March 24, 2018
March 22, 2018
March 18, 2018
Ghosts of Bhopal?
In
a CSB investigation report about a Nitrous oxide explosion in 2016 that
killed an employee, the following causes were listed in the report.
Many of the causes identified by the CSB are identical to the causes of
the Bhopal gas disaster in 1984. Can you identify some of them?
1. XXXXXX did not evaluate inherently safer design options that could have eliminated the need for the pump;
2. XXXXXX never evaluated its process to identify and control process safety hazards;
3. XXXXXX did not effectively apply the hierarchy of controls to the safeguards that the company used to prevent a possible nitrous oxide explosion;
4. XXXXXX installed equipment that increased the likelihood of an explosion without performing a management of change safety review;
5. XXXXXX did not apply an essential industry safety instrumentation standard, or key elements of a voluntary safe storage and handling standard, both of which are intended to prevent nitrous oxide explosions;
6. XXXXXX safeguards that failed to prevent the explosion include an automatic shutdown safety control and an explosion prevention device;
7. The automatic shutdown safety control XXXXXX relied on required the XXXXXX worker to be physically present – and located immediately adjacent to the trailer truck – in order to bypass the shutdown at a time when an explosion was most likely to occur; and
8. The XXXXXX explosion prevention device – a flame arrestor – was never tested or inspected to ensure it could protect workers from an explosion.
9. XXXXXX failed to apply lessons from previous nitrous oxide explosions; and
10. XXXXXX did not provide its Cantonment facility with an appropriate level of technical staffing support.
1. XXXXXX did not evaluate inherently safer design options that could have eliminated the need for the pump;
2. XXXXXX never evaluated its process to identify and control process safety hazards;
3. XXXXXX did not effectively apply the hierarchy of controls to the safeguards that the company used to prevent a possible nitrous oxide explosion;
4. XXXXXX installed equipment that increased the likelihood of an explosion without performing a management of change safety review;
5. XXXXXX did not apply an essential industry safety instrumentation standard, or key elements of a voluntary safe storage and handling standard, both of which are intended to prevent nitrous oxide explosions;
6. XXXXXX safeguards that failed to prevent the explosion include an automatic shutdown safety control and an explosion prevention device;
7. The automatic shutdown safety control XXXXXX relied on required the XXXXXX worker to be physically present – and located immediately adjacent to the trailer truck – in order to bypass the shutdown at a time when an explosion was most likely to occur; and
8. The XXXXXX explosion prevention device – a flame arrestor – was never tested or inspected to ensure it could protect workers from an explosion.
9. XXXXXX failed to apply lessons from previous nitrous oxide explosions; and
10. XXXXXX did not provide its Cantonment facility with an appropriate level of technical staffing support.
March 15, 2018
PGS 29: New risk-based Dutch regulations for storage terminals
PGS 29: New risk-based Dutch regulations for storage terminals: Alwin van Aggelen, CEO of A-Risc, explains how terminals can deal with new scenario analyses and risk assessment requirements for PGS 29
March 12, 2018
March 9, 2018
March 5, 2018
Fatal accident while repair of insulation on ammonia storage tank
A fatal accident occurred in 2015 when workers were weatherproofing the outer layer of a large ammonia tank, when a piece of equipment struck the tank’s valve,
which caused an ammonia leak that killed one worker.
This accident highlights the need to ensure that proper job safety analysis is carried out especially when working with ammonia tanks.
This accident highlights the need to ensure that proper job safety analysis is carried out especially when working with ammonia tanks.
March 1, 2018
And then there is a fatality!
How many of you have experienced good safety records when suddenly a
fatality occurs in a non process area? Well, you have? The management of
Process Safety and Occupational Health and Safety in a chemical plant
have a few common elements like incident investigation, work permits,
training, emergency planning and response etc. However there is one most
important underlying foundation for both- it is a good safety culture.
Recently, a large chemical plant experienced two fatalities within a
span of two months. Both the fatalities were not in a process area
(covered process as defined in PSM) but were road accidents within the
factory complex. One of them could have been prevented if the driver was
wearing a seat belt. I had visited the plant a month before the fatal
road accident (driver without seat belt) and had observed that in the
township (where employees reside) of that plant, many of the staff were
not wearing crash helmets when riding a two wheeler or were not buckling
up when driving a car. This is the problem. You cannot throw away your
rules just because you have come out of the factory and entered the
township! Safety Culture should be developed assiduously by management
both in and outside the plant. Breaking safety rules outside a plant
will carry the same behavior inside the plant and other employees will
start emulating this. After a fatality, there is always a lot of
introspection, but don't forget the basics - Management staff must walk
the talk both inside and outside the plant. Plain and simple.
