Oversight in inspection causes a pressure vessel lid to blow off

A pressure vessel exploded, sending the vessel’s 250 Kg lid six metres into the air. No one was injured in the incident.
The explosion was found to have been caused by a failure of the vessel’s regulator and pressure relief valve. The investigation determined that sufficient maintenance of the safety devices was not being carried out. Also, statutory inspections were not completed for three years.Read about the incident in this link.

 
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23 injured in flare-up at SAIL’s Burnpur plant | Business Line

23 injured in flare-up at SAIL’s Burnpur plant | Business Line


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Another pressure testing incident

A technician suffered serious injury during a pressure test when a thermowell failed and hit him in the leg. Read the incident in this link.

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Technology of the future today

World’s First Plant to Print Jet Engine Nozzles in Mass Production

What does the above link have with process safety? Technology is rapidly changing. Try to guess how 3D printing will influence process safety management.


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California Proposes Major Changes to Refinery Process Safety Management (PSM) Standard

California Proposes Major Changes to Refinery Process Safety Management (PSM) Standard



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Interaction with chemical engineering students

Today I gave a presentation on "Bhopal and it's relevance today -what young chemical engineers should know" to a group of 60 smart final year chemical engineering students in a leading university. My learnings from the interaction:
This generation of post bhopal chemical engineers are very curious to know what exactly happened at Bhopal and how they can use the learnings in their career in industry. If we do not pass on the relevance of the Bhopal disaster (and the learnings from Bhopal will remain relevant as long as the human being exists) to the present and future generations, we will continue to have major disasters in the Chemical industry. It would be nice if, during the students summer training in Industries, a topic on process safety is also mandatorily included.
The Management of Process safety should be taught as part of the core curriculum of undergrad chemical engineers. They will be the future decision makers in the industry.

I request Associations like the ICC and other chemical associations to take up the points mentioned above.
Also, every Responsible Care certified company may teach the lessons from Bhopal to chemical engineering students in at least three universities every year.


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Deaths Involving the Inadvertent Connection of Air-line Respirators to Inert Gas Supplies

Safety and Health Information Bulletins | Deaths Involving the Inadvertent Connection of Air-line Respirators to Inert Gas Supplies


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PRESENTATION TO BOARD OF DIRECTORS ON BHOPALS 30TH ANNIVERSARY

As you are aware, this year marks the 30th Anniversary of the Bhopal Gas Disaster. To commemorate the event, I am offering a 1 hour free presentation to boards of directors (including the Occupier and Finance Director) of any chemical manufacturing company on the topic "Are you in control of Process Safety"?
I will discuss all the current issues facing process safety and risk management in a chemical manufacturing  company and how directors can ensure effective risk management of a hazardous chemical facility.


If you are interested, please contact me at bkprism@gmail.com

My CV is given below:
I am a Chemical Engineer with over 35 years experience in the Industry in Operations, Technical Services and Process Safety. Prior to starting my Process safety consultancy in 2001, I had worked in India and Saudi Arabia.I have implemented risk based Process Safety Management systems based on best practices of OSHA CFR 1910.119 and others, in many plants in India and overseas. I have carried out many process hazard analysis studies and process safety related assignments in India, Germany, Greece, South Africa and the Middle East. I have also conducted many process incident investigations involving toxic gas releases, fires and explosions, runaway reactions, equipment failures, flare system explosions etc. You can contact me at bkprism@gmail.com


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Hazard of Potential Sidewalk Grate System Failure

Safety and Health Information Bulletins | Hazard of Potential Sidewalk Grate System Failure


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Hazards of overloading cable trays

Safety hazards of overloading cable trays -OSHA fact sheet


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22 wouldn’t have died in pipeline blast had GAIL installed safety features: Probe report :Indian Express

22 wouldn’t have died in pipeline blast had GAIL installed safety features: Probe report - See more in this link - Indian Express
Please also see comments by the papers readers, below the article.

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GAIL pipeline fire due to collective failure: Probe report | Business Line

GAIL pipeline fire due to collective failure: Probe report | Business Line

By the way, collective failure is not a term used in "root cause analysis".

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Ammonia leak in China plant sickens 33

An emission of unburnt ammonia from a flare due to a plant problem has led to ammonia release , causing 33 people to require treatment. Read about the incident in this link.


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Potentially Hazardous Amoebae Found in Eyewash Stations

Safety and Health Information Bulletins | Potentially Hazardous Amoebae Found in Eyewash Stations


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The boy who beeps - from GE

GE has brought out an interesting video on a young boy who can talk to machines by a beep! What does this have to do with process safety? You figure it out in this video.


