Safety in Industry Learn From Experience (2023)

Safety in lndustry
learn from Experience

Safety in lndustry
Learn from experience
Brij Mohan Bansal
0 CRC Press
Taylor & Francis Group
Boca Raton London New York
CRC Press is an imprint of the

Taylor & Francis Group, an informa business
WOODHEAD PUBLISHING INDIA PVT LTD

NewDelhi
First published 2024
byCRCPress
4 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN
and by CRC Press
2385 NW Executive Center Drive, Suite 320, Boca Raton PL 33431
CRC Press is an imprint of Informll UK Limited
© 2024 Woodhead Publisbing lndia Pvt. Ltd., 2022
Tiw right of Brij Mohan Bansa1 to be identified as author of this work has been asserted
in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988.
All rights I'CIIeiVCd. No part of this book may be rqninted or rcprod~ or utiliscd in
any form or by any electronic, mechanical, or other means, now k:nown or hereafter
invented, includmg photocopying and recording, or in any information storage or
retrieval system, without permissi.on in writing from the publishers.
Por permission to photocopy or use material electronically from this work, acccss www.
copyrigbtcom or oontact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood
Drive, Danvers, MA 01923, 978-750-8400. For works that arenot availabl.e on CCC
please contact [email protected]
Trademark 110tice: Product or corporate names may be trademarks or registered
trademarks, and are uaed only for ident:ification and explanation without intent to
infringe.
Print edition not for sale in South Asia (India, Sri Lanka, Nepal, Bangladesh, Pakistan
or Bhutan).
British Library Cataloguing-in-Publication Data
A catalogue record for this book is availablc from the British Library
ISBN13: 9781032630120 (hbk)
ISBN13: 9781032630137 (pbk)
ISBN13:9781032630144(ebk)
001: 10.432419781032630144
Typeset in Tim.es New Rmna.n
by Bhumi Graphic11, New Delhi
WPI
Contents
Preface viii
Introduction xiii
1. Basics of safety and safety management system 1

1.1 Safety 2
1.2 Incident 2
1.3 Accident 2
1.4 Near-miss incident 3
1.4.1 Incident ratio study 3
1.4.2 Basic causes 6
1.4.3 Lack of control 8
1.4.4 Safety management system 8
1.4.5 Process of managing risks 8
2. Operational safety 11
2.1 Operational safety 12
2.2 Plant Iayout 17
2.3 Fire protection measures 17
2.5 Safety during plant operation 19
2.6 Training to personnel 20
2.7 Inspection and Maintenance 20
2.8 Permit to Work (PTW) system 21
2.9 Personal Protective Equipment (PPE) 22
2.10 Management of Change (MOC) 23
2.11 Workers' participation in safety 23
2.12 Contractor safety 24
2.13 Good housekeeping 25
2.14 Mockdrills 25
2.15 Safety inspections and audits 26
2.16 Safety during shut-down 26
2.17 Plant start-up after shut-downs 27
3. Case studies 29
3.1 Pump house fire 30
3.2 Fire at emde oi1 heater due to leakage in outlet flange 30
3.3 Avoid shortcut 31
3.4 Never allow anyone under the influence of alcohol 32
inside the premises
3.5 Kerosene over flow due to no supervision 33
3.6 Cleaner sleeping under a trnck 34
3.7 Risks in crane operation 35
3.8 Static electricity causing fire due to and improper earthing 36
3.9 Presence of nrind can avert a crisis 37
3.10 Safety culture is driven from the top 37
3.11 Allpetroleum product tanks on fire 38
3.12 Escape of toxic vapours from chemical plant 40
3.13 Fire in LPG trnck loadiuglunloading facility 42
3.14 Fatal accident due to asphyxiation inside a 43
vessel/confined space
3.15 Fire due to electric short circuit 45
3.16 Accident due to wrong line-up 46
3.17 Fire due to line vibration 47
3.18 Accident during excavation 48
3.19 Handling of oil at auto-igoition temperature 48
3.20 Pyrophoric iron on fire 49
3.21 Oil-soaked insulation on fire 49
3.22 Accidents during turn around of processing units 50
vi
3.23 Chlorine gas cylinder leak 51
3.24 Improper stacking of pipes 52
3.25 Explosion and fire in gas processing plant 53
3.26 Fatal accident due to harmful gas in an eastern sector 55
refinery, India
3.27 Fire and explosion in flixborough (UK) 57
3.28 Explosion and fire in olefins production unit of 59
formosa plastics corporation in point comfort, texas
3.29 Fatal accident in a petroleum refinery during 63
hydro-jetting operation
3.30 Fatal accident at a construction site in a petroleum 66
refinery due to fall of scaffold pipe from height
3.31 Explosion in BP rcfinery, texas 67
3.32 Explosion inside flammable solvent storage tank due 71
to static electricity
4. Tips to maintain a healthy safety system 75
Bibliography 82
vii
Preface
There are many books available in the market on safety covering different
aspects of safety. In the book, I have attempted to share my experience on safety
through some case stodies which are explained in a very simple manner, with
simple sketches at some places and with basic purpose that even work-force
in field can understand the reasons for the accident I Fire and remernher them
for long time. I have gone through many case stodies, where author writes
about the chemical process in complicated language, explaining the process,
fiow-Diagram ofthe process and what could have been the probable reasons
for the accident. While I appreciate their approach but to my mind, the person
in field wants to understand the cause and remedies in a very simple langnage
with reasons and learuings. I hope that my assumption will be helpful to all
the readers.
I have covered in my discussion and may be seen in these case studies that
the reasons for accidents are almost common i.e.;
i. Design mistake
ii. Human error I Negligence;
iii. Lack oftraining I knowledge;
iv. Emphasis on production nos;
v. Poor maintenance practices;
vi. No standard operating procedures (SOP);
vii. Non-availability ofproper PPEs
viii. Instrument failure;
ix. Over confidence;
x. Person not medically fit.
Another salient observation is that if the mistake is corrected or fire is
tackled at the initial stage, the major accidents can be avoided. To achieve
that, people in field are required to have knowledge about do's and don'ts,
koowledge on Standard Operating Procedures (SOP), Emergency handling
and use ofPPEs. Sametime cornmon sense is essentially needed to understand
the problern and act for its inunediate control.
ix
Reader's views
I have gone through the book Safety in industry. Leam from Experience
written by Mr. Brij Mohan Bansal, former Chairman ofindian Oil Corporation
Limited. Mr. Bansal has bad a long and diversi.fied experience in the Oil
Industry. In this book, he has explained very will the importance ofnear-miss
incidents and covered a good number of case studies in as simple a manner
as possible. He has elucidated the lessons learnt and given bis valuable
recommendations thereof. Basedon a world-wide-experience, he has even,
clearly and succinctly, listed the vital tips for maintainiog safe working
conditions in the industry.
I think this book will prove very useful for the workforce as weil as
the management of the industrial sector. Safety in industry is likely to even
demoostrate a practical aspect ofworking in industry to students ofengioeeriog
who will be entering the industry in the near future.
PrabhDas
Managiog Director &
Chief Executive Offleer
Reader's views
Truly the lirst safety book ofits kind •••••••
Industrial safety refers to the safety management practices which apply

to the industrial sector for safe-guarding workers, machines, plants and
equipment ,buildings, structures and the environment.
Being myself,a chemical engineer experienced in handling all sorts of

chemicals,I have read several books on safety in the past but this one written
by B. M. Bansal is truly the first of its kind.
Bansal gives to thereaders his entire life span of40years ofexperience,from

a trainee engineer rising to the CMD ofiOC, a Fortune I 00 conglomerate, in a
very simple but lucid and effective manner through:
• 17 major reasons of most accidents, expertly culled out using his
sieves of experience
• 32 case stndies with learuings from each of these pearls of wisdom.
Very costly for those who underwent these cases but presented to the
readers in a very easy- to- grasp manner
• 55 golden tips to maintain a good and healthy safety system
I strongly recommend this book titled "Safety in Industry. Learn from
Experience" for everyone who is part of the industrial environment to study
and imbibe the valuable lessons imparted by Bansal.
Sincerely yours,
Vijay Kumar Soni

