This alert is issued following the failure of a spring return pipeline emergency shut down valve (ESDV). The failure left the primary platform isolation device inoperable with the valve failed in the open position. Other ESDVs have been examined and have found to be at risk of failing in this manner. Spring return valves other than ESDVs are equally vulnerable.
Read the full report in https://www.hse.gov.uk/safetybulletins/pipelinevalve.htm
"This safety notice describes a specific degradation mechanism found inside stainless steel thermowells operating where the external atmosphere contains halides, as is typical in coastal locations or near to cooling towers. Thermowells can 'breathe' during normal operation as vessels heat up and cool down, drawing in the external atmosphere through non gas tight fittings. If the atmosphere contains halides this can leave any stainless steel susceptible to Chloride Stress Corrosion Cracking (CISCC). The HSL Research Report 902 (Reference 1) covers the susceptibility of stainless steel to CISCC in some detail and links to other research papers and published documents".
Read the full safety alert in this link https://www.hse.gov.uk/safetybulletins/thermowell-corrosion.htm
"A recent failure on a UK refinery involved an 8" diameter vertical relief line, approximately 5m in length, which catastrophically failed during normal operation part way along its length, releasing approximately 75 tonnes of extremely flammable material at elevated temperature and pressure. Connected to an insulated process header and vessels, the failure involved complete separation of the relief line (which was not insulated).
Subsequent examination of the line revealed excessive internal thinning which was very local to the failure point, but relatively normal wall thickness elsewhere along its length. The inspection regime included regular thickness testing at four locations, but not at the area local to the failure. Notably, an adjacent relief line was also found to have very similar localised and severe internal corrosion, which had also gone undetected".
Read the full incident in this link https://www.hse.gov.uk/safetybulletins/catastrophic-rupture-dead-leg-pipe-work.htm
"This safety alert is aimed at haulage contractors, users of tank containers and road tankers, companies servicing pressure/ vacuum relief valves and authorised inspection bodies contracted to verify the functioning of these valves.
Tank containers and road tankers used for flammable, corrosive and toxic liquids and gases will normally have a valve fitted to prevent damage to the tank from changes in the internal pressure. Haulage containers used for less hazardous liquids and gases may also have a valve.
Following a road incident in April 2020, investigations by Cleveland Police and HSE found evidence that a pressure/vacuum relief valve, originally manufactured by Fort Vale Engineering Ltd, had been modified by a third party. The valve cap had a nut welded to the top, most likely to allow it to be serviced without the use of a special tool to remove the valve cap. The unauthorised modification prevented the valve’s safe operation"
Read the full report here https://www.hse.gov.uk/safetybulletins/failure-road-tanker-pressure.htm
The 8-inch nominal bore, hydraulically operated MLA involved in the incident had been in service for 11 years and had been regularly maintained by various recognised industry contractors. It had a rigid link pantograph balancing system with independent primary and secondary counterweights linked to the inboard and outboard arms. The MLA failed as it was being manoeuvred towards a ship manifold for connection. A section of the MLA fell backwards onto a jetty handrail narrowly avoiding live plant and pipework on an upper-tier COMAH establishment.
Source: https://www.hse.gov.uk/safetybulletins/marine-loading-arm-failure.htm
Stored Energy: Injury Caused by Failure of Expansion Joint in Fire-Fighting Equipment
What happened?
During a trial of fire-fighting equipment, a hose expansion joint or bellows failed. The release of pressurized water hit a crewman who was standing nearby, slamming him backward and knocking him
unconscious. The fire pump was shut down and help was sought. CPR was administered; subsequently the injured person was medevaced. This incident was considered by our member to be a potential fatality. The injured person was in hospital for some weeks.
What went wrong? What were the causes?
Some identified issues were:
What actions were taken? What lessons were learned?
"Nearly two decades ago, a disgruntled former employee used network access to remotely release sewage.
In 2007, researchers demonstrated that a generator could be destroyed by remotely opening and closing circuit breakers rapidly.
In 2014, hackers broke into the industrial network of a German steel mill and prevented a blast furnace from shutting down.
With respect to the more modern IoT devices, a researcher hacked his insulin pump, others managed to compromise smart meters, and, in a segment aired on "60 Minutes," Defense Advanced Research Projects Agency (DARPA) scientists remotely controlled automobile brakes"
Read the article
https://www.controleng.com/articles/managing-the-risk-of-the-internet-of-things/
.