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Root causes - Unveil them to prevent future incidents

Often, I see incident reports where it mentions the root causes of the incident, but actually they are not the root causes.
I am taking the example of a case study put up on the OISD website called Fire Incident in Process Cooling Tower
in which it mentions the following as "Root Causes" for the incident: My comments are given in brackets.

ROOT CAUSE

1. The reason for explosion and major fire is gushing out of entrapped hydrocarbon from the cooling water return header to new cell, which got ignited since hot jobs were being carried out in close vicinity. The ingress of hydrocarbon was from leakage of hydrocarbon in cooler/condenser in connected process units. (This is the direct cause of the incident)


2. Not adhering to the practice of stopping all work (especially hot work) and prohibiting all unrelated contractor and company personnel at site, before commissioning a new system/ facility. Also, carrying out hazard analysis/ risk assessment would have probably indicated that there could be trapped HC gas, and prompted commissioning/ operation team to vent out entrapped gases. (Why was the work not stopped before commissioning of a new facility? Why was hazard analysis/risk assessment not carried out?)

3. Failure to prevent commissioning activities, even though several jobs were unfinished:

· HC and H2S detectors were not installed.

· Instrument cabling, cooling fan jobs were still unfinished.

· Decision to go ahead with commissioning at fag end of the day.

· Improper coordination amongst Operation, Maintenance and Project  departments.

· Unable to ensure the gaps identified in internal safety audit & operation check-list are liquidated before commissioning

(Why was the commissioning done even though several jobs were unfinished?)


I am hoping the OISD will publish the detailed investigation report of the HPCL Visak cooling tower fire incident and the GAIL pipeline leak incident, just as they have put up the Mr MB Lall's committee report on the Jaipur oil depot fire on their website.

 
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Times of India: Nagaram blast: Probe nails GAIL, says it ignored disaster warnings

Times of India: Nagaram blast: Probe nails GAIL, says it ignored disaster warnings


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Pneumatic test fatality

Read the case study about a fatality during a pneumatic test in this link.

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CSB Chairperson Moure-Eraso Warns About Danger of Hot Work on Tanks Containing Biological or Organic Material - General News - News | the U.S. Chemical Safety Board

CSB Chairperson Moure-Eraso Warns About Danger of Hot Work on Tanks Containing Biological or Organic Material - General News - News | the U.S. Chemical Safety Board



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Near miss, near hit: Don't let the terminology bog you down| Plant Services

There is often confusion among people about what is a "near miss" . See the link below for an explanation:

Compliance | Near miss, near hit: Don't let the terminology bog you down — Whether called near misses, near hits, close calls or something else, the key is to make sure organizations track and investigate them | Plant Services



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Automation and the human

An incident with a plane when it descended  5000 feet without the knowledge of the pilots is reported in newspapers. The commander of the aircraft was under "controlled rest" , (naps allowed by rules) while the co pilot was reported to be busy with the flight data on her ipad. The ATC in Ankara, over which the plane was flying,noticed the flight dropping from its assigned altitude and radioed an emergency alert to the co pilot. The flight was then brought back to its designated altitude.  This incident is being investigated and the results of the investigation will be interesting to see. With so much automation, how did the plane drop 5000 feet without the co pilot noticing it?
In chemical plants, also, an alert and trained operator is the best defence against an incident. Automation is only an enabler and cannot replace the human. Focus on competency development program for your operators and shift crew. Establish a fatigue management program for your shift crew. When I was working in shifts in the Middle East in 1990's the management gave a lot of importance to fatigue management. In fact a near miss incident was reported when a maintenance worker was working on overtime on a critical equipment.


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Negligence caused fire at GAIL pipeline in Andhra: OilMin | Business Line

Negligence caused fire at GAIL pipeline in Andhra: OilMin | Business Line



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Design and robustness

 How GE designs its jet engines

The above link is worth watching and it is interesting to see how strict mandates for aviation design are!
Of late, in India, I see a deterioration in design aspects in chemical plants., mainly because of cost cutting pressures and severe competition in the EPC space. This leads to some dilution in design. Let me give you an example. There were two EPC contractors bidding to build a new ammonia storage tank. One of them who was the lowest bidder got the assignment. Tank was erected, commissioned and everything went off well. As time went by, corrosion started affecting the tanks and only then it was noticed that the designer had scrounged on the number of root isolation valves to cut costs. This meant that if there was a leak in an instrument manifold tapping coming from the top of the tank to the bottom, the leak could not be isolated. You might argue that a HAZOP study should have spotted this, but the quality of HAZOP studies has nosedived!