[email protected]
Director GFCL EV Products Ltd;

Director GFCL Solar & Green Hydrogen Products Ltd;
Head ofProjects & Key Initiatives, GFL;
Director GFLGM Fluorspar Co., Morocco;
Director Swamim Gujarat Fluorspar Ltd ;
Director SCC Consulting India Pvt Ltd
lntroduction
Firstjob in paper mill: Tea every two hours

After having done my B. Tech in Chemical Engineering from IIT, Delhi,
my first job was in a paper mill. The mill was located near a bamboo forest
in a remote area of Orissa. Bamboo is tbe essential raw material for tbe
manufacturing of paper. Sbredded bamboos are cooked witb caustic in tbe
'Digester' machine, which gives off quite an unpleasant smell, and it took me
several days to get used to it.
In tbe 'Soda Recovery Uuit', tbe 'Black Liquor', ernerging from tbe
combined bamboo and caustic soda, is tbcn fircd in a boiler, where liquid is
bumt aod sodium recovered in malten form. The air in tbe plaot would be
very dusty aod full of soot, especially during tbe soot blowing operation of
tbe economizer coils. It would be so bad we would be forced to run away to a
faraway spot aod gulp down cups ofhot tea to sootbe our choking tbroats.
I was aghast: tbere was no formal safety department in tbe mill except for
tbe firefighting facility.
Decision to leave paper mill

Since tbe paper mill was in a remote place, I bad no intention to continue tbere
for long, anyway.
When I received tbe offer from a major oil compaoy, I left for Delhi by
an early moruing train tbe very next day. It was a circuitous joumey, first
coming to Raipur, tben to Nagpur, and finally Delhi, taking almost two days
to complete tbe journey. Since it was tbe firsttime tbe paper mill management
had recruited engineers from IIT as Management Trainees, tbey tbreatened to
take action against me for jumping the bond. I did not budge however on my
decision, and with time, tbe matter cooled down.
First impression of petroleum refinery

In college, our impression of petroJeum refineries was !bat these would be dirty
places witb puddies of oil everywhere. When I entered the refinery however, I
was pleasantly surprised to see a very neat and tidy plant area. In college, our
knowledge was limited to simple distillation columns, with single retlux and
top and bottom products only. Here I leamt that to get various products from
the same column, there are number of side-draws and circnlating retluxes
to the columns for better fractionation. In chemical engineering, a general
concept about design of columns, exchangers and other equipment is taught.
A special course on petroleum techoology was arranged by the oil company
for the entire batch of chemical engineer trainees. Being in a hazardous and
disaster-prone industry dealing with Oil and Gas, they knew how essential it
was to lay special focus on safety aspects.
Exposure to safety norms

The oil company had an excellent schednle for training the new recruits. For
the first few weeks, we were given an orientation to the company, its policies,
plant operations and safety and fire-fighting training. We were explained the
dos and don'ts of the plant area and the uses of various safety equipment,
including the types of fire extinguishers and where each one was to be used.
In practical training, we bad to leam to extinguish the fire in a small oil tank,
kept specially for demonstrative purposes. I was told to extinguish this fire
by throwing foam on the tlames. I was to aim at the oillayer so that the foam
floated on top of it, cutting off air supply, and hence extinguishing the fire.
Trainees were exposed to unit operations for a few months to get a hands-
on experience. Safety shoes, hehnets and goggles were issued for use inside
the plant. The Fire and Safety Department was headed by a dynamic Sikh
gentleman who was fondly nicknamed 'Safety Surd'. Later, he procured a
good job somewhere in the Middle Bast. The department circulated safety
instructions, kept a record ofthe hot jobs going on in the battery lirnit, inspected
reportedly unsafe conditions in the plant area and carried out investigations in
case of any accident or fire. Fire-fighting was required ouly once in a while,
but they were supposed to be always ready to reach the danger spot in the least
time possible.
Safety - whose responsibilty

Safety plays a very important roJe in maintaining the reputation, sustainability
and growth of an organization. Frequent accidents I fires I fatalities in any
industry Iead to de-motivation amongst the employees, tarnish the image in
the community as weil as in the eyes of other stakeholders, apart from paying
xiv
huge compensation and penalties (while the direct Iosses may be only the tip
of the iceberg).
Safety is everyone's responsibility, but the drive has to come from the
top. The top management has to fonnulate the safety policy, prepare safety
mannals and distribute to all Supervisors and control rooms, provide the
requisite number of Personal Proteelive Equipment (PPE) and train and retrain
on the proper use of PPEs througb the safety department, bring awareness
among employees through safety talks and departmental safety meetings.
Management has to introduce work permit systems, incident reporting,
analysis and investigation procedure, emergency handling plans and mock
drills, safety inspection and safety audit, Hazop studies and monitor the action
plan to Iiquidale the recommendations of such audits.
Even if all the above steps are taken, unless safe habits are inculcated
among the employees as a safety culture, unsafe operations will still be
prevalent. Hence, it is very important to develop a safety culture in the
organization by everyone following the safety gnidelines at all times. The
top and middle management play a very crucial roJe by setting examples and
keeping a close watch on near-miss accidents.
Safety: Not a one-time assignment

Safety is not a one-time assignment, and people have to be always alert.
ln fact, safety starts from home. Once it is a culture, one can locate unsafe
activity wherever it is and take inunediate corrective action. Safety cannot
wait. A company migbt have prepared nice mannals and instroction books
or obtained a high safety rating frum international agencies. However, safety
perfonnance cannot be improved uuless there is awareness in the field and a
push from management to ensure implementation and follow-on gnidelines.
A small Iire, if controlled at the initial stage, can avert a major fire, but if the
operator chose a wrong extingnisher to figbt this small Iire, or if he does not
know its operation or suppose the extingnisher is not charged after its use in
past, the small fire will turn into a major one.
Hence, Training and Retraining of the manpower on a regular basis
is a mnst for any industry, if it is to be believed safe. Mock drills help in
understanding role-play during an emergency and to ensure the readiness
of all the equipment and alertoess of the employees. Frequent safety audits
(even by third parlies) bring out the weaknesses in the system, and their
redressal through a strictly monitared action plan is the responsibility of the
management.
Even at the design stage, we should follow the guidelines laid down
in manuals, standards and suggested by bodies like Oil lndustry Safety
Directorate (OISD). Hazop and Hazard analysis must be carried out to take
care of design mistakes in the implementation stage of the project. Before
commissioning, a proper safety audit is a must from the operational safety
angle.
Construction- Safety is another important part of safety culture. Training
of contract labour, supply of PPEs and strict implementation of these as weil
proper precautions are to be taken for working at heights, as weil as whlle
working on pipelines and excavation work.
Near-miss incidents - not to be ignored

