The bio diesel tanks fire

A couple of pictures of the bio diesel facility tank farm fire in Andhra Pradesh.

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Biodiesel Magazine - The Latest News and Data About Biodiesel Production

With news reports coming in of a major fire in a bio diesel facility in Andhra Pradesh, it is relevant to mention the importance of process safety in such facilities. Read an article about this in this link:

Biodiesel Magazine - The Latest News and Data About Biodiesel Production



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Tanks and Liners: Is Conventional Wisdom or Reliance on Internet-Based Answers Putting your Company at Risk? : Products Finishing

Tanks and Liners: Is Conventional Wisdom or Reliance on Internet-Based Answers Putting your Company at Risk? : Products Finishing


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Blast in petrochemical plant in Mexico kills 3

Read about an explosion in a petrochemical plant in Mexico that has killed 3 persons in this link.

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Quick intervention helps avert major explosion as LPG tanker overturns

Quick intervention helps avert major explosion as LPG tanker overturns:

Soon, a fire broke out in a hotel located about 200 metres away from the accident spot, following fluctuation in power supply. A fire tender reached the spot at 12.30 a.m. and began pouring water over



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The dangers of contact cleaners

Read about the dangers of contact cleaners that are used ubiquitously in the CPI in the safety bulletin in this link
Train your maintenance and operation personnel about the hazards involved with such cleaners.


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How we prevent another West ammonium nitrate explosion: Q

How we prevent another West ammonium nitrate explosion: Q: In January, the Tribune-Herald published the U.S. Chemical Safety Board’s findings and recommendations regarding storage of fertilizer-grade ammonium nitrate after a 2½-year study of the fire at and explosion of the West Fertilizer Company. The blast left 15 people dead (12 of them first responders) and more than 260 injured; it destroyed or seriously damaged homes, schools and a nursing home — more than 150 buildings in all — in West, population 2,800. Before the board’s formal report to the public (but after privately reporting to family members of the dead), Trib opinion editor Bill Whitaker and veteran staff writer J.B. Smith sat down to discuss the findings with Chemical Safety Board Chairwoman Vanessa Sutherland and lead investigator Johnnie Banks. They discussed the importance of construction materials in facilities housing ammonium nitrate; how the tragedy of West influenced Texas firefighters in a potentially deadly ammonium nitrate fire a year later; and whether the fertilizer industry is doing enough to stress safety.

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Fire in petrochemical plant kills 12

News reports coming in of a fire in Jubail United Petrochemical Plant in Saudi Arabia, during maintenance, which has killed 12 people and injured others. 3 Indians are reported to be among those killed. I know that these companies follow very good safety management systems and this serves as a reminder about how careful we must be.

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The use of Residual current circuit breakers

The use of 30 milliampere RCDs has been commonplace.RCDs used to be called ELCBs – earth leakage circuit breakers.
Safety switches monitor the leakage of electrical current to earth through faulty appliances or incorrect wiring and disconnect the power quickly.
A safety switch can cut off power in 30 milliseconds - a 30th of a heart beat.
If a fault occurs in an appliance or wiring causing current to flow to earth - perhaps through a person - the switch's earth leakage sensor responds to the imbalance of current and cuts the power.
However, the passage of 30mA through a person, even for only 30 milliseconds, may be painful. Unfortunately, for the RCD to work when a person is involved, this has to happen! If the person affected is on a ladder or in a similar elevated situation this shock may cause a fall, which could lead to further injuries!
Over the years the mining and quarrying industry has become familiar with, and in some cases, over-dependent, on these devices. It appears as if people are relying purely on the RCD to protect them rather than ensuring that the equipment is being used correctly. One incident occurred recently where a contractor using a portable device which had no "Test or Tag" label stated emphatically that it was not necessary as the outlet he was using was protected by a 30mA RCD! There have been several reported incidents where portable appliances and/or their power leads have been subject to excessive moisture and the operator felt a tingle. Fortunately the RCD worked and no long-term ill effects occurred.
An RCD is an electro-mechanical device that is inherently extremely reliable, however, they can fail and in this case the tingle may become more serious!
An RCD is there to isolate faulty electrical items; the primary barrier to prevent inadvertent contact with dangerous electrical conductors is the integrity of the insulation.
The users of portable electrical appliances and/or electrical leads must ensure that they are not subject to mechanical abuse or the ingress of water. Testing and tagging should weed out damaged items but will not eliminate misuse particularly if moisture is present. The user has the primary responsibility and obligation to visually check and use portable appliances in a safe manner.
NB: An RCD will not provide protection against a live to neutral fault!

