May 17, 2018

Human error and Human factor incident

Reaction containing flammable mixture was completed. The batch was transferred to another kettle. Inerting was carried out. As soon as the nitrogen gas was admitted, an explosion took place in the system. Two operators were killed & five injured. Root Causes: Instead of inert gas, air was admitted, by mistake. There was no system to ensure the specific inert gas or air in the cylinder.


Courtesy: A.G.Shingore, National Safety Council
 

May 9, 2018

Interpreting Piping and Instrumentation Diagrams-Symbology

Interpreting Piping and Instrumentation Diagrams-Symbology: Get a thorough explanation of symbology as it relates to Piping and Instrumentation-controls symbology, tag identification, I/O devices, valve symbol, primary flow element, horizontal line types, dashes, and more. As I mentioned in Part 2, the meanings of the various symbols used on P&IDs (aka, symbology) are defined on separate drawings called “Lead Sheets” (or Legend Sheets). These are your “secret decoder rings” to P&ID symbology interpretation. Every company that builds process plants should have a set of lead sheets customized to their particular ways and means.

April 27, 2018

The Integrity Initiative @EthanolMagazine

The Integrity Initiative @EthanolMagazine: FROM THE APRIL ISSUE: Predictive maintenance, active management and proper use of inspection results keep a plant on track.

April 23, 2018

Explosives Company That Emitted 6 Tons Of Ammonia Near St. Helens Pleads Guilty

Explosives Company That Emitted 6 Tons Of Ammonia Near St. Helens Pleads Guilty: An explosives manufacturing company pleaded guilty in U.S. District Court Friday for failing to notify authorities of the release of 13,000 pounds of ammonia into the air at its St. Helens plant.

April 14, 2018

Are you doing your asset inspections properly?


The final inquiry report for an incident where smoke was observed in the passenger cabin of a flight in India has pinpointed lapses by the airliner in carrying out inspection on power turbine blades, as the probable reason behind the incident. The report mentions the following:
“Immediately after takeoff, at an altitude of about 4,500 feet, a master caution warning was triggered. The crew looked up the readings on the panels, checked all operating parameters and since everything looked normal, they continued with the ascent.
However, after reaching a height of around 6,000 feet, the crew got a call from the cabin crew in-charge about smoke inside the passenger cabin. Passengers were immediately given wet tissues and asked to go in for protective breathing system over the Public Address System.
The aircraft had a valid certificate of airworthiness and the maintenance schedule was adhered to. However, the Eddy Current Testing (inspection of thin metal for potential safety issues) later incorporated into the Engine Maintenance Manual was not carried out, the report pointed out.
The probable cause of the smoke in cabin was contamination of bleed air by engine oil due to failure of the air/oil seals of turbine shaft bearings and impeller bearings.”
http://indianexpress.com/article/india/maharashtra-chemical-factory-fire-tarapur-midc-blast-palghar-5093675/

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.

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.

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 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 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.

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