas receive priority consideration. At a minimum, the more robust PHAs must be consistent with the approach applied to post-incident reviews described above in paragraph 10.
Ensure Active Workforce Participation
Work together with the International Chemical Workers Union Council of the United Food and commercial Workers (ICWUC/UFCW) Local 900C and the ICWUC/UFCW staff (at the request of the local) to develop and implement a plan to ensure active participation of the workforce and their representatives in the implementation of Recommendations R1 through R4. In addition, provide a copy of DuPont’s integrated plan for restart to La Porte workers and their local union representatives.
Public Transparency and Accountability
Make publicly available (on a website) a summary of the DuPont November 15, 2014 incident investigation report, the integrated plan for restart, and actions to be taken for the implementation of Recommendations R1 through R5. This website must be periodically updated to accurately reflect the integrated plan for restart and implementation of Recommendations R1 through R5."




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Safe in India - a new initiative

I came across the website www.safeinindia.org run by three IIM graduates. SafeInIndia is an initiative to address the issue of crush injuries in the Automotive Sector and work on win-win sustainable solutions.
Glad to see such initiatives springing up. Their report on the automobile sector is available for download from their website which can be accessed here www.safeinindia.org.
 
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September 30, 2015

Two dead in mishap at Birla copper plant in Gujarat | Business Standard News

More details in this article:

Two dead in mishap at Birla copper plant in Gujarat | Business Standard News

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2 killed in accident at Birla Copper unit in Dahej | Business Line

 Thanks to Mr M.S.Srinivasan for sending this

2 killed in accident at Birla Copper unit in Dahej | Business Line


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The Volkswagen emission issue and risk management

I had posted this question to a group in Linkedin: "The ongoing Volkswagen emission issue raises a bigger issue of corporate risk management. From a reading of its annual report, the company did have in place all risk management controls, yet the issue took place. While only a deeper investigation will reveal the details, what is your take on improving risk management? We in the chemical Industry deal with process safety risks among other things and the incident does raise an alarm bell about corporate risk management and its effectiveness". 

Nigel Cann (Process Safety and Dangerous Goods Risk Specialist, Australia) responded with this very good reply:
"Karthikeyan - this is a good topic for this group. I wonder how many people in the PSM field have seen this incident playing out in the news and thought it doesn't apply to them. High profile cases like this need to be taken as the warning for the rest of us that they are. So like every incident that makes the headline, have you (and everyone else) thought about how things could go wrong in the plants and processes that I am responsible for.

Some thought provoking questions for people:

* Where have we met the letter of the law, rather than addressing the spirit of it?

* Have we had a problem that was causing issues at high level that seemed to magically disappear? Do we understand why?

* Do we have people checking the checkers?

And one that I had a concern for when a GM at an operating plant:
* Are the regulators technically competent to give me a critical assessment of my PSM system? (or in some cases...)

* Do they even turn up to review our operation?"

 
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The Chemical Engineer | News | Employee killed at Nufarm site in Austria

Thanks to Mr M.K.Rao for sending this link:
The Chemical Engineer | News | Employee killed at Nufarm site in Austria


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September 28, 2015

September 27, 2015

Hydrogen explosion incident due to a change

A company, which produces metal catalysts had made a modification to one of its reactors.
An explosion occurred on the first day of production following the modification and blew the lid through the roof of the factory.


Read about the incident in this link


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September 16, 2015

Severe acid burns to foot as drain collapses

This safety alert highlights the importance of integrity of drain covers:
 Severe acid burns to foot as drain collapses


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September 13, 2015

September 7, 2015

Fatality during pneumatic test

Read an OSHA accident report of a fatality during pneumatic test in this link. 

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September 6, 2015

The evolution of aviation safety

The evolution of aviation safety
Interesting take on statistics and safety!


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September 2, 2015

MOVING PROCESS SAFETY INTO THE BOARD ROOM - ARTICLE IN CHEMICAL ENGINEERING PROGRESS

To all my readers,
My article "Moving process safety into the board room" has been published in the September 2015 issue of Chemical Engineering Progress of American Institute of Chemical Engineers.

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August 25, 2015

Nitrogen pipeline rupture incident

 Read the lessons learnt from a nitrogen pipeline rupture incident in this link.
 
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August 22, 2015

Sealant injection accident

An accident involving a fatality during a leak sealant injection job in a piping highlights the dangers. Read about the incident in this link.

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August 18, 2015

Lessons from confined space fatalities

 In 2010, two welders died in a confined space accident.

The two welders were welding the 36'' final tie from piping system to exchanger. After completion of root welding, one welder made an unauthorized confined space entry into the exchanger to check welding root pass. He was thought that the argon purge was off but one valve was not completely closed and one purge line remained on. This resulted in the argon atmosphere being sustained within the exchanger. In addition, the purge plug ( which is put in place to reduce argon consumption during welding) was in place, which increased the concentration of argon in the vessel. So the first welder collapsed and the second entered for rescue without PPE. Both welders were overcome and died.