Minor incidents like slipping of a person, stumbling agaiust some obstruction
in the path, losing balance, etc., keep happening in industry, but these are
termed as near- miss incidents, whlch could have become serious accidents.
Such near- misses should not be ignored as worldwide analyses show that if
these incidents are not analysed properly and corrective action is not taken
immediately, these can result in major accidents and cause casualties.
More than forty years' industry experience

In my long working experience of more than forty years, I have worked as
a production engineer, section head, Departmental Head, Refinery Head and
finally as Director I Chairman I CEO. More than twenty years were spent in
refineries and among other fimctions, safety was one of the key focus areas.
My phllosophy on safety was that "we must learn from others' mistakes,
as to learn from our own is very expensive". Hence, apart from the safety
instructions and advice, company should circulate the findings and learnings
of accidents happening in lndia and the world over. In training, videos of
accidents are very useful, as what we see remaius fresh in the mind for a
long time. Senior executives should take rounds in the field and develop
rapport with employees to understand their knowledge on safety. They have
to understand whlch safety issues are still pending and how to improve
the safety of both employees and plants further. These executives have to
demonstrate their seriousness about safety by wearing PPEs whlle moving
in the field and ellJjure that everyone in the field is using PPE as per the site
reqnirements.
xvi
From my experience in the industry, I have come across and reviewed the
cases of many accidents and carried out safety audits of a number of refineries
and projects. One of my observations was that the shortcomings in these
accidents were similar in nature. The main reasons for the accidents have been
• Design mistakes
• Human Errors I Negligence
• Lack of knowledge
• Lack of management's focus on safety (Priority to production
maximisation and profit, neglecting proper inspection and
maintenance ofthe equipment)
• Non-availability of standard PPEs and training to staff for proper use
• Non-availability of Standard Operating Procedures (SOPs) and
Emergency handling guidelines
• Carrying out some activity without proper permit or non-compliance
of safety conditions stipulated in the work-permit
• Over confidence or taking action without understanding the risk
• Person not medically fit to work at height I in confined space
• Instrument failure or leakage due to defective metallurgy or gasket
• Negligence in ensuring proper line-up after maintenance work
• No proper instructions to the field operators or briefing by the shift
reliever
• Not giving importance to abnormal behaviour of the equipment or
vibrations in pipelines, etc. (predictive and preventive maintenance is
neglected).
In the following pages, I would like to narrate some incidents and my
learuings from them. These incidents are from my own experience and
reviews during my forty years. The analysis and recommendations are as I see
them, and they are only to give broad guidelines. They may have to be revised
to some extent on case-to-case basis, depending on the actual situstion and
type of industry.
xvii
Chapter 1
Basics of safety and safety
management system
The purpose of this chapter is to understand the

basics of Safety and Safety Management System and
the process of risk reduction in the workplace. The
importance of reporting and analysing near-miss/sub-
standard actsjsub-standard conditions in an accident-
prevention programme has also been discussed.
Chapter 1
Basics of safety and safety
management system
1.1 Safety
Safety may be defined as 'control of accidental loss' or 'freedom from
accident'. The definition relates to injury, illness, and darnage to anything in
the occupational and extemal environment. Here, the term 'lass' means harm
to people, darnage to property, equipment and/or environment.
1.2 lncident
An event which could or does result in unintended harm or lass may be defined
as 'incident'. This includes accidents as weil as near-misses. All accidents are
incidents, but all incidents are not accidents.
1.3 Accident
It may be defined as 'an event which results in unintended harm or loss.' This
includes anything in the work or external environment. An accident occurs
normally due to contact with a source of energy (kinetic, chemical, thermal,
acoustical, mechanical, electrical, radiation, etc.) or substance above the
threshold limit of body or structore. The humao body has certain tolerance
Ievels or an injury threshold for each form or energy or substance. Normally,
the harmful effects come from single contact, such as cut, fractore, sprain,
amputation, chemical bum, etc. The harmful effects of repeated contacts are
often repetitive motion injuries, cancer, liver darnage, hearing loss, etc and are
termed illnesses. Illness may of course also be sometimes the consequence of
single contact.
In terms of people, contact may result in a cut, burn, abrasion, dislocation,
etc. or interference with anormal body function (asbestosis, cancer, etc.).
In terms of darnage, it could be property/equipment darnage due to fire,
explosion, breakage, distortion, etc. or darnage to environment in the form of
poisonous air or heavy pollution.
2 Safely in industry - leam from experience

1.4 Near-miss incident
A near-miss incident is an unplanned event that has the potential to cause, hut
does not actually result, in human injury, environment or equipment darnage
or a severe interruption in normal operation. Only a fortunate break in a chain
of events can prevent an injury, fatality or damage; in other words, a miss is
nonetheless a very lucky escape, sometimes by a whisker.
1.4.1 lncident ratio study

Various orgauisations and agencies have carried out comprehensive study and
analysis on incident data, and an example of incident triangle is given below.
The figures in each block of the triangle may differ depending on the type
of sectors, and any available information may depend on country and work
culture, but in each survey/study, the basic concept of Incident triangle was
found true.
Serious or major injuries are rare events, and many opportuuities are
afforded by the more frequent, less serious events to take the necessary actions
to prevent major Iosses from occurring. These actions are most effective
when considered as near-misses and sub-standard acts and conditions. Many
orgauisations are finding success by focusing specifically on the behaviour
which plays a major role in accident causation, particnlarly those behaviours
which have a potential to cause major lasses.
A study says (as seen from the figure 1.1) that for every fatal accident,
one may get about 30,000 opportuuities to address and rectify it. Out ofthese,
no one knows which one will be a serious one. Addressing the bottarn of the
triangle means that a focus on unsafe acts/practices and unsafe conditions
will help in reducing the number of near-miss and first-aid cases. Hence, the
possibility of a major accident will be remote.
The lesson to learn here is that the orgauisation should focus on the base
ofthe triangle to minimise the possibility ofmajor accidents.
Further studies have shown that the major contributor to the base of the
Incident triangle is unsafe acts/practices. These unsafe acts and practices
create unsafe and hazardous conditions, which Iead to accidents. These unsafe
acts and practices are directly inf!uenced by human behaviour, so these are
called 'at-risk behaviour'. Promoting the right approach and encouraging
desired behaviours of the employees and discoumging undesired behaviours
in the workplace can be a game changer in accident prevention. This concept
forms the basis ofbehaviour-based safety.
Basics of safety and safety management system 3

Flgure 1.1 lncident triangle
(LWC: Loss Workdays cases) (RWC: Res1ricted Workdays cases)
At-risk behaviours and sub-standard condition.s are always symptoms of

deeper issues. Examples are given below:
SuiMitandard condlllons At·l1•k behavloure

