Process-safety case studies – catastrophic failures of heat exchangers

Process-safety case studies – catastrophic failures of heat exchangers

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Accident Investigation Board determines maintenance error damaged JSTA

Accident Investigation Board determines maintenance error damaged JSTA: Drain holes in the radome of an E-8C Joint Surveillance Target Attack Radar System (JSTARS) aircraft were left covered after depot maintenance, allowing water to accumulate and damage some of the electrical components.


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Human error in aviation

An incident involving a passenger jet flying over Europe was due to human error. The pilots of the jet while crossing countries failed to establish contact with the next Air Traffic Controller as they were entering the wrong radio frequency. Both the pilots missed the error. The result was that air force jets were scrambled to escort the passenger jet, as per emergency protocol. Finally the pilots managed to contact the ATC in emergency frequency and the situation was controlled.
Think about it....highly trained pilots making a mistake....


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Indvertent mixing causes incident

 http://www.binghamtonhomepage.com/news/local-news/accident-at-walton-wastewater-treatment-plant-produces-potentially-harmful-gases/711841809

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23rd Anniversary of deadly explosion at Belpre chemical plant

http://www.thenewscenter.tv/content/news/23rd-Anniversary-of-deadly-explosion-at-Belpre-chemical-plant-425129014.html

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Fires at Pharma units

http://www.thehindu.com/todays-paper/tp-national/tp-andhrapradesh/ganta-asks-official-to-probe-fire-at-pharma-unit/article18387827.ece

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Unknown leaks are also dangerous!

In a petrochemical plant in Europe, an incident has been reported where a carcinogenic chemical was emitted without being noticed for two months as a valve was left inadvertently open. Approximately 28 MT of the chemical was released into the atmosphere in a period of two months. The plant in question has very good PSM system. But the release of a carcinogenic chemical over a period of 2 months was not detected and has been treated by authorities as a Major Accident.

Do you have proper checks after a  plant startup whether all vents are closed?

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 In 1989 an explosion occurred in the Phillips 66 plant in Texas killing many.
The following is a summary of the major findings of OSHA's investigation of the accident.
"1. A process hazard analysis or other equivalent method had not been utilized in the Phillips polyethylene plants to identify the process hazards and the potential for malfunction or human error and to reduce or eliminate such hazards.

2. Phillips' existing safe operating procedures for opening lines in hydrocarbon service, which could have prevented the flammable gas release, were not required for maintenance of the polyethylene plant settling legs. The alternate procedure devised for opening settling legs was inadequate; there was no provision for redundancy on DEMCO valves, no adequate lockout / tagout procedure, and improper design of the valve actuator mechanism and its air hose connections.

3. An effective safety permit system was not enforced with respect to Phillips or contractor employees to ensure that proper safety precautions were observed during maintenance operations, such as unblocking reactor settling legs.

4. There was no permanent combustible gas detection and alarm system in the reactor units or in adjacent strategic locations to monitor hydrocarbon levels and to provide early warning of leaks or releases.

5. Ignition sources were located in proximity to, or downwind (based on prevailing winds) from, large hydrocarbon inventories. Ignition sources also were introduced into high hazard areas without flammable gas testing.

6. Buildings containing personnel or vital control equipment were not separated from process units in accordance with accepted engineering principles or designed with sufficient resistance to fire and explosion.

7. Ventilation system intakes for buildings in close proximity to, or downwind from, hydrocarbon processes or inventories were not designed or configured to prevent the intake of gases in the event of a release.

8. The fire protection system was not maintained in a state of readiness necessary to provide effective firefighting capability. Unknown to the fire chief, one of three emergency standby diesel-powered water pumps had been taken out of service, and another was not fully fueled, with the result that it ran out of fuel during firefighting activities. Further, electric cables supplying power to regular service fire pumps were not located underground, thereby exposing them to blast and fire damage."

In many accident investigations I conduct and also during PSM audits, I still see many of the findings of OSHA for the Phillips accident being repeated.
It seems we have an inherent ability NOT to learn from past incidents because, often,  Money Matters More than Mankind!

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Pigging incident

"A worker was killed operating on a natural gas pipeline. At a receiver station the man intended to pick up two so called cleaning pigs, each weighing about 150 kg, diameter 0.5 m. For this purpose the gas pressure in the pig trap was let off by a valve, manometer controlled. According to an eyewitness's statement, the receiver pressure was equal to outside air pressure before the accident. The victim stood right in front of the flap of the receiver when he began to unfix the screws of the flap. Whilst working, the flap snapped out driven by the two cleaning pigs. The man and the devices were flung through a wire-netting fence and dropped down on a nearby field at a distance of 27, 29 and 38 m, respectively, from the receiver. The man died on the scene of the accident. 
It was determined that the second pig had got stuck in the receiver and that gas pressure had built up behind the pigs due to a leaky valve. As a consequence the pigs were expelled at a velocity of approximately 220 km/h causing a pattern of injury comparable to that of a fall from a great height."
Courtesy:
Death by a cleaning pig--an unusual accident at work].
[Article in German]
Weber M1, Arnrich S, Wilk E, Lessig R.


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Water leakage into furnace causes blast

Leakage of water is likely to have caused the blast in a 20-tonne electric arc furnace at a factory. The accident claimed two lives and left seven others injured. Water is used as a coolant in electric arc furnaces. In case water, in sufficient quantities, leaks into a hot furnace, a violent steam explosion is triggered.Treat water with respect!

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GAIL pipeline leak in 2014

I came across this order from PNGRB about the GAIL pipeline leak in 2014 that killed more than 20 people in AP. Read the order in this link

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The issues in BA and back up systems

The recent problems in British Airways flights all around the World due to failure of their computer systems is being attributed to a power failure and the back up systems did not come in line. Even though you have power back up systems, have you tested the time it requires to kick in? There are lessons to be learnt from the BA incident including crisis management.....

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