February 27, 2018
February 25, 2018
With Team PSM at HPCL Mittal Refinery
I have been interacting with the PSM team at HPCL Mittal Energy Limited, Punjab since 2016 and I am happy to post a pic with this young, energetic and dedicated team. I wish them all the best!
 |
| From L to R: Pankaj, Anshul, Me, Vishal and Tarun |
February 22, 2018
February 19, 2018
Singapore safety initiative secures global award from IChemE
Singapore safety initiative secures global award from IChemE: IChemE, an international professional body for chemical engineers with over 44,000 members in 120 countries, has congratulated Singapore’s Ministry of Manpower (MOM), National Environment Agency (N…
February 14, 2018
How automation and the human avoided a disaster!
A near miss in aviation has been reported on Feb 7th when two Indian
air carriers avoided a mid air collision thanks to the traffic collision
avoidance system (TCAS). The pilot of one of the aircraft obeyed the
command of the TCAS and immediately climbed to avoid disaster. Perfect
example of automation and human avoiding a disaster!
Read about it in this link.
Read about it in this link.
February 11, 2018
February 8, 2018
February 7, 2018
February 3, 2018
February 1, 2018
ZUARINAGAR RESIDENTS SITTING ON AMMONIA ‘TIME BOMB’
ZUARINAGAR RESIDENTS SITTING ON AMMONIA ‘TIME BOMB’: Ammonia tanker mishap at Chicalim re-ignites the issue; Residents say they have been suffering for years; ZACL
officials emphasise that new equipment and upgradation will solve the issue soon
officials emphasise that new equipment and upgradation will solve the issue soon
January 31, 2018
Confined space fatality
Two cylindrical foam sponge pads had been inserted in a riser guide
tube to form a plug. Argon gas had been pumped into the 60 cm space
between the two sponges as shielding gas for welding on the exterior of
the riser guide tube.
After completion of the welding, a worker descended into the
riser guide tube by rope access to remove the upper sponge. While
inside, communication with the worker ceased.
A confined space attendant entered the riser guide tube to
investigate. Finding his colleague unconscious, he called for rescue and
then he too lost consciousness.
On being brought to the surface, the first worker received CPR;
was taken to hospital; but died of suspected cardio-respiratory failure
after 2 hours of descent into the space. The co-worker recovered.
Source:IGOP
Source:IGOP
Councillors across party lines ‘file’ out of MMC after ammonia file goes missing
Councillors across party lines ‘file’ out of MMC after ammonia file goes missing: File finally traced after noisy scenes in council; Council presses for resolution to shift hazardous ammonia tanks outside the city’; Sealing of ammonia tank demanded
January 30, 2018
January 27, 2018
Fatigue and an incident
A worker on a pipe laying barge suffered a blackout without warning and fell. The worker had no previous medical condition and had passed a pre-employment medical the day before the event. He was medivaced for treatment of cuts and bruises and underwent further extensive medical examination. The examination did not find any medical condition that could explain the blackout.
The worker had been working for at least 22 hours, including travelling. After arrival on the facility and induction he went straight into night shift. He suffered the blackout in the first shift. Had he been operating heavy equipment or machinery, the consequence of the blackout could have been far more significant.
A significant contributing factor for the above case is fatigue. The effects of fatigue vary from individual to individual. They can include impaired decision making, delayed response time, inability to concentrate, reduced alertness, and blackout. In the cases above, the site management team failed to manage the risk associated with fatigue. There was a perceived need to carry on with the job.
Key Lessons
Recognise fatigue as a serious safety risk that requires appropriate risk management. Fatigue can cause impaired decision marking, delayed response time, inability to concentrate, and reduced alertness.
Set a clear policy relating to hours of work and communicate it to management and employees. Include travel time as working hours.
Courtesy: NOSPA
The worker had been working for at least 22 hours, including travelling. After arrival on the facility and induction he went straight into night shift. He suffered the blackout in the first shift. Had he been operating heavy equipment or machinery, the consequence of the blackout could have been far more significant.
A significant contributing factor for the above case is fatigue. The effects of fatigue vary from individual to individual. They can include impaired decision making, delayed response time, inability to concentrate, reduced alertness, and blackout. In the cases above, the site management team failed to manage the risk associated with fatigue. There was a perceived need to carry on with the job.
Key Lessons
Recognise fatigue as a serious safety risk that requires appropriate risk management. Fatigue can cause impaired decision marking, delayed response time, inability to concentrate, and reduced alertness.
Set a clear policy relating to hours of work and communicate it to management and employees. Include travel time as working hours.
Courtesy: NOSPA
January 23, 2018
January 19, 2018
January 16, 2018
Floating roof drain incident
In a hydrocarbon storage tank, the floating roof drain valve was kept open during rainy season. One night, operators smelt hydrocarbon vapours in the dyke area and found hydrocarbon liquid coming out of the open floating roof drain. The connection of the floating roof drain to the roof had failed due to corrosion. Are you checking them for internal corrosion?