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Temporary change and asset integrity

This case study from OISD highlights the importance of asset integrity and managing temporary changes. Share it with all your operation and maintenance crew.

 

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Video of fire in service station

Leak + ignition source = fire. See the leak of a flammable fuel then catching fire from an ignition source (vehicle) in this link

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Fatality due to fall in molten iron bucket

News reports indicate that an employee of a major steel company has died after falling into a molten iron bucket which was at 1600 deg C. The investigation will reveal the cause of the tragic incident.

I want to share an incident in another company I heard about few years back, where an engineer fell into a shredding machine that was operating. The fall was due to an open manhole, left open by maintenance. The engineer did not see the open manhole and fell into it. The maintenance crew had taken a break and left without barricading or closing the manhole cover.

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CSB Emphasizes Existing Resources Available on Hot Work Safety

CSB Emphasizes Existing Resources Available on Hot Work Safety - General News - News | the U.S. Chemical Safety Board

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Basic safety guidelines while using gas cylinder

Air products has brought out a simple and effective safety bulletin on gas cylinders.
Read it in this link

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Taiwan gas pipeline blast

Close on the heels of the GAIL pipeline blast in Andhra Pradesh recently, comes news of a similar blast in an underground gas pipeline in Taiwans second largest city. The pipeline was passing through a busy road. See the video and 10 photos of the blast in this link. (Courtesy of Time magazine)


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Lessons from an air crash

The NTSB's investigation of an air crash at San Francisco airport during landing last year mentions that

"The board’s acting chairman, Chris Hart, warned that the accident underscores a problem that has long troubled aviation regulators around the globe — that increasingly complicated automated aircraft controls designed to improve safety are also creating new opportunities for error. 

The Asiana flight crew ‘‘over-relied on automated systems that they did not fully understand,’’ Hart said. 

‘‘In their efforts to compensate for the unreliability of human performance, the designers of automated control systems have unwittingly created opportunities for new error types that can be even more serious than those they were seeking to avoid,’’ he said. "

Read the article in this link. 

I am a firm believer of keeping it simple. Just because that vendors try to sell you a piece of "latest" technology, do not buy it unless you are convinced it will be useful for you. If the argument is that we need more automation systems as competency is going down, I would answer by saying, keep your systems simple so that your training programs become more effective!


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Operational Safety and Maintenance: Fear Ad Hoc Fixes | Chemical Processing

Operational Safety and Maintenance: Fear Ad Hoc Fixes | Chemical Processing



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We are like this only........

Recently I was travelling on a highway which is notorious for accidents. The company car which had picked me up had 4 other employees in it. Only the driver and me (sitting in the rear seat) were wearing the seat belts. I finished my work in the company (which has many plants at various locations) and was travelling back with the corporate safety head of the company along with me. He was not wearing his seat belt!! The driver was rash but none objected till I told him to drive safely. Guess you know where the problem is!!
Why are we like this??

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Pneumatic test accident

The dangers of pneumatic testing is highlighted in this fatal accident.


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PROCESS SAFETY TRAINING SERVICES BROCHURE

To all my readers, please find the process safety training brochure listing out the various topics I provide training in this link. 

 
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Major fire in chemical factory in AP

A major fire in a chemical factory in Nalgonda in Andhra Pradesh has been reported. The fire apparently began due to methanol catching fire. Read and see the video at NDTV in this link 



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Bypassing overrides and the metro incident

The recent incident in the Delhi metro where the train travelled some distance with the doors open has a parallel to process safety. Apparently, problems were observed by the driver with the door closing system and he requested permission to override it and operate it manually. After getting the permission, he apparently did operate the doors manually in a few stations, but forgot to do so at one.

When you authorise trip or override bypasses due to a malfunction, the sense of vulnerability must increase ten fold with close supervision to prevent human error remember WHERE HUMAN, THERE ERROR!

Read the article mentioning the incident in this link. 


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Controlling a chemical plant by thought

 Engineers are perfecting the art of flying a plane just by using a pilots thoughts. This research has progressed rapidly and the article in this link explains the status.
Is it possible that a few years down the line, we may be controlling plants through the DCS operator thoughts? If they perfect the art of flying a plane just by thoughts, then I am sure the technology will filter down.


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Explosion in chemical plant injures one

 News reports in the USA indicate an explosion occurred in a chemical plant, injuring one. "A broken process line produced a chemical reaction, causing a small explosion in the chemical production area" is the statement made by plant official in this link. 

 While I am not commenting about the cause of this incident which is under investigation, how good is your asset integrity program? A good asset integrity program should ensure that you do not have failures like broken lines etc.

