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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Powder fire incident

An operator was pouring a sack of chemical powder manually into the hopper of a blending machine. The charging process took place while a welder was installing a sign board near the hopper. When the welder started welding, a spark fell into the hopper and a flash fire occurred. The operator who was loading the chemical powder suffered

burns.

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Fatality due to improper view glass

In a chlor alkali electrolyser plant, an acrylic view glass in a manifold gave way and an electrician was exposed to chlorine and died. The acrylic view glass that failed was found to be single layered as against the specification of double layered. No one knew when the change was carried out. Which elements of PSM failed?

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Are your systems password protected?

An incident in a major US airline when the password for opening a commercial planes cockpit door was inadvertently made public is in the news recently. If you have any passwords for your control systems, do you manage them securely?

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Tank cleaning in explosion-proof zones

Tank cleaning in explosion-proof zones


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Vacuum truck explosion

 Vacuum truck explosion incident

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Industrial accidents raise safety questions -The Hindu

 Industrial accidents raise safety questions -The Hindu

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Response teams stage training session at Tyson

Response teams stage training session at Tyson: Hazmat crews from area fire departments converged in the parking lot of Tyson Foods waiting for a call on Saturday morning.


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Road safety intiatives by Corporates

As per a TOI report dated 23.4.17, 410 people died every day last year on the roads of India. It is heartening to know that more and more Corporates in India are emphasizing on road safety. Two such initiatives that I came across, are given below

India Glycols Limited Road Safety

HP lubricants - roads that honk


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The fallacy of lessons learnt by Smartbrief

 The fallacy of lessons learned


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OSHA safety standdown to prevent falls from height

Contractor management is an important element of PSM. OSHA is holding a safety standown week for preventing fatalities from fall from height. The webpage has two videos also.
See OSHA's program in this link. 

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Fire in ammonia plant in Europe

News coming in of a fire in a compressor house of an ammonia plant in Europe.No one was injured It is reported to be an oil fire but has caused extensive damage. Investigations in progress.
Read an article by FAI "Causes of downtime in Ammonia Urea plants in this link.

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Thermal decomposition incident

At approximately 9:15 p.m., in a sealant adhesive manufacturing plant, a mixer producing an epoxy adhesive overheated causing thermal decomposition. The smoke from the mixer filled most of a 3000 sq. ft. production room. The Fire alarm was pulled by an operator outside of the production room. The fire department arrived on scene and took control as Incident Command and called for a shelter-in-place of surrounding neighborhood. Initially, about a 4-block radius around plant was blocked to any traffic. By about 10:20pm, the fire department reduced the blocked off area to only the plant perimeter. A representative from the Emergency Response section responded to the scene and verified that there were no chemical release issues.
The fire department relieved pressure off the mixer and then set up additional exhaust fans to air out the production room, and after getting readings of less than 10 parts per million Carbon Monoxide the Fire Department gave the all-clear, which was about 12am. There was no explosion, no fire and no environmental release and the fire department did not use any extinguishing agents. 

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How technology prevented a major aviation accident

The Times of India paper dated 20.4.17 carries an article of a near miss incident involving two planes with hundreds of passengers that came less than nine kilometres and roughly 15 seconds from each other over Varanasi before the ACAS (Airborne Collision Avoidance System) sounded an alarm and told the pilots what to do. It appears that one of the planes decended more than what he was told to do and thus allegedly caused the near miss. The incident is under invetsigation.
However the role that technology played in avoiding a disaster is highlighted in the incident. The ACAS, automatically scans for other planes that are in a collision course and warns pilots to take timely evasive action. The ACAS systems in each plane talk to each other and order one plane to descend and another to ascend, thus preventing a collision.

 
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"In Europe we have the best safety standards in the world don’t we? An illuminating visit in India suggested why we can perhaps learn from them"

Dr R.K.Sharma, who is General Manager,HSE at India Glycols and whom I admire as a very experienced and innovative safety professional sent this news item. Makes interesting reading!
“In Europe we have the best safety standards in the world don’t we? An illuminating visit in India suggested why we can perhaps learn from them.....”
Martin Lill | Apr 6, 2017
https://www.linkedin.com/pulse/europe-we-have-best-safety-standards-world-dont-visit-martin-lill
 
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Accident during pumping of hazardous chemicals

 Accident during pumping of hazardous chemicals

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CCPS Process Safety Vision 2020

 CCPS Process Safety Vision 2020


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Hot liquid sulphur splash incident

 Hot liquid sulphur splash incident

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abb-organisational-silos-could-increase-the-risk-of-major-accident-hazards

 https://www.hydrocarbonengineering.com/refining/24112016/abb-organisational-silos-could-increase-the-risk-of-major-accident-hazards/

  
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Officials Blame Mechanical Failure For Explosion at Dow Plant

Officials Blame Mechanical Failure For Explosion at Dow Plant


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Does risk management help?

 http://www.govinfosecurity.com/whitepapers/does-risk-management-impact-business-success-w-2959

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http://www.isssource.com/process-safety-and-the-next-generation/

http://www.isssource.com/process-safety-and-the-next-generation/


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Ammonia gas leak triggers explosion killing people

Thanks to Mr Satya Subrahmanyam for sending news about an ammonia receiver explosion in Kanpur cold storage facility that brought down the building, killing 6 people. Read about the incident in this link.