January 13, 2018
Hazardous Energy source kills engineer
An analyser engineer was killed when the engineer removed the cover on an explosion-
proof enclosure during preventive maintenance. As the engineer loosened the cover, it came out with force and hit him on the head. The force was caused by pressure inside the enclosure from leaking sample gas or instrument air components. It was not equipped with an external indicator to determine the pressure inside the enclosure nor did it have any pressure relief device.
When you hand over equipment for maintenance, make sure all sources of energy are locked out, tagged out and tried.
proof enclosure during preventive maintenance. As the engineer loosened the cover, it came out with force and hit him on the head. The force was caused by pressure inside the enclosure from leaking sample gas or instrument air components. It was not equipped with an external indicator to determine the pressure inside the enclosure nor did it have any pressure relief device.
When you hand over equipment for maintenance, make sure all sources of energy are locked out, tagged out and tried.
January 9, 2018
Is your organization pulling people out of safety training or safety meetings?
In my long process safety consulting journey, I have seen really
committed organizations who demonstrate their commitment to safety as
well as those who don't really walk the talk. In one of the plants where
I was implementing PSM, the Vice President of manufacturing came to the
each of my training sessions 10 minutes before the sessions were
starting even though he was not required to be part of that training
session. He would stay for the first 15 minutes of every session and
then leave. Initially, there were latecomers to the meeting, but when
word went around that the Vice President himself is attending the start
of each session, people started coming on time. In over 20 training
sessions I had conducted, he never missed one. This was his way of
demonstrating his commitment and operational discipline.
In a diametrically opposite example, I had started implementing PSM in a medium scale organization that was very hierarchical in nature and was run by the top boss ("Owner"). In the first session with top management, the top boss thought that it was not important for him to demonstrate his commitment because he had other "important" things to do, I tried explaining to him the importance of his commitment and involvement, but when things did not improve, I stopped the project.
In another organization, the bosses of the Vice President who was attending my sessions kept on sending messages to him to contact them to discuss some organizational issue, while the planned session was on, even though they knew he was in a process safety session. I tell such organizations.....get your act together or do not implement PSM at all. It will be a guaranteed failure!
In a diametrically opposite example, I had started implementing PSM in a medium scale organization that was very hierarchical in nature and was run by the top boss ("Owner"). In the first session with top management, the top boss thought that it was not important for him to demonstrate his commitment because he had other "important" things to do, I tried explaining to him the importance of his commitment and involvement, but when things did not improve, I stopped the project.
In another organization, the bosses of the Vice President who was attending my sessions kept on sending messages to him to contact them to discuss some organizational issue, while the planned session was on, even though they knew he was in a process safety session. I tell such organizations.....get your act together or do not implement PSM at all. It will be a guaranteed failure!
January 5, 2018
Leadership and Process Safety Management
Every now and then we read about incidents of loss of containment even in reputed companies. Why do these incidents happen?
The incidents that I have investigated brings out two categories of leadership - one who think that once a PSM system is implemented, their role is over and the system should prevent incidents. The other is "We did not know this was happening or this risk was being taken at the plant".
Both are leadership issues that form the crux of why incidents continue to occur.
A PSM system is not like a light bulb....switch it on and no incidents occur! It requires top leadership on a daily basis to send the right signals to ensure the PSM system works as intended.
The leadership should also be competent in understanding the process safety risks and should spend quality time to seek and ensure that these risks are controlled on a day to day basis. PSM dashboards are good but can be more useful if leadership does a deep dive into the indicators. The dashboards can also lull you into a sense of complacency if the right indicators are not chosen.
Last, but not the least....Leaders should not review the PSM system AFTER an incident occurs but must proactively understand whether process safety risks are controlled on a day to day basis.
The incidents that I have investigated brings out two categories of leadership - one who think that once a PSM system is implemented, their role is over and the system should prevent incidents. The other is "We did not know this was happening or this risk was being taken at the plant".
Both are leadership issues that form the crux of why incidents continue to occur.
A PSM system is not like a light bulb....switch it on and no incidents occur! It requires top leadership on a daily basis to send the right signals to ensure the PSM system works as intended.
The leadership should also be competent in understanding the process safety risks and should spend quality time to seek and ensure that these risks are controlled on a day to day basis. PSM dashboards are good but can be more useful if leadership does a deep dive into the indicators. The dashboards can also lull you into a sense of complacency if the right indicators are not chosen.
Last, but not the least....Leaders should not review the PSM system AFTER an incident occurs but must proactively understand whether process safety risks are controlled on a day to day basis.
January 2, 2018
Good pragmatic article on BBS
BBS is not a panacea for everything. This article is a pragmatic view of the BBS process
Read it in this link
Read it in this link
January 1, 2018
Happy New Year!
Another dawn of a New Year! Wish you and your family a very Happy, Healthy and Safe New Year!
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