Fast Forward As more wireless and Web-based applications boost IIoT adoption, some functions have moved into safety areas.The wireless diagnostic devices and applications available now covers a huge range and continues to grow.The same techniques used to monitor equipment condition can also be used to monitor safety devices and systems protecting the plant.
https://www.isa.org/intech-home/2018/march-april/features/iiot-in-safety-applications
https://www.safework.nsw.gov.au/__data/assets/pdf_file/0008/1054718/liquid-nitrogen-explosion.pdf
Part of the pipeline network used to channel nitrogen gas at a manufacturing plant has suffered a failure and ruptured. This incident took place after the refilling of liquid nitrogen from transportation vehicle into the storage tank was done. No loss of life or injury was reported because there was no worker in that area during accident.
Investigation found (revealed) that the pipelines which are made of carbon steel, ruptured in many parts during the accident. Failures on welded part of the pipeline were also detected.
Recommendation of Improvement:
Source: https://www.dosh.gov.my/index.php/osh-info-2/safety-alert/749-nitrogen-pipeline-ruptured
On 28th August 1992, there was a catastrophic failure of a storage tank containing liquefied nitrogen. The failure resulted in the collapse of almost half of the manufacturing site and damage to houses and vehicles within a 400 metre radius. Fragments of the vessel were projected up to 350 metres, the largest of which, a section of the outer shell head was 1.5 metres wide and 8mm thick.
The tank was a double-walled vacuum-insulated ultra-low temperature storage vessel designed to operate at -196°C and 9.3 bar (maximum normal operating pressure).
The inner vessel broke into seven fragments and the outer vessel broke into eleven main fragments and numerous smaller pieces. It was discovered during the course of the investigation that most of the valves on the system were closed including the top liquid inlet, liquid outlet and the isolation valves for the relief valve and bursting disc. The vessel was therefore under completely closed conditions at the time of the accident. The bursting disc was found to be ruptured despite the closed inlet valve, however it was believed that the valve might have been closed after the disc ruptured on a previous occasion. The inner and outer shells ruptured as a result of excessive pressure under closed conditions. It was estimated that the inner shell ruptured at a pressure of 68.7 bar. The pressure reached this level as a result of heat inflow over the sixty days between its final filling and the time of the explosion.
Source: https://www.hse.gov.uk/comah/sragtech/caseliqnitro92.htm
At 5:30 p.m. on February 5, 2017, an employee was responding to an emergency alarm. As he entered a space that was oxygen deficient, he was knocked unconscious. The employee was rescued from the space and was hospitalized, where he received treatment for having been exposed to an oxygen deficient atmosphere, as well as hypothermia and frostbite. His injuries resulted in amputation of an unspecified extremities. The incident investigation revealed that the space contained liquid nitrogen.
Source:Osha.gov
On January 14, 2004, Employee #1, was contracted by the client to provide additional electrical power to boost up the power available from the utility company, which the client needed to test some special equipment. This client is involved in the manufacture and testing of cryogenic pumps and other parts used in the aerospace industry. The manufacturing and testing operations are housed in a large building. The employer had temporarily wired up additional generators to a transformer owned and maintained by the client. This temporary wiring setup including the generators and the transformer was entirely located outside in the parking area behind the manufacturing building. This testing had been completed and the employer was in the process of dismantling this temporary setup when this incident occurred. The circuits containing generators and the transformer had been completely shut down and there was no live part in the temporary wiring setup. The enclosure that housed this transformer for the temporary setup had three additional cables running through it. These cables were spliced inside this enclosure and had no connection to the transformer. These spliced cables carried Edison 4160VAC power for a 150-horse power motor used by the client as permanent equipment, which was not involved in the temporary wiring setup by the employer. It appears that the transformer enclosure was also used as a junction box for the spliced cables. Each of the spliced connections was covered with pieces of PVC pipe and some duct tape. Before the incident a coworker had tested transformer terminals and determined that there was no power in any part of the transformer. As part of the temporary setup dismantling process, Employee #1 was helping the corker to disconnect the cables from the transformer. While Employee #1 was disconnecting a cable from the transformer, one of the spliced connections was exposed, which started an electrical arc and fire. The right forearm of Employee #1 was burned in the fire before he could get away. Employee #1 suffered third degree burns to his right forearm and was hospitalized for three weeks.