• Defec:ts of tools or equlprnent • Servlc:lng equlprnent ln operatfon
,/' lmproper design ,/' Cleaning, oiling, adjusting, repairing
,/' Sharp, slippery, wom, c:racked, equipment while running
Broken, etc. ,/' Welding or repairing tanks or containers
• Dren or apparel hazard wiltlout purging
.1' Lack of suitable proteelive .1' Wortäng on elec:trically energised
equipment equipment
.1' lmproper or inadequate c:lothing
• Errvironmental hazarcl • Failure to wam or ..eure
,/' Excessive noiae ,/' Failure to place waming signa, tags, or
,/' lnadequate traffic control signals
,/' lnadequate ventilation ,/' Releasing er moving Ioads without giving
,/' lmproper illumination adequat& waming
,/' Airlwateriland contamination ,/' Starting er stopping vehicles without
,/' Tempereture extremes giving adequat& waming
,/' Radiation expoaurea • Making eafety devic. inoperativ•
,/' Poor houaekeeping, disorderly ,/' Diaconneding 01t removing safety
workplace devices
,/' Adjualing safety device inadequat&ly
Contd...
4 Safety in industry- leam from experienoe

GonteL
Sub-standard condltlons At-rlsk behavlours
• Placement hazard '" lmproper use of hands or body parts

.r lmproperiy placed/positioned .r Grasping objects improperiy
./ lnadequately secured against ./ Using hands instead of tools
undesired motlon • Operating or work.ing at improper speed
• Hazards from lnapproprlate Guard .r Feeding or supplying malenals too rapidly
.r Unguan:ted/inadequate ./ Running/Jumping from eievatians
tl' Mechanical or physical hazard ./ Operating vehicle at an unsafe speed
./ Lack of shoring or support .,1' Throwing material instaad of passing it or
./ Ungrounded electric current carrying it
./ Uninsulated electric current • lmproper positioning or posture for task
.r Unshieldedllnadequately .,1' Entering enclosed space without
shielded radiation clearance
.r Uniabolied or inadequately ./ Riding in unsafe position
labellad malenals .,1' Moving under suspended Ioad
• Hazards outside the organlsatlon's ./ Exposure to swinging Ioads
work environment
• lmproper placing, mixing, or combing
./ Defective equipmenUmaterials/
,/ lnjecting, mixing orcombining substances/
premises of others
equipment
./ Other hazards associated with
./ lmproper positioning of vehicles or
activities of others
materials handling equipment for loading/
./ Natural hazards: weather, terrain, unloading
animal, etc.
.,1' lmproper placement of materials which
• Public hozards create hazards, such as tripping or
.r Public Iransport hazan:ts bumping
./ Traffic hazards • lmpropar usa of equipment
,/ Using tagged or obviously defective
equipment
./ Using equipment or materials in a manner
for which H: was not intended
./ Overloading equipment or structures
.. Othar sub-standarcl practicas
rl No attention to footing or surroundings
rl Failure to wear safe personal attire,
failurelimproper use of available PPE
.r Horneplay
• Hazardous methods or procedures
./ Use of inherently hazardous materials/
equipmenUmethodslprocedures
,/ Use of inadequatelimpraper equipment
rl lmproper assignment of personnel

1.4.2 Basic causes
Basic Causes are the actual underlying or root causes behind the visible
symptoms. These are the reasons why the sub-standard acts and conditions
occurred at all. When identified, they permit meaningful incident control.
Often, these are referred to as Root causes, Real causes, Indirect causes,
Underlying or Contributing causes. This is because the immediate causes (the
symptoms, the at-risk behaviours and substandard conditions) are usually
quite apparent, but it takes probing to understand or diagnose the basic causes
and to get control over them. The basic causes of incidents can be broadly
divided into Personal Factcrs and Job Factors. The example of the same is
given below:
Personal factors Job factors
• Physlcai/Physlologlcal capablllly • Leadership andfor Supervision

./ lnappropriate height, weight, size, .t Unclear or oonflicting reporting
strength, rasch, etc. relationshiplassignment of responsibility
,/ Restricted range of body movementf or insuflicient dalegation
limited ability to sustain body posttions .t Giving objectives, goals or standards
.t Sensitivities to sensory extremes that oonflict
(temperature, sound, etc.) .t lnstructions, orientation and/or training
.t Vision/hearing deficiency .t ldentiflcatlon
and evaluation of loss
./ Respiratory incapacity exposura
./ Other sensory deficiencies (tauch, ./ Lack of supervisory/management job
taste, small, balance) knowledge
./ Other permanent physical disabilities .t Lack of matehing of individual
qualifications and jobftask requirement
./ Temporary disabilities
./ Performance measurement and
./ Height sickness evaluation or
,. MentaiiPsychologlcal capablllty ./ lnoorrect performance feedback
.t Fear and phobias • Engineering
./ Low leaming aptitude ./ Assessment of loss exposure
.t Emotional disturbance ./ Consideration of human factor/
./ Memory failure/mental illness ergonomics
,/ Poor judgement/Poor coordination ./ Standard, specifications, design criteria
.t Slow reaction time ./ Monitaring of oonstruction
• Physicai/Physiological sb'ess ./ Assessment of operational readiness
./ lnjury of illness ./ Monitaring of initial operation
.t Oxygen deficiency .t Evaluation of changes
.t Fatigue due ta task Ioad or duration/ • Purchaslng
Fatigue due ta Iack of rest .t Specifications on requisttions
.t Atmospheric pressure variation .t Research of materials/equipment
.t Exposure to health hazard .t Specification ta vendors
./ Exposure to temperature extremes .t Mode or reute of shipment
./ Drugs!under influence of alcohol .t Receiving inspection and acceptance
ContcL
6 Safety in industry - leam from experience

Contd...
Personal factors Job factors
" Mentai/Psychologlcal strass .1' Communication of safety and health

./ Emotional over1oad data
./ Fatigue due to mental task Ioad or ,/ Handling of materials
speed ,/ Transperling of materials
./ Extreme judgement/decision demands ,/ ldentitication of hazardous items
./ Routine monotony, demand for ,/ Salvage andlor waste disposal
uneventful vigilance • Work standard
./ Extreme concentration/perception ,/ Adjustmentlrepair/Maintenance
demands ./ Communlcation of standards
./ 'Meaningless' or 'degrading' actlvlties ./ Maintenance of standard
./ Confusing directions/Conflicting ,/ Missing or unclear
demands
• Malntenance
./ Preoccupation with problems
./ Preventive /Predlctive
./ Frustration/mental illness
./ Reparative
• Lack of knowledge and skill
./ Assessment of needs
./ Experience
,/ Communication of needs
./ Initial orientation training/Updated
./ Lubrlcation and servlcing
training
,/ Scheduling of work
./ Misunderstood directions
,/ Adjustmentlassembly
./ Lack of coaching
,/ Examination of units
• Lack of motivatlon
,/ Cleanlng and resurfacing
./ Performance is rewarding
,/ Part SUbstitute
./ Proper performance is punishing
• Tools and equlpment
./ Lack of incentives
,/ Assessment of need and risk
./ Excessive frustration
./Human factors/ergonomics
./ lnappropriate aggression
considerations
./ Attempt to avoid discomfort
,/ Standards or specifications
./ Attempt to gain attention
,/ Availability
./ Peer pressure
./ Adjustmentlrepalr maintenance
./ Supervisory example ,/ Salvage and reclamation
./ Performance faedback ,/ Removal and replacement of unsuitable
./ Reinforcement of improper behaviour items
./ Production incentive • Waar and tear
,/ Planning of use
,/ Extension of service life
,/ lnspection andlor monitaring
,/ Loadlng or rate of use
,/ Maintenance
,/ Use by unqualified or unlrained people
,/ Use for wrong purpose
• Abuse or misuse
,/ Condition of Supervision
,/ Intentional
./ Not condoned by Supervisor
./ Unlntentlonal