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Contamination in pipelines can cause disasters

In 2009, a commercial jet liner had to declare an emergency and land at Hong Kong airport after its engines lost thrust due to contaminated fuel. The reasons for the contamination was because of salt water in the fuel which was loaded in the previous airport. The underground fueling system at that airport was being extended. During the commissioning, salt water in a new pipe entered the main fuel lines as the clearing procedures were inadequate. This caused the thrust problems in the engines. In our chemical process industry, we often line up equipment after repair/hydrotest. Any remnants of water could cause a catastrophic incident later. Make sure your commissioning and start up procedures address this.


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People, Processes And Problems: Better Understanding The Three P’s Of Manufacturing

People, Processes And Problems: Better Understanding The Three P’s Of Manufacturing

Thanks to Balachander Rao, my chemical engineering classmate for sending this insightful article.

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GAIL officials’ negligence led to pipeline blast: expert - The Hindu

GAIL officials’ negligence led to pipeline blast: expert - The Hindu

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Deadly reaction of lime sulphur with NPK solution

An incident where a farm worker was exposed to Hydrogen Sulphide due to mixing of Lime sulphur (mixture of calcium polysulfides formed by reacting calcium hydroxide with sulphur) with NPK solution is highlighted in this link.

MSDS of lime sulphur is given in this link where it mentions acidic materials or dilution with water will cause the release of hydrogen sulfide.



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Article on flange leaks

Even though this article is 9 years old, the causes of flange leaks remain the same. Worth reading in this link.
PS: This is for information only.

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Responsible Care - reinforcing public opinion

The Indian Chemical Council is promoting Responsible Care and trying to motivate organisations into obtaining the RC logo it awards. This is a good initiative but the public needs to have faith in the process. The public are always sceptical of any self regulation by an industry body as they feel that it will be compromised. I have a few suggestions to the ICC to help to make RC more acceptable by the public:

1. The logo should be awarded with the condition that it will be withdrawn if a fatal or reportable accident occurs after awarding the logo. The company then has to go through the whole process for obtaining the logo. ICC must not only publicise the list of companies that have been awarded the logo, but also publicise the names of companies for which the logo has been withdrawn.
2. The best practices of every company that has been awarded the logo should be publicly displayed in ICC website for anyone to emulate.
3. One of the conditions of awarding the logo should be contribution to a fund to improve safety in the SME sector of chemical industries, including fireworks industries. The contribution could be fixed as a percentage of turnover.The improvement of safety in the SME sector of chemical industries should be taken up by ICC themselves and this must be publicised.


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Hydrogen safety in the sulphuric acid industry

Good article - hydrogen safety in the sulphuric acid industry

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A simple slogan

 Yesterday, while driving behind a car, I saw a sticker on  its rear window which said
" WEAR YOUR SEAT BELT - YOU PAID FOR IT"
 A simple yet effective slogan!

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Technology is not a complete substitute

The saga of the missing Malaysian airlines MH370 flight highlights the fact that technology is an enabler but it cannot override the human. The way in which vendors are hard selling process safety technology these days worries me. A typical case is SIL rated instrumented systems. While the statistics and numbers sound very good, no vendor is gong to tell you about the life cycle needs and cost of maintaining these systems.

Nowadays, I also see many cases of the operation staff  left out of the design loop. The net result is that the operator gets a system which leads to work overload during emergencies. Then the vendor hard sells "alarm management software"!!
Somewhere in our journey of process safety management we have forgotten Dr Trevor Kletz's inherent safety philosophy of "keeping it simple".
I often see complicated PSM systems in many "World Class" companies. These systems are "managed" by separate PSM cells.....have we forgotten that the owner of PSM is operations? I often see the systems getting more complicated because the PSM cell needs to justify their existence! (My due apologies if I have hurt anyone).

Having had the fortune to learn about process safety when the word was not in "fashion" , I pray the post bhopal generation of chemical engineers realise that managing process safety is not only about technology........design it for humans who make mistakes.....keep it simple and easy to understand.


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Visakhapatnam pharma unit blast: Condition of three critical - The Hindu

Visakhapatnam pharma unit blast: Condition of three critical - The Hindu

Thanks to Mr Subbu for sending news about the blast.
Ammonia and high temperature are dangerous due to the thermal expansion coefficient of liquid ammonia.

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Update on GAIL pipeline blast

The Hindu: GAIL pipeline blast in AP


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Pipeline fire kills 14 in AP

News filtering in of a GAIL pipeline blast in Andhra Pradesh which has reportedly killed 14 people. Read the story in this link


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