Source:Osha.gov
Employees were tasked to fill a series of Chart MVE 1842P-150 Cryogenic Freezers in an enclosed storage room on a weekly basis. The room was not equipped with an adequate engineered ventilation system or oxygen monitoring equipment or system. On the evening of November 20, 2019, an employee began topping the bulk tanks off with liquid nitrogen when the room became filled with nitrogen gas causing the employee to collapse and eventually succumb to the oxygen-deficient atmosphere created in the room. The room was not equipped with an adequate engineered ventilation system or oxygen monitoring equipment or system. This condition exposed an employee to an oxygen deficient atmosphere while filling bulk tanks with liquid nitrogen.
Source:OSHA.gov
On September 21, 2003, Employee #1 and several coworkers were working at a chemical plant that deals with nitric oxide. On the day of the accident, a major leak occurred in a stainless steel distillation column. The nitric oxide leaked into the facilities surrounding vacuum jacket and into the atmosphere through a pump, which controls a high quality vacuum inside the jacket to minimize transmission of heat toward the cryogenic distillation columns. A brown cloud quickly formed and the temperature and the pressure inside the distillation column and its surrounding vacuum jacket began to rise. The leak was detected and the vacuum pump was turned off to halt the leakage of nitric oxide into the atmosphere, allowing the pressure inside the column and vacuum jacket to stabilize around 130 psi. Although stabilized, the pressure was far above the normal pressure of less than or equal to atmospheric pressure (14.7 psi). Approximately 3 hours later, an explosion occurred. The operation and process were destroyed, and debris flew through the plant. Employee #1 suffered lacerations due to flying glass and was treated at a local hospital, where he received stitches and then released. A detailed investigation determined that the cause of the explosion was most likely due to something inside the vacuum jacket initiated the dissociation of nitric oxide, a reaction that is very rapid, exothermic, and self-propagating once started.
Source:Ohsa.gov
On April 2, 2003, Employee #1 and a coworker, the technicians, were watching a polymerization process involving styrene and acrylonitrile monomers. Employee #1 and the coworker's jobs involved monitoring a reactor vessel throughout the process. At the end of the batch process, non-polymerized monomer and vapors were stripped from the reactor through a condenser system to a distillate collection tank and were ultimately charged to subsequent batches. Toward the end of the stripping process, Employee #1 left the control room to determine if enough distillate had been removed to allow the remaining water and mixture to be dumped to the "dirty" sewer and a collection system. While Employee #1 was in the vicinity of the reactor, an explosion occurred in a small auxiliary charge tank. A piece of metal struck Employee #1's abdomen and killed him. Although the charge tank was not in use at the time of the accident, a small amount of the batch had back-flowed through a valve between the reactor and the auxiliary tank during the reactive process. The batch continued to react in the auxiliary tank, overheating and overpressurizing the tank.
Source:Osha.gov
Employee #4 was cleaning the #6 chemical reactor on July 19, 1990, with a flammable mixture of solvents when the reactor burst its rupture disc and the mixture was expelled into the plant. The solvent ignited and the vapor cloud explosion resulted in the plant's 43 employees being injured by flying debris and/or being thrown by the force of the explosion. Employee #4 eventually died from his burns. Employee #1, a maintenance employee, was moving away from the area when he was struck in the head and killed by debris flung during the explosion.
Employees #3, #6, #7, #8, #9, #16, and #19 were located in the manufacturing offices in Building 4, about 75 ft south of the reactor. Employees #2, #10, #11, #12, #14, #15, and #17 all worked in Building G, 50 to 75 ft southwest of the reactor and were leaving when the explosion either threw debris at them or threw their bodies onto equipment or debris. Employee #5 was in the same building as the reactor and was thrown down by the explosion, sustaining burns and crushing injuries. Employee #13 sprained his knee while moving from the break room to the courtyard, about 100 ft southeast of the reactor. Employee #18 suffered a sprained left thigh and a bruised shoulder.
It appeared that the reactor was not vented to a safe location and had primitive temperature controls, and the company did not enforce the mandatory attendance of operators at the reactors during operation. All of these factors, including minimal operating procedures (none specifically for cleaning), led to the explosion and the resulting extensive injuries and property damage.
Source:Osha.gov
https://www.linde-gas.com/en/images/Campaign%20against%20asphyxiation_tcm17-13907.pdf
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