1.4.3 Lack of control
A few of an organisation's problems can be controlled by individual
emp1oyees or a group of employees, but the majority ofloss-producing events
are controllab1e only through the management system.
1.4.4 Safety management system

A system of managing safety may be inadequate because of too few or
ineffective system activities. While the necessary activities may vary with
each organisation, the Iist of elements which covers the Safety Management
System may include the following:
I. Leadership and administration
2. Leadership and skill training
3. Planned inspection and audit
4. Task analysis procedure and task observation
5. Behaviour-based safety
6. Emergency preparation
7. Personal Protective Equipment (PPE)
8. Safety rules, work permit system and job safety analysis
9. Accident/incideut analysis
10. Systemevaluation
11. Engineering and management of change
12. Communication
13. Health and hygiene
14. HSE promotion
15. Hiring and placement
16. Material and service management
17. Off-the-job safety
1.4.5 Process of managing risks

Hazard identi.fication: The process of managing risks starts from hazard
identification. Various techniques, such as HAZOP, HAZIN, safety audits,
incident records of premises and e1sewhere at similar plants, brainstorming
with field personoel, are used to ideutil'y the hazards in the workplace. This
helps in preparing a Iist of hazards existing in the premises.
a Safety in industry - leam from experience

Risk ana/ysis: Each hazard in the Iist of hazards is assessed with respect
to probability and consequence to assess its risk Ievel. The consequence is
given a nurober (1-5), and the probability is also given a nurober (1-5}. The
High Risk, Medium Risk and Low Risk Ievels can be decided as per the matrix
drawn based on consequence and probability.
Risk value judgement: AB we know, the risk is multiplication of
Consequence and Probability. Each hazard, when estimated from the angle
of consequence and probability, gives a value. The higher the value, the more
severe the risk. High risks need to be addressed on priority.
Tolerate: On evaluation of the Risk Value, the organisation can decide
whether it can talerate it or not. Now, all such risks are to be measured and
monitored to assess and judge the decision.
Risk reduction: The hazard which cannot be tolerated will go for Risk
Reduction to bring down the Risk Level to As Low AB Reasonably Practicable
(ALARP). The method ofRisk Reduction is as follows:
• Terminate
In this method, the risk needs to be terminated from route, such as
replacing a high hazard chemical with a non-hazardous chemical.
This method is no doubt very good, but application in practice may
be difticult and so used in limited cases ouly.
• Treat
This method is very common and very effective. Risk is treated by
applying engineering control, administrative control, medical control,
development of SOPs and implementation, detection system, PPE,
training, etc.
• Transfer
This method is allied to transfer the risk, such as insurance of compaoy
assets to cover the lasses, or transferring the handling of hazardous
materials, including processing and neutralising to government-
approved agencies in their premises.
Implement and manage: The control measures finalised to reduce the risk
is to be implemented systematically and retained on consistent basis.
Measure and monitor: Once the control measures have been implemented,
it has tobe measured and monitored. There is a saying that what can't be
measured can't be controlled. Hence, the measuring criteria for control
measures are to be finalised and the job should be monitared and recorded.
The minor risk which falls under Tolerable category has also to be monitored.

Evaluate resultsllnvestigate: The data obtained through measurement and
monitaring need to be evaluated!investigated to judge the improvement in the
risk Ievel.
If the results show improvement in the Risk Level and falls under
Acceptable Risk, this job shall join the Iist of risks for further risk value
judgement. If there is no substantial improvement in the risk Ievel, the risk
willjoin the Iist ofhazards aod go for further risk aoalysis.
This is the way the risk cycle rotates and contiouous reduction in risk
Ievel takes place, thereby ensuring contiouous improvement in safety in the
workplace.
1o Safely in industry - leam from experience

Chapter2
Oparational safety
Safety is taken into consideration in a process industry

right from the conceptual stage of design. Safety is
thereby impregnated in design, Iayout, engineering,
construction, pre-commtsstoning, commtsstoning,
day-to-day operations and turnaround. This chapter
gives an overall picture of the safety measures
embraced at various stages in any Process Industry.
I have added my personal experience also at various
stages to give depth to the understanding and make
it more meaningful.
Chapter2
Oparational safety
2.1 Operational safety

Keeping focus on productivity, safety, health, environment and reliability,
running of process units and their allied facilities smoothly on a continuous
basis is of prime importance.
Operational safety in a plant starts from the conceptual stage of plant
design and ends with the day-to-day smooth, uninterrupted running of the
plant in total safety.
I. The following tools are used to assess the Ievel of in-built safety in
the system:
• HAZOP: Hazard Operability Study
• HAZID: Hazard Identification
• PHA: Process Hazard Analysis
• LOPA: Layer ofProtectionAnalysis
• Otber safety reviews such as QRA: Quantitative Risk Analysis, etc.
A. Hazard Operability Study (HAZOP)

The HAZOP study is to carefully review a process or operation in a struetured
and systematic manner to determine whether deviations from the design or
operational intent can Iead to undesirable consequences. Suitable guide words
are used to create deviations in process pararneters. This technique can be
used for continuous or batch processes and can be adopted to evaluate written
procedures. The HAZOP team creates a plan for the complete work process,
identitying the individual steps or elements. This typically involves using
the Piping aud Instrument Diagrams (P&ID) or a plant model as a guide for
examining every section and component of a process. Foreach elernent, the
team identifies the planned operating pararneters of the system at that point:
flow rate, pressure, temperature, vibration, and so on. The HAZOP team
lists potential causes and consequences of the deviation as well as existing
safegnards protecting against the deviation. The team Ieader controls the
discussion, so that meaningful results are obtained. When the team determines

that inadequate safeguards exist for a credible deviation, itusually recommends
what action be taken to reduce the risk in a comprehensive worksheet.
In the case study on FLIXffiOROUGH given in this book, it was a case
of not doing proper HAZOP before putting a by-pass line to the reactor.
Objectives of carrying out a HAZOP study:

• To check a design
• To decide whether and where to build
• To decide whether to buy a piece of equipment
• To obtain a list of questions to put to a supplier
• To check running instructio]]jj
• To improve the safety ofthe existing facilities
HAZOPteam:
In addition to the Chairman, the HAZOP team may comprise ofthe following
personneI:
• Design consultant/project manager
• Production maoager
• Cheruical engineer
• Maintenance manager
• Electrical engineer
• Instrument engineer
• HSE engineer
B. Hazard identification (HAZID):