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Explosion in tank in paper mill

A tank at a packaging plant exploded in USA, killing three contractors and injuring at least seven, according to State Police. The explosion happened at an old paper mill.
Three men, all contractors, are confirmed dead. An unaccounted for person reported earlier has been located and is safe. State police have confirmed that there are six minor injuries and one moderate injury after the explosion. Contractors were working on the tank that exploded, and at least some of the people who died were contractors, a state police spokesman said. However, he said he wasn't able to say how many of the men killed were contractors and how many were plant employees.

The U.S. Chemical Safety Board (CSB) announced that a three-person investigation team from the board is deploying to the scene. Chairperson Sutherland said, “The CSB continues to be concerned about the frequency of dangerous hot work incidents and has added safe hot work practices to the agency’s Drivers of Critical Chemical Safety Change Program, a list of key chemical safety advocacy initiatives.”


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Trumps 2018 budget eliminates CSB

President Trump's 2018 proposed budget eliminates the Chemical Safety Board which has done yeomen service by publishing incident investigation reports and videos available on the internet. Let us wait and see whether the proposal will go through. Read the statement by CSB chairperson Vanessa Sutherland in this link.
 
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Learn from this incident

On Wednesday 12 October five people were injured after being exposed to H2S gas (hydrogen sulphide) at an oil and gas terminal.
Five people; two operators, one apprentice and two students on work placements, were exposed to H2S gas at the terminal in connection with work on an H2S reactor. A 14-metre high concrete vessel, the H2S reactor works as a produced water and ballast water cleaning facility with a short vent pipe on the top. One of the five individuals was critically injured, one seriously injured and three individuals were slightly injured. All made a full recovery and are now back in normal routines at work and/or at school.
The internal investigation report defines the incident as having the highest degree of seriousness, and concludes that in other slightly different circumstances the incident could have resulted in fatalities.
The report emphasises several root causes of the incident. Inadequate risk understanding, inadequate skills and emergency response management, in addition to failing barriers in connection with the inspection of the H2S reactor are key elements here. The report forms the basis for measures including: specific operational measures such as more use of portable gas detectors and improved operational procedures related to the H2S reactor, as well as general actions to help increase risk understanding among all employees and improve the quality of the safety work.
Courtesy:PSA

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Electrical installations fires

Electrical installations and equipment are often involved when incidents occur which involve fires and near-fires.These incidents are often caused by technical faults.

Technical causes also constitute a large portion of the underlying causes. Recurring factors include deficient earth fault protection, deficient overcurrent protection and degraded insulation as a result of high temperature.
As regards the preparedness handling of incidents, it emerges that it is challenging to shut down power to the installations before starting extinguishing efforts. Furthermore, in several of the incidents, there are ambiguities in connection with counting personnel present in the installation. Six of the investigation reports reported significant preparedness deficiencies.
The risk of fire appears to be particularly great during the start-up phase of new installations, as well as installations commissioned following a re-build or modification.
Courtesy: PSA

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Chingari trust for young victims of Bhopal disaster- Video

In our busy day to day lives operating chemical plants and maximising production safely, we often forget the miseries that have been inflicted on the poor victims of the Bhopal gas disaster. I have been regularly contributing the sale proceeds of my book to the Chingari trust since 2009. I urge all readers to contribute to the work they are doing for the next generation children who are affected by tragedy. You can see a youtube video of the trust acitvities in this link. 
For those of you who want to donate to the trust from India, here are the details

DETAIL OF THE BANK ACCOUNT FOR DONATION LOCAL REMITTANCE IN INDIA
In favour of : CHINGARI TRUST
Account Number 030072405206
Bank Detail: STATE BANK OF INDIA
Chowk Bazar
113, Marwari Road,
Bhopal - 462001 (M.P.)
Branch Code: 30003
IFSC Code SBIN0030003
Email ID sbi.30003@ sbi.co.in
Telephone No. (0755) 2536188 / 2543248Fax 0755 -2543453


I am making this appeal out of good faith and trust it will receive your due consideration.


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Electrical safety alert MSHA

 http://arlweb.msha.gov/Alerts/electrical-alert9-26.pdf

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Do not neglect H2S

I was going around a plant recently and I observed H2S odour in two places in the plant - one from one of the chemicals used causing its generation and another from an open sewage manhole. Personnel in the plant were treating the odour as a "normal" occurance. Treat H2S with the respect it deserves or it will kill you.

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Singapore industrial fire triggers series of explosions

Singapore industrial fire triggers series of explosions: SINGAPORE - Two hundred firefighters battled a blaze at a Singapore waste management plant which triggered a series of explosions and sent a plume of black smoke into the early morning sky.


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Pump rupture incident

 Pump rupture incident


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CSB's strategic plan 2017 to 2021

 CSB's strategic plan 2017 to 2021

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Industrial air compressor receiver explosion incident

Industrial air compressor receiver explosion incident

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Safety Alert -SCBA cylinder

 https://www.cdlive.lr.org/information/Documents/classnews/2006/cn1806.pdf

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Accident due to corrosion by Cola

 https://www.osha.gov/pls/imis/accidentsearch.accident_detail?id=170764161

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How automation is improving

 How automation is improving

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The importance of redundancy!!

 The importance of redundancy!!

http://www.cornwalllive.com/pilot-blacked-out-on-flight-to-ireland-investigation-reveals/story-30077751-detail/story.html

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http://www.timesofisrael.com/environment-ministry-to-close-haifa-ammonia-storage-tank/

http://www.timesofisrael.com/environment-ministry-to-close-haifa-ammonia-storage-tank/


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