Courtesy: Queensland department of mines:




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What if somebody opens a door during flight?

What if somebody opens a door during flight?


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Explosion-at-petrobras-oil-refinery/

http://www.inquisitr.com/2859213/explosion-at-petrobras-oil-refinery/

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PROCESS SAFETY CULTURE POSTER

 https://store.iomosaic.com/docs/whitepapers/Process%20Safety%20Culture%20poster_CCPS%20Europe%20watermark.pdf

 
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http://www.delawareonline.com/story/money/2016/04/01/dupont-closing-texas-plant-where-4-died/82512270/

 http://www.delawareonline.com/story/money/2016/04/01/dupont-closing-texas-plant-where-4-died/82512270/


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Emergency Preparedness and Response | Safety and Health Guides - Critical Incident Stress Guide

When I investigate fatal accidents in chemical industries, I often see the witnesses are traumatized due to the horrific nature of the incident and the persons who are gravely injured or killed may be their colleague.

OSHA has published a critical incident stress guide which must be made part of every organisations emergency response recovery phase. You can read it in the link given below:

Emergency Preparedness and Response | Safety and Health Guides - Critical Incident Stress Guide


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Poignant message!

 




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The Link between Reliability and Safety

The Link between Reliability and Safety

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Incorrect rotation of positive displacement pump

 Incorrect rotation of positive displacement pump

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Interesting presentation on human factors by NTSB

 http://www.ntsb.gov/news/speeches/RSumwalt/Documents/Sumwalt_140112.pdf

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Seafood Company Had History Of Violations, Including Ammonia Concerns

Seafood Company Had History Of Violations, Including Ammonia Concerns: The seafood company where an employee was killed in an ammonia leak that prompted a large Hazmat response Wednesday had a history of OSHA violations.



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University of Hawaii researcher loses arm in lab explosion | Chemistry World

University of Hawaii researcher loses arm in lab explosion | Chemistry World



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Automatic mustering and personnel locating system

Automatic mustering and personnel locating system
Note: The above is for information purposes only

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Safety in oil movement and storage

Safety in oil movement and storage

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Remote Safety Shower Monitoring Using Wireless Transmitters

 Remote Safety Shower Monitoring Using Wireless Transmitters

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Eight killed in Thai bank chemical accident

Eight killed in Thai bank chemical accident:

At least eight people were killed and seven others injured after fire suppression chemicals were accidentally released at a bank in Thailand's capital Bangkok, the media reported on Monday.
This incident has lessons for us in CPI- what is your control room fire suppression system? Do you practice drills in case the system is activated? Does the timer for evacuation allow enough time for all people to escape?


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EPA safety alert on applicability and limitations of excess flow valves

 EPA safety alert on applicability and limitations of excess flow valves


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Sewage systems and H2S

Plant and housing colonies sewer systems must be treated as a confined space entry with permit requirements as they may contain hydrogen sulfide. Read about a warning in this link

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Hydrotest fatality

 Hydrotest fatality incident

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The Value of Machine Criticality Ratings

The Value of Machine Criticality Ratings


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OSHA QUICK CARD: Hazard Communication Standard Pictogram

OSHA QUICK CARD: Hazard Communication Standard Pictogram


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Confined space hazard alert

Confined space hazard alert

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Baffles Needn't Be Baffling | Chemical Processing

Baffles Needn't Be Baffling | Chemical Processing

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Work permit incident

A hot liquid sulphur splashed in the surrounding area as a maintenance technician opened a filter cover on a live line. Fortunately, no injuries happened.
Operations raised notification to clean the filter in the molten sulphur line. A work permit was raised by maintenance personnel. Shift Supervisor approved the permit without asking the field operator to isolate the equipment. Field operator also signed the hard copy of the permit without isolating the equipment. However, the field operator told the maintenance foreman that the line is not yet isolated and it would be isolated when he was ready to carry out the job. The maintenance foreman gave the permit to the technician but forgot to tell him that it was still live. The technician opened the drain blind flange and opened the drain valve. On finding nothing coming out, he opened the filter cover. Since the line was not isolated hot liquid sulphur sprayed all over the area. Fortunately nobody was injured.