HAZID is a qualitative techuique for the early identification of potential
hazards and threats affecting people, the environment, assets or reputation.
The major benefit of tbe HAZID study is to provide an essential input to
project development decisions. It is a means of identitying and describing
HSE hazards and threats at tbe earliest practicable stage of a development or
venture.
Objectives ofthe study:
• To identify tbe potential hazards and to reduce the probability aod
consequences of an incident in tbe site tbat would have adetrimental
impact on tbe personneI of tbe plant, properlies and environment.
Scope of the study will depend on tbe particular project.
Operalienal safety 13
Methodology:
The study method is a combination ofidentification, analysis and brainstorming
by the HAZID team members in a structured and systematic manoer under
a team leader, who controls the discussion so !hat meaningful results are
obtained. Guidewords are used in order to identify possible potential and
hazardous effects as weil as threats. Furthermore, the team analyses the
appropriate controls !hat should be put in place in order to preveot or control
each identified threat.
The analysis ofHAZID will be conducted on a session basis, grouping the
processes with the Process Flow Diagram (PFD) and plant layout into a series
of sections where the various sources will have similar characteristics and
hence consequences. The entire discussion is to be recorded in a prescribed
data sheet and submitted with report.
HAZIDTeam:
In addition to the chairman, the HAZID team will be constituted on the same
pattern as in case of HAZOP.
Benefits of carrying out HAZID:
• Identify opportunities for inherent safety.
• Identify fire, explosion, toxic-release seenarios and measure to
prevent it.
• Any special preparations required to be taken to handle these can be
pre-planned.
• Any specific process modifications if required can be established at
an early stage.
• Prepares the system and team, ready aod confident to go ahead for
commissioning. Avoids major surprises.
• Hazards involved in operaring each equipment can be enlisted at the
beginning, leading to better process mapping and better control in
future for getting OSHAS/ISO approvals.
• The major beoefit of HAZID is early identification, and assessment
of the critical health, safety and environmental hazards provides an
essential input to the project development decisions.
C. Process Hazard Analysis (PHA)

PHA is a systematic assessment of all potential hazards associated with
an industrial process. It is necessary to analyse all potential causes and
consequences of:

• Fires
• Explosions
• Releases of toxic, hazardous or fiammable materials, etc.
Focus on anything that might impact the process, including:

• Equipment failures (refer case study No.27 in cbapter No.3 of
Flixborough disastet in 1974)
• Instrumentation failures or calibration issues
• Loss ofutilities (power, cooling water, instrument air, etc.)
• Human errors or actions (refer Case Study No.-12 in cbapter No.3
Bhopal Case study in Union Carbide in December 1984)
• External factors, such as storms or earthquakes, etc.
Both the.frequency and severity ofeach process hazard must be analysed:

• Haw often cou/d it hoppen? Tank spills could bappen any time there,
ifthere is a manual fill operation (multiple times a year).
• Haw severe is the resu/t? Localised darnage, fire, explosion, toxic gas
release, death.
Core to the PHA analysis is the fact that things can and do go wrong. You
have to forget IF it will bappen and instead consider WHEN it will bappen.
Each identified hazard is assigned an 'acceptable' frequency. For purposes of
the PHA, you cannot assume a hazard will 'never' bappen.
• Ahazard that results in simple first aid could be considered 'acceptable'
if it could happen only once a year.
• An explosion and fire due to a tank rupture could have an 'acceptable'
frequency of once in 10,000 years.
The end result of the PHA is a Iist of a11 possible process hazards with
each one assigned an acceptable frequency of occurrence. The next step in the
safety life-cycle is the layer of protection analysis.
Inadequate study and implementation of PSM led to many disasters in
process industries. One of them being BP Refinery disaster, Texas.(please
refer case study no 31 in cbapter 3 for details.)
D. Layer of Protection Analysis (LOPA)

No single safety measure alone can eliminate risk. Forthis reason, an effective
safety system must consist of protective layers. This way if one protection
layer fails, successive layers will tske the process to a safe state. As the
Operalienal safely 15
number of protection layers and tbeir reliabilities increase, the safety of the
overall process increases.
Some specilic examples of protection layers include:
• Fire suppression systems
• Leak containment systems (dikes or double walls)
• Pressure relief valves
• Gas detection/waming systems
E. Quantitative Risk Analysis (QRA)
QRA is proven as a valuable management tool in assessing the overall safety
perforrnance of a chemical process industry.
Objectives ofQRA:
• To identify, quantify and assess the risk from the facility, from the
storage and bandling of chemical products.
• To identify, quantify and assess the risk to nearby facilities/
installations.
• To suggest recommendations in order to reduce the risk to human life,
assets, environment and business interruptions to as low as reasonably
practicable.
Risk Analysis tecbniques provide advanced quantitative means to
Supplement other hazard identification, analysis, assessment, control and
management methods to identify the potential for such incidents and to
evaluate control strategies.
Risk Assessment procedure: Assessment of risks is based on the
consequences and likelihood.
• Consequence estimation is the methodology used to determine the
potential for darnage or injury from specific incidents such as jet fire,
BLEVE,etc.
• Likelihood assessment is the methodology used to estimate the
frequency or probability of occurrence of an incident.
Software packages, suchasPHAST RISK MICRO 6.7, WHAZAN v2.0,
and EFFECTS v2.0, are used to carry out the modelling ofprobable outcomes
such as fire, explosion, vapour cloud explosion and BLEVE.
Risks are quantified using this study and ranked accordingly based on
their severity and probability. Acceptability of the estimated risk must then be
judged based upon criteria appropriate to the particular situation. Study report
is used to understand the significance of existing control measures and to

follow the measures continuously. Wherever possible, additional risk control
measures are to be adopted to reduce the risk Ievels.
2.2 Plant Iayout

Layout: To decide separation, isolation, drainage, accesses/roads considering
foreseen seenarios for normal operation and emergencies. All regulations/
standards/statutory clearances shall be complied.
3-D review of plant during Iayout and engineering is an important tool
to identify gap io safety and provides an opportunity to improve the safety
standard in design stage.
While decidiog the Iayout, the findings of QRA, population/facilities
beyond factory area should also be taken ioto consideration. HSE aspect and
best engioeering practices shall also be taken into consideration.
The Iayout should also facilitate primary containment of chemieals in
case of leakage/spillage for their safe recovery. Relevant statutes shall be
followed as mioimum requirement
2.3 Fire protection measures

In addition to fire prevention and protection measures in design, engioeering
and Iayout, it should be supplemented to take care, if it does occur. In the first
phase, passive fire protection measures need to be considered, which may
include fire-proofing of structures/ equipment, use of intrinsically safe/flame-
proof electric equipment as per area classification, use of earthing!bonding in
equipmentlpipes, use of flammable gas detection system, ete.
The Active Fire Protection System may include well-designed emergency
communications, fire detection system, firewater system, other automatic as
weil as manual firefighting systems, fire extinguishers at plant site. All such
facilities and equipment should be freely accessible and well maiotaioed for
use during emergency. The facilities in premises may include a full-fledged
fire service, stationed round the clock at fire station(s) with crew withio the
complex. The facility at the fire station shall include provision of mobile fire
and rescue tenders with various firefighting facilities aod chemicals.
Additionally, the complex should have well-developed 'Emergency
Response aod Disaster Management Plan' for all foreseen on-site as well as
off-site emergencies. While preparing plan, the HAZOP and QRA findings
are to be referred. The complex should identify all resources io terms of
equipment/facilities and manpower as per requirement and should develop
mobilisation plan. For the purposes, the complex may seek help from nearby
industries (in form of Mutual Aid Scheme), government agencies, NGOs,
medical services, etc. The requirement is mandatory in nature for most of the
process industries in India.
An evacuation plan with Assembly Points should exist at all working
locations for safe evacuation of people in case of emergency. This may be
included as part of 'Emergency Response and Disaster Management Plan'.
2.4 Plant commissioning

Once the plant is ready, it has to go through various checks and documentations
to ensure tbat plant is ready for safe commissioning. This includes
• All statutorypermissions/clearances are in place andrecommendations
implemented.
• Plant mechanically ready and checked manually as per the prescribed
checklist.
• Allinstrumentationsystem and electrical system and utilities facilities
(such as power, air, nitrogen, water, steam, etc.) checked and are in
place as per the prescribed checklist.
• All emergency handing facilities are in place and are in ready-to-use
condition.
• Operatingmanual (including SOP, start-up and shut-down procedure,
process emergency handling, utilities failures, etc. ), maintenance
manual, instrumentation manual, fire and safety manual, HSE
management system, etc. are in place.
• Commissioning procedure has been established, and concemed
persans are fully aware off the steps to be followed.
• Pre-commissioning audit has been carried out before the
commissioning aod recommendations have been implemented.
In case it reqnires some statutory audits/checks, those need to be
completed.
• Trained and experienced working personnel have taken their charge
for safe aod smooth commissioning of plant.
• Expert team from licensors, if needed, is available.
• Safety system addressing work permit system, PPE, emergency
handling, MOC, etc. is in place.

