Human error by a Pilot

On 08.08.2014, an Indian commercial passenger jet was involved in loss of altitude incident during cruise over Turkish Airspace. The incident occurred after the aircraft had flown for 04 hours 43 minutes from Mumbai. The aircraft was flying on westerly track which was between 230 and 300 degrees and was flying on auto pilot at a height of 32000 feet. The Pilot in command was undergoing controlled rest as per statutory requirements and the controls were with the First Officer.

The First Officer, while updating the direction heading 292 degree, instead turned the altitude knob to 292 FL (29000 feet) and pressed thereby causing the aircraft to descend as the auto pilot obeyed the order to descend to 29000 feet. The Turkish Air Traffic Controller noticed the aircraft descent and called through radio about the unauthorized descent. Subsequently, the First Officer pressed ALT HOLD and climbed back to FL320 (32000 feet). The First Officer then woke up the Captain who was undergoing controlled rest and informed him of the incident. (Source: DGCA incident report).

In our industry, there have been numerous incidents where wrong setpoints or outputs have been entered by the DCS operator, leading to plant upsets. Do you consider this in HAZOP's?

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One man dies in water-treatment plant explosion - MRT.com: Top Stories

One man dies in water-treatment plant explosion - MRT.com: Top Stories



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OSHA Announces Top 10 Safety Violations for 2015

OSHA Announces Top 10 Safety Violations for 2015



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WISH ALL MY READERS AND THEIR FAMILIES A VERY HAPPY, HEALTHY AND PROSPEROUS 2016!

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Weak Sulphuric acid FRP tank collapse

In a factory, where 10 MT weak sulphuric acid was stored, suddenly the suction line valve tank nozzle assembly got broken and through this opening sulphuric acid drained out from the tank. This resulted in vacuum formation in the tank. This FRP tank hit against the supporting channel legs due to the formation of vacuum.
Causes :
1. The FRP tank was not maintained with a adequate strength and stability

2. The FRP tank was not tested and certified by the Competent person every year

 Source: DGFASLI

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Urea prill tower incident

In a Fertilizer manufacturing factory urea manufactured in prill tower passes through a grizzly (a stainless steel sieve) and falls on a conveyor. To facilitate repair works to be carried out to a grizzly bar, two metal rods were placed above the grizzly bar and this was covered by a tarpaulin sheet.Right below this arrangement welding of grizzly bar was carried out. When the welding process was being carried out heavy lumps of urea started falling down from the prill tower and fell on the iron plates placed over the grizzly bar. The iron plates along with heavy lumps of urea fell on the workers working right below the covered tarpaulin sheet and they sustained head Injuries and died.
Causes :
The temporary arrangements made above the grizzly bar to facilitate welding work was not of a strong and rigid construction to withstand falling of heavy lumps of urea from prill tower.

Ref:DGFASLI




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How the Apollo 1 Fire Changed Spaceship Design Forever

Interesting article on how designers learn from their mistakes.....after all they are also human.
How the Apollo 1 Fire Changed Spaceship Design Forever


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Accident and emergency | Chemistry World

Accident and emergency | Chemistry World

‘2015 should be remembered as a year when the chemical industry was sharply reminded of its social responsibility’



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Empty drums are deadly drums

Often empty drums are treated with much less safety precautions than filled drums. An empty drum that has not been purged free of residues chemicals is a potential bomb. Read about an incident from HSE UK, with a small film about the incident in this link.


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Management of Change or Change of Management?

In 1999, when I was carrying out a PSM audit, we were auditing a maintenance mechanic. I was asking whether he can explain what is the meaning of management of change. He replied that when his company was recently taken over by another company, that is management of change!
Are you carrying out MOC for change in Management?

 
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Whitepaper on dust explosions

Read a good white paper by Fike about Dust explosions in this link.

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Ammonia leak kills one

News reports coming in of an accident in an ammonia plant in Canada when a contractor employee who was doing weather proofing job on an ammonia storage tank was killed due to an ammonia release. Apparently, a piece of equipment struck a valve on the tank and caused the leak. This accident highlights the dangers of working with highly hazardous chemicals and the need for proper JSA's to be carried out.

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