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Inside the control room of the future: Experion Orion Console [VIDEO]

Inside the control room of the future: Experion Orion Console [VIDEO]: Honeywell Process Solutions offered a rare insight into the development work being done in Australia to create the advanced display technology that brings the plant control room of the future to life.


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IOCL Paradip Refinery: An Engineering Marvel IOCL

Read about the details of the recently commissioned Paradip refinery in this link. The CCR is blast proof.

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Massive fire at steel plant in UK caused by lightning

 News reports coming in of a massive fire at a steel plant in UK, attributed to lightning. See the news and pictures in this link

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The Chemical Engineer | News | Three killed in Pemex rig fire

The Chemical Engineer | News | Three killed in Pemex rig fire


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6 burnt alive in factory blast

6 burnt alive in factory blast:
Six workers were burnt alive and one sustained injuries in a fire following an explosion at around 6.30 a.m. in Hasita Aromatics Private Limited factory, at Maheshwaram, located in Telegana.


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TransAsia Airways slammed for poor flight safety management | Society | FOCUS TAIWAN - CNA ENGLISH NEWS

Lessons to learn:
TransAsia Airways slammed for poor flight safety management | Society | FOCUS TAIWAN - CNA ENGLISH NEWS


'Though the council put most of the blame for the accident in Penghu on the pilots, it said the airline was also responsible, citing numerous flaws in the carrier's management, including inadequate risk management processes and ineffective safety meetings.
It also questioned senior management's commitment to safety."

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Propane incident

Read about a propane explosion in the incident available in this link.
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Handling of a cyclone with high wind speeds

I was recently talking to the Unit Head and Head-EHS of a large chemical company which had safely managed a cyclone of wind speeds upto 220 KPMH. They had warning about the cyclone and had planned very well, safely shutting down the plants ahead of the cyclone. Their lessons learnt are summarised as follows:
There is no greater safeguard than pre planning to the last detail before the cyclcone hits.
You must have alternate means of communication (radio) ready
Big trees should be avoided near OHC, Fire station, emergency control centres, main entrances etc as they may fall and block access.
Access to JCB's which can be used to clear pathways is necessary.
Remember every cyclone has an eye. Once the initial phase passes, there will be a calm when the eye passes, followed again by ferocious winds, when the rest of the cyclone passes through.
Insulation damage is inevitable and a plan to restart the plant with partial insulation should be discussed and a management of change done.

The unit managed the cyclone safely without a single injury. Hats off to them!

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Agencies need to address ammonium nitrate safety, report on West Fertilizer explosion says | AgriPulse

Agencies need to address ammonium nitrate safety, report on West Fertilizer explosion says | AgriPulse


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Hazards of aerosol cans

 "Two electricians suffered singeing burns when residue in an electrical switchgear cubicle was ignited shortly after an electrical contact cleaner aerosol had been used. In another case  solvent from a pressure can was ignited by a heat gun. A safety risk exists where any aerosol container with flammable contents is used in a confined space or near an ignition source, whether this is electrical switchgear or some other source of raised temperature.
As they are used so frequently, it is important to refer to information on the can itself or preferably to the appropriate material safety data sheet regarding the flammability of the contents or any other restrictions on usage. Some material safety data sheets state that the aerosol container must not be used in confined spaces or may burst if exposed to temperatures exceeding 50°C.Incorrectly used or stored aerosol containers may represent a safety risk. It is important that material safety data sheets are available" Courtesy Queensland Government - department of mines

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Fire at Deccan Fine Chemicals unit

Fire at Deccan Fine Chemicals unit: Creates panic in Vizag villages

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Updated: Worker injured as high-pressure hose ruptures at Cassar Ship Repair - The Malta Independent

Updated: Worker injured as high-pressure hose ruptures at Cassar Ship Repair - The Malta Independent


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Common sense is not so common

 I was chatting with a Plant Manager recently when he lamented the fact that his operators believed the instrumentation rather than common sense. A pump was not delivering the required flow, even though the current drawn by the motor was normal. The operators checked the position of the recirculation control valve in the DCS and it indicated close. They then requested maintenance to replace the pump twice but the problem remained. Finally they found out that the recirculation valve was open in the field though it was indicating close in the DCS.
I see similar things happen in complicated PSM systems where poeple loose sight of what is the objective of PSM. PSM is common sense applied to keep the hazardous chemicals where they belong.