2.5 Safety during plant operation
I. The additional document/procedure, which can strengthen the
operational safety, includes:
(a) Competent and healthy person(s) should only be placed for
field work. Pre-employment medical check and periodic
medical checl<S aretobe carried out as company's policy and/
or statutory requirement and records should be maintained.
(b) Starring for induction and familiarisation, training and re-
training should be part of culture to be maintained by the
company to keep their employees updated.
(c) Provision of log book for shift in-cbarges, instruction
register, work permit register, incident register, PPE register,
maintenance notification register, training register, process
mock drill register, etc should be adequately made.
(d) Procedure for critical activities, such as fumace lighting
procedure, caustic/water draining procedure from LPG vessels,
sampling procedure, etc. should be displayed at site. Safety
signs, hazard Ievel and Material Safety Data Sheet (MSDS) for
chemicals, irnportant dos and don'ts should also be displayed
at site.
(e) Interlock by-pass procedure and authority with alternate
arrangement during by-pass should be in place. Any interlock
by-pass has to be with approval of competent authority and to
be recorded in instruction book for knowledge ofthe operation
people as weil displayed on boards beside of DCS panel.
(f) Procedure to record 'excursion ofSafe Operating Limit (SOL)'
and their investigation and monitoring. The procedure is
commonly known as Process Safety Performance Indicators
(PSPI).
(g) Procedure ofTask Observations should be in place, and record
of the same should be maintained. For the purpose, total task
should be identified and critical task should be segregated. The
frequency for observing each type of task should be decided.
(Case study on over-flowing of kerosene from the bullet in a
refinery is discussed in CHAPTER III.)
Operalional safety 19
2.6 Training to personnel
The Operating personnel should be thoroughly trained on SOPs, emergency
procedures and systems, action in case of utilities/equipment failure, safe
start-up and shut-down procedure, handing over and taking over procedure,
preparation of equipment'facilities for inspection and maintenance, etc.
Safety training should include SOPs, work permit system, Lock-Out
and Tag-Out (LOTO) procedure, incident reporting procedure, management
of change procedure, PPE requirements, emergency handling procedure,
including hands-on exercise on fire fighting and PPE, safe maintenance
procedure, etc.
Suflicient manpower should be exposed to first aid training to ensure that
first aid trained person is available duriug operation of the plant. The !ist of
authorised first aiders should be displayed near the first aid box in uuits/areas.
Knowing the procedure is not enough, unless it is implemented and followed
in true spirit. Hence, the system should be in place to check compliaoce at site.
2.7 lnspection and Maintenance

Inspection, testing and maintenance of equipment and facilities shall be carried
out as per the approved frequency. Preventive and predictive maintenaoce of
equipment and facilities need to be carried out on time without fail.
Many companies practise Risk-Based Inspection (RBI) and Reliability-
Centred Maintenance (RCM) for inspection and maintenance for equipment'
facilities. If so, the same should be practised religiously.
Some of the equipment and facilities do need statutory tests, which may
include Iifting tools and tackles, pressure vessels, boilers, etc. The statutory
requirement must be complied. Guidelines available in Standards for frequency
of uuit turnaround and storage tanks, etc. shall be followed.
Pressure vessels also need periodic inspection and testing because of
normal wear and potential corrosion either at welds or in the base material.
The combination ofpressure and volume deterruines the hazard: high-volume,
low-pressure systems can have the same potential energy for release as low-
volume, high-pressure systems.
When potentially corrosive chemieals are used (acids, caustics), or the
plant atmosphere is corrosive (maybe near the ocean, or from chemical
releases within the plant), what measures are taken to ensure the system
integrity? Examples include periodic pressure testing, X -ray, etc.

Whenever a safety interlock of an equipment/facility is required to be
by-passed due to one or other reason, this should be entered in interlock by-
pass register and apprcval should be tak:en from competent authority based on
criticality andlor duration ofby-pass. The alternative safety measures should
be categorically spelled out during the period ofby-pass. It is asound practice
to display the sarne near the operating panel and entered in the instruction
book. Once the interlock is attended and tak:en in line, this should be entered
in the by-pass register.
2.8 Permit to Work (PTW) system

Procedure and compliance of the Work Permit System is the heart of safety in
any prccess industry during inspection, maintenance, testing and construction
activities. Poliey of 'No Perrnit, No Work' should be in place.
This is a written document to carry out particular job safely, avoiding any
commuuication gap.
Work permit in prccess industry is also a statutory requirement. Permits
are issued in the prescribed formal, depending on the type ofwork. Format has
a checklist, which is to be addressed by permit issuer. There is also provision
for the entry of gas test readings, PPE in the permit format.
Permit shall be issued by owner of area; like in process uuit, it will be by
operation offleer and will be received by offleer of the executing department
such as concemed maintenance personnel for maintenance jobs. All permit
signatories must be thoroughly trained and approved by authorised person for
the purpose.
Forjobs such as hotwork, entry into con:fined space may require mandatory
testing of gases. All such detectors should be timely calibrated and maintained
in healthy condition. Persons, using these testers, should be thoroughly trained
in use, advantage and limitations of equipment and interpretation of gas tester
reading.
The type ofwork permit formals may inelude:
• Hot work permit/vehicle entry permit
• Confined space entry permit (case study in CHAPTER III on this
point)
• Cold work permit
• Excavation permit
• Road cutting/blockade permit
• Electrical permit (energisation and de-energisation), including LOTO
system
• Work at height permit
• Radiography permit, etc.
Job Safety Analysis (JSA) is a structured technique, used to identity
risks at critical maintenance, inspection, testing and construction jobs, and
take suitable measures to reduce the Ievel of risk. Many companies practise it
for all maintenance and construction-related jobs.
Durlug perfarnring JSA for a task, the task is broken into logical steps. At
each step, hazards and risks are identified with control measures. After control
measures, again risk Ievel is assessed to ensure that risk has been reduced to
an acceptable Ievel. JSA is carried out by a tearn of operation, maintenance
and safety officers; any other knowledgeable officer may be included as per
requinement.
The JSA is used to supplement the safety steps of the PTW system. The
findings of JSA are enclosed in the format to permit implementation at site.
2.9 Personal Protective Equipment (PPE)