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August 12, 2015

Best practices to avoid glass lining damage

Often, we do not treat glass lined equipment with care. Read a good blog post on best practices for avoiding damage to glass lined vessels (two parts) in this link 

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August 9, 2015

Piping incidents

 Read about piping misalignment / vibration related incidents in this link.

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August 6, 2015

Inspecting pressure vessels


 Good practical article on best practices in inspecting pressure vessels in this link.

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August 3, 2015

Controlling Legionella in cooling towers

See a write up by the Cooling Tower Institute on the best practices of controlling Legionella bacteria in cooling towers in this link


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August 1, 2015

DGCA orders removal of AI flight safety chief - The Hindu

DGCA orders removal of AI flight safety chief - The Hindu

Interesting article....especially the reasons mentioned



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July 27, 2015

How speaking up can save lives - BBC UK

Excellent article from BBC UK How speaking up can save lives

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July 12, 2015

Cracking issues

Cracking issues

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July 8, 2015

Six killed in tank explosion

News reports from South Korea indicate a waste water tank explosion when hot work was going on. It is suspected that a welding spark ignited methane, a biochemical gas. It appears that workers conducted a safety check and measured gas concentrations around the tank but not in the interior of the tank, which was sealed. It indicates the importance of analysing atmospheres inside tanks when hot work takes place outside.
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July 5, 2015

Pilots' brains can shut down during crisis | Business Standard News

This article has learnings for designers of plant control systems!

Pilots' brains can shut down during crisis | Business Standard News


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July 1, 2015

Testing of valves in cryogenic service (LNG etc)

When isolation valves in cryogenic service like LNG need to be tested after maintenance, the test should be carried out at the temperature at which the valve operates. Read an explanation of the test bench in this brochure.
Note: This is only for information.


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Hicks on biz: Human error is inevitable | Columnists | Opinion | Edmonton Sun

Hicks on biz: Human error is inevitable | Columnists | Opinion | Edmonton Sun

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June 30, 2015

Chemical Safety Alert: Safer Technology and Alternatives.by EPA

EPA has brought out a Chemical Safety Alert: Safer Technology and Alternatives. As per them, "This alert is intended to introduce safer technology concepts and general approaches, explains the concepts and principles, and gives brief examples of the integration of safer technologies into facility risk management activities."
Read the alert in this link.

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June 17, 2015

Fire in confined space incident

An interesting incident of a fire in a confined space in a ship has lessons for us in the Chemical industry. In this incident a technician was trying to use a cleaner spray to remove moisture from a junction box in a confined space. To speed up the process of drying, he then decided to use a heat gum. The moment the gun was switched on, the flammable vapours of the cleaner caught fire. Dont take anything for granted.
Read and see pictures of the incident in this link.


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June 13, 2015

Ammonia leak from road tanker kills 6

An ammonia road tanker apparently hit a low bridge in Ludhiana, causing damage to the tanker valves and subsequent release of ammonia gas that reportedly killed 6 people and sending 100 to hospital. Read about the accident in this link


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Advances in control systems

This 15 minute video from ABB is worth seeing to see clever uses of technology to make the operators job easier.  I would like your views on alarm shelving that is mentioned in the video. You can see the video in this link:
System 800xA with extended operator workplace

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June 11, 2015

Selection of Gaskets are important

During a process upset in a plant, a pressure transient took place. This led to two gaskets leaking in a pipeline carrying hazardous gases. Luckily the plant was shutdown and no untoward incident occurred. The investigation determined that improper gaskets were used.
1. Gasket failure
– A process shutdown lead to a transient pressure surge in the pipework which resulted in the failure of two gaskets, and a subsequent leak of hydrocarbons. The release activated the facility fire and gas
system, resulting in an emergency shutdown. Deluge was manually activated until the system had bled down and the release was confirmed to have ceased. There was no resultant fire or injuries.
2. Fuel line failure
– A fuel leak from a generator fuel line resulted in fuel being sprayed onto the generator exhaust resulting in a small pool fire. A Maintenance Engineer, working in an adjacent workshop, smelt
fuel and entered the generator room to investigate. He found a fuel oil mist around the generator and call ed the control room and notified of the leak. He then called for a ships generator to be put on line and left the generator room and shutdown the generator remotely. On his return to inspect the
engine, a small pool fire had started on the hot exhaust manifold covers. The fire was extinguished with a hand held extinguisher and there were no injuries.

What went wrong?
The incorrect installation of parts was a contributing factor in both incidents. Investigation of incident 1 found that a large number of installed gaskets did not meet the pipe specification. Two gaskets failed when exposed to an elevated pressure. Likewise for incident 2, the investigation found that incorrect hoses had been installed in a fuel supply service on the generator, which consequently leaked, resulting in a fire.