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Deadly accident sounds alarm for safety in Chinese labs | Chemistry World

Deadly accident sounds alarm for safety in Chinese labs | Chemistry World

Good article on why lab safety needs to be focussed on .



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One dead, three injured in plant accident

One dead, three injured in plant accident: One person is confirmed dead and three others injured following an incident Saturday afternoon involving a chemical explosion at a Pasadena chemical plant.


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Explosion report issued - Vernon Morning Star

Explosion report issued - Vernon Morning Star

The above news item about an incident investigation is worth reading as an explosion occurred in a dryer furnace because the combustion air fan was shut off before the furnace was cooled adequately. When the furnace was opened, an explosion occurred. This incidents highlights the importance of following SOP's

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U.S. Chemical Safety Board Finds Multiple Safety Deficiencies Led to February 2015 Explosion and Serious Near Miss at the Exxon Mobil Refinery in Torrance, California - General News - News | the U.S. Chemical Safety Board

Initial findings seem familiar!

U.S. Chemical Safety Board Finds Multiple Safety Deficiencies Led to February 2015 Explosion and Serious Near Miss at the Exxon Mobil Refinery in Torrance, California - General News - News | the U.S. Chemical Safety Board



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Maintaining old assets

An interesting article has been published in Offshore Engineer, titled "Tackling the backlog".
It talks about how many assets in the UK oil exploration industry is more than 25 years old and  that critical maintenance backlogs have been going up since 2010. It mentions "Safety critical maintenance backlog has increased from just above 700 man hours per installation to more than 4000, as at Q3-4 2014, with the increase having started from 2010, and the greatest rises in 2013 and 2014. Meanwhile, unplanned losses account for the greatest increase in the lost production efficiency, with planned shutdown time also increasing” . The article is worth a read. Please google "Offshore Engineer Tackling the backlog"

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Skyscraper blaze in Persian Gulf raises questions about safety | The Japan Times

Skyscraper blaze in Persian Gulf raises questions about safety | The Japan Times



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Explosion in plant injures 4

 http://www.breakingnews.com/t/IKq

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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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4 die in boiler explosion - TAMIL NADU - The Hindu

4 die in boiler explosion - TAMIL NADU - The Hindu


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OSHA Investigating Explosion at Orla Gas Plant Previously Fined - KWES NewsWest 9 / Midland, Odessa, Big Spring, TX: newswest9.com |

OSHA Investigating Explosion at Orla Gas Plant Previously Fined - KWES NewsWest 9 / Midland, Odessa, Big Spring, TX: newswest9.com |



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Caspian sea oil rig fire

Thanks to S.Sanjeevi for sending news about the Caspian sea oil rig fire. Read about the incident in this link.

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Lessons relearned - TCE - inadequate isolations

Read a TCE article on Lessons relearned - inadequate isolations in this link.

 
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The Ghosts of Bhopal

On the 31st anniversary of the Bhopal Gas Disaster, and with the post Bhopal generation of Chemical Engineers now managing Chemical plants, let us remind ourselves that the Ghosts of Bhopal are still around. We continue to see compromises in process safety management leading to catastrophic accidents.

• For a new generation who have grown up with ISO and PSM systems, remind yourself that systems alone cannot prevent accidents. 
• You must not be deaf and blind to what the systems are telling you. 
• You must also speak up and not be mute when you observe process safety issues. 
• Do not forget the lessons from the past. 
• For people at the highest level in the organization, do not get lulled into a false sense of security just because nothing has happened. 
• Actively seek out bad news...remember the ghosts of Bhopal are still around, waiting to give you a scare....

An example of the Ghosts of Bhopal is the recent CSB incident investigation report of the Caribbean Petroleum Tank terminal explosion and multiple fires released by CSb in October 2015.
CSB finds that systemic failures at CAPECO included: (The highlighted failures are the same failures that happened in Bhopal)

1. A history of poorly maintaining terminal operations;
2. An inherent financial pressure to fill the tanks within the Planning Department’s stipulated time, which was at odds with safety;
3. A failure to learn from previous overfill incidents at the facility;
4. A lack of preventative maintenance for the malfunctioning float and tape device, automatic tank gauge transmitters;
5. An unreliable computer for calculating tank fill times;
6. A lack of overfill prevention safeguards as an independent alarm;
7. A lack of formal procedures for tank-filling operations for operators and managers;
8. An insufficient mechanical integrity program for safety critical equipment;
9. Poor adherence to human factors principles for safety critical equipment.

I also managed to locate a Dec 31, 1984 article on the Bhopal Gas Disaster written in India Today. Read it in this link.

Read an eyewitness account of a IIT professor who was travelling by train at Bhopal station when the disaster occurred in this link 

Remind your employees, including top management that the ghosts of Bhopal are still around by organizing a process safety week from December 2nd every year
 
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Beware of hose worm clamps!

 A chemical cleaning unit of a heat exchanger was rigged up with hoses, fixed with clamps. When the cleaning operation was going on, one of the workers accidentally stepped on the hose which was sending in pressurised chemical cleaning solution. The hose worm clamp gave way and the hose sprayed chemical cleaning solution into the eyes of the worker, causing permanent damage to his vision.

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A non profit organisations view about Process Safety in the USA

The Center for Effective Governance in the USA (a non profit organisation) has published a report called "Blowing smoke" where they say that " Voluntary standards don’t work, and existing regulations are not effectively enforced"
Read about the report in this link.
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Report Finds 85 Fatalities in The Chemicals Industry Last Year

Report Finds 85 Fatalities in The Chemicals Industry Last Year



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Quest Integrity: Inspecting fired heaters with plug headers

Quest Integrity: Inspecting fired heaters with plug headers



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Fatality due to inadequate LOTO

 Fatality due to inadequate LOTO

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12 injured in explosion in Tata Steel plant - The Hindu

12 injured in explosion in Tata Steel plant - The Hindu

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Chlorine accidents

Chlorine accidents

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Learn from a Safety Guru | Chemical Processing

Learn from a Safety Guru | Chemical Processing

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Process Engineering | August Process Puzzler: Avoiding a future accident | Chemical Processing

Process Engineering | August Process Puzzler: Avoiding a future accident | Chemical Processing

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Incident due to nomalization of deviation

Operators used to routinely try to clear blockages in an asphalt line by heating the line externally with a propane torch. In this incident, this normalisation of deviation turned into an incident when it caused an explosion in the tank. Read about the incident in this link.

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Key Takeaways from National Chemical Safety Symposium | Powder/Bulk Solids

Key Takeaways from National Chemical Safety Symposium | Powder/Bulk Solids



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Virtual Reality Provides Real Benefits | Chemical Processing

Virtual Reality Provides Real Benefits | Chemical Processing

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When cranes collapse

See a video and photographs of crane accident that happened in Aug 15 in the Netherlands in this link
There are lessons to learn....

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Be careful when dealing with pressurised lines

A man was killed in an accident involving a high-pressure water line at a well site. The victim along with two other men

was trying to heat a frozen high-pressure water line when the line ruptured. The victim was hit by a stream of high pressure water  at a pressure of 3,500 to 4,500 psi.The victim died from the impact of the water.

Read another safety alert from HSE UK http://www.hse.gov.uk/safetybulletins/hydraulic-injection-injury.htm


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Sealant reinjection incident investigation

A paper presented in the Process safety congress at Dordrecht on June 4th, 2015 depicts the detailed incident investigation of the accident at a refinery in Antwerp in 2013 during sealant re injection. Read about it in this link.

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Forty-Eight Case Histories of Intriguing Machinery Problems

Forty-Eight Case Histories of Intriguing Machinery Problems - Nelson Baxter, ABM Technical Services, Mooresville, Indiana


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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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Hydrogen explosion incident

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


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Get To The Root Of Accidents | Chemical Processing

Get To The Root Of Accidents | Chemical Processing


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Dead leg incident

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

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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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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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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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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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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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