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June 8, 2015

Leadership Lessons from Retired Air Force General Charles V. Ickes from Crane Institute Certification.

 There are excellent leadership lessons to be learnt (applicable for process safety, too) in the following link:
Leadership Lessons from a Top Gun: Retired Air Force General Charles V. Ickes from Crane Institute Certification.

 
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June 5, 2015

Pipelne that spilled oil was badly thinned

There are excellent lessons to be learnt fom this incident. It reinforces what I have always been saying : Smart technology needs Smart people! It cannot function alone...

http://news.yahoo.com/pipeline-spilled-oil-california-coast-badly-corroded-073802050.html?soc_src=copy


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Lessons from the Maggi Noodles relevant to process safety!

I am keenly following the current crisis in Maggi Noodles being withdrawn temporarily in many states in India due to alleged high content of lead and mono sodium glutamate. What can we learn from this episode? CRISIS MANAGEMENT!

Are you ready for crisis management in your organization?

I cannot but draw attention to the tylenol crisis in the mid 80's in USA when some tylenol tablets were contaminated with cyanide by a miscreant. The way Johnson and Johnson handled that crisis is a text book case of Crisis Management.
Read about that in this link. Be prepared!


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June 4, 2015

Hydrogen safety

Good practical article on hydrogen safety. Worth reading in this link

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May 28, 2015

NTSB Safety Alert Urges Pilots to ‘See and Be Seen’ in the Air

NTSB Safety Alert Urges Pilots to ‘See and Be Seen’ in the Air

The safety alert has parallels in Process Safety. I feel that with overdependence on automation and technology, plant operators also are slowly forgetting how to run a plant!


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May 24, 2015

Piping failure incident

 Read about a case study of a piping failure incident due to external corrosion in this link


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May 18, 2015

Phosphoric acid tank explosion

The late Dr Trevor Kletz had written about this incident in a safety bulletin:

'Small quantities of hydrogen are usually produced when corrosion occurs. If the hydrogen cannot escape and accumulates in the plant, an explosive mixture may be formed. This has caused some fires or explosions in surprising places. Some years ago an explosion occurred in a storage tank of phosphoric acid due to hydrogen produced by corrosion. The tank vent discharged downwards near a walkway. A welding spark ignited the escaping hydrogen and blew the roof off the tank.

The tank was modified so that the vent was in the centre of the roof and the hydrogen could escape easily".

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May 12, 2015

Process Safety Challenge

PROCESS SAFETY CHALLENGE

A fertiliser plant burns natural gas in a hot air generator and uses the hot air to dry the product. The natural gas line inside the enclosed fertiliser plant building is getting corroded due to the corrosive atmosphere inside. Recently, a leak occured in the natural gas line due to corrosion. The NG line pressure is 2.5 barg. A suggestion to enclose the NG line inside the building with an enclosure and providing gas detectors within that enclosure has been raised. You are the MOC (management of change)  approving authority. Will you agree for this change? If not, please list down your comments.

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May 10, 2015

Firefighters, DuPont employees evaluated after leak at plant

Firefighters, DuPont employees evaluated after leak at plant


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Be careful while cleaning "empty" drums

During drum washing operations, a 45 gallon drum exploded due to a buildup of pressure inside the drum.The force of the explosion resulted in the drum flying out of the site onto the roof of a neighbouring building.The drum was one of a batch 70  "empty" drums delivered to the site to be cleaned.The drums all contained residues of acetyl-chloride (a water reactive substance).
Treat "empty" drums with great care! It may look innocent but can kill.


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May 4, 2015

LOPA and its usefulness

 I posted this question in a PSM group in LinkedIn:

"I am interested to know whether a comprehensive study has been done anywhere, after the introduction of LOPA in the late 90's, with the study objective - "Has LOPA actually led to a reduction in incidents?"
Thanks, in advance.."

William Bridges, one of the co inventors of the LOPA technique posted his comments as follows:

"I doubt seriously if such a study is possible as you have to hold ALL OTHER influences constant and then start doing LOPA after that. I think this would be useless graduate project as well (for the same reason).

As one of the co-inventors of LOPA, the greatest improvements I have seen from the introduction of a LOPA, are from using the definition of an IPL within PHA/HAZOPs and from maintaining all IPLs per their respective industry best practices.

At a macro scale, it does not appear that introduction of LOPA or even introduction of process safety best practices have reduced the number of catastrophic accidents. This is no fault of the methods or disciplines; this is because Most companies still choose to do the bare minimum. Some companies have made great strides due to implementing best practices in risk assessment and process safety management; the majority have NOT improved because (1) their PHAs/HAZOPs still fail to find scenarios during all modes of operation so they are missing IPLs they need for those modes of operation, or (2) they fail to maintain IPLs appropriately, or (3) they fail to implement effective steps against the effectives of corrosion, erosion, or external impacts (for which there are no IPLs)."


 
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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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