PPE is considered as the last layer of protection against the risk. The minimum
basic PPE requirement for anyone entering in plant/area should be defined
fust. Many companies define safety shoes, safety helmet and safety glass as
the minimum PPE reqnirement for entry into battery area. This needs to be
categorically displayed at entrance.
Some of the companies use the concept of 'WEAR 3 & CARRY 3'
for PPE. WEAR 3 means everyone in plant/area will always use three PPE
(safety helmet, safety shoe and safety glass), and CARRY 3 means everyone
will always carry three PPE (safety gloves, respirator and ear protector) with
them.
For persons working regularly, these PPEs are to be issued to them
individually.
The premises should maintain respinatory-type as well as non-respiratory-
type PPEs as per normal as weil as emergency requinement.
Other PPEs are job-specific. The assessment of PPEs for various jobs
should be made forthe area, and the sarne should be available in unit/complex.
The Iist ofPPEs requined for immediate job or for emergency handling should

be readily available in process unit/areas. Sucb equipment should be checked/
tested as per schedule by HSE/operation personnel and the record should
be maintained. List of equipment may include Self-Contained Breathing
Apparatus (SCBA) set, escape set, PVC/neoprene suits, water gel blanke!, fire
proximity suit, ear protector, face sbield, various types of respirators, furnace
glasses, chemical suits, etc., depending on the type ofhazards.
All PPEs shall be BSIEN-marked and sball be periodically inspected
and maintained. The equipment shall be markedas 'out of service' on expiry
or when it is dsmaged and sball be removed from the workplace with an
immediate replacement. The standard guidelines and OEM recommendations
shall be followed in discarding any PPE.
2.1 0 Management of Change (MOC)

All process modifications and changes in SOP sbould be subjected to
Management of Change procedure. All such proposals shall be reviewed as
per procedure by various departments, at various Ievels to assess the safety
and operational requirements (HAZOP study in case ofprocess modification),
and on approval, cbanges shall be incorporated at site as weil as in documents/
drawings. Training shall also be imparted to operating personnel on changes
before implementing them.
The improper MOC during retrofitting has led to many accidents
worldwide(please refer to case study no.27 in chapter3.)
The primary agency of the MOC system lies normally with the technical
services departments.
2.11 Workers' participation in safety

The system sball be in place to involve all Ievels of employees in safety
management system. Safety is a continuous journey and not a destination.
The safety system can only be effective when all Ievels of employees,
including contractor employees, are involved in system development and
their implementation. The various forums used for the purpese include:
• Safety committee mectings
• Safety training and awareness programmes
Safety competitions and appreciation
• Job Safety Analysis (JSA)
• Task observations
• HSE motivation and awareness campaigns
• Reporting of incident and sub-standard acts/practices/conditions
• Multidisciplinary safety audit (internal as weil as external) and
compliance ofrecommendations,
• Regular and statutory healtb check-ups.
2.12 Contractor safety

In today's scenario, many jobs and responsibilities are assigned to contractors.
The contractor employees should be exposed to tbe same Ievel of safety as
company employees.
The contract document should specify tbeir roles and responsibilities,
skill and knowledge requirements and responsibilities witb respect to safety
and health. Ouly competent contract employees should be given charge at
work site. Necessary training on safety, health and environmentshall be given
at tbe induction stage and later refreshers to keep them updated. Health check-
up of all workers coming inside may be done, and fitness certificates are to be
obtained. This may be done on an annual basis.
The contractor employees should be involved in all safety-related
activities, to ensure their active participation in company's safety management
system.
Safety appreciation and instruction shall go hand in hand in tbe work site.
All positive behaviours shall be appreciated andrecordedas part of company's
prograrnme to reinforce safe behaviour. All shortcomings observed during task
observations and plant visit shall also be addressed to change the behaviour of
theperson.
Persons shall be encouraged to report Substandard act/practices and
conditions and shall be suitably rewarded for reporting. Forthis purpose, a
'Drop Box' shall be provided at work sites. All such reports shall be quickly
addressed. High-potential Observations (which may Iead to severe injury/
fire/explosion, etc.) shall be investigated, and recommendations shall be
implemented. All findings shall be shared witb employees during safety
committee meetings and otber occasions.
Traflic safety will also be addressed to encourage safe driving habits.
Habits of over-speeding, non-wearing of seat belts and carrying passengers
on vehicles not registered as passenger's vehicle shall be discouraged.
The improper implementation of contractor safety have in the past led to
fatal accidents of many contractor employees. Refer case study for accident

during working on hydro-jetting and LPG unloading ( case studies no.29 and
13 in chapter 3).
2.13 Good housekeeping

'A place for everything and everytbing in its place' is commonly known
as good housekeeping. Maintaining good housekeeping not only Ieads to
reduction of incident of fire and accident, it also keeps the morale of workers
high. Examples of good housekeeping include:
• Floors and work platforms that are free from slip, trip, trap and fall
hazards.
• Monkey ladder with provision of cage and barriers at ex.its; staircase
with hand rail and toe board.
• Garhagel dustbins for various types of materials and an organised
system of garbage collection and disposal.
• Lube oil and other droms at their specified location. Measures in
place to collect spillages and wastage and their disposal.
• Practice to remove surplus materials/scraps/ debris materials from
work site on completion of work and the same properly implemented.
• Foundation of equipment (pump/compressors, etc.) kept free from
oiV deposits and scraps.
• Adequate number of toilets/washrooms/wash basins/check and
change rooms are available and maintained in hygieuic condition for
an.
• PPEs are maintained properly and kept at specified locations.
• All pipelines are painted as per their colour code. Direction of flow
are marked on pipelines.
• All safety signs and procedure for critical activities are displayed.
• All emergency communication facilities and equipment are readily
accessible and weil maintained.
2.14 Mock drills

In addition to process mock drills, the plant should also carry out emergency
drills at specific intervals. The drill should include evacuation drill and
casualty handling. Depending on the Ievel of emergency, the mutual aid
partners should also be eogaged time to time in drill. Any gap observed should
be noted and corrected timely
Operalional safely 25
2.15 Safety inspections and audits
Periodic safety inspection/audits shall be carried out by multidisciplinary team;
normally, it is conducted annually in line with various statutory requirements.
The recommendations of the audits should be implemented in a time-hound
manner.
2.16 Safety during shut-down

Plant can go to shut-down in a planned manner for scheduled maintenance/
idling or due to some emergency. Normally in shut-down, many exterual
agencies are involved and many workers of various skill Ievels are
deployed. It is a difficult task to hring the same safety Ievel to a functioning
work site.
In a planned shut-down, since it is a planned activity with known jobs,
the safety activity during the shut-down should also be planned in a manner
that is incident-free. The safety management system should be incorporated in
the contractor document, and the contractor should be held clea.rly on safety
commitrnent. Ouly a contractor with a good safety record should be allowed to
pa.rticipate in the contract. For criticaljobs, specialised agencies may be lined
up. The Iist of jobs may include scaffold erection and dismantling, equipment
erection, catalyst replacement, material handling (crane, fork Iifts, excavators,
JCBs, etc.), hydro-jetting/sort blasting, etc. The main contractor shall have his
own safety officers in the set-up to ensure safety. At site, the system rnay focus
on:
• Mandatory safety training for allpersans coming for shut-down,
• Tool Box Talk (TBT) before the start ofwork in each shift by officer
from executing depa.rtment. In some cases, the contractor may also be
allowed for TBT.
• Specialised training for critical activities, such as hot work, entry
into a confined space, hydro-jetting/shot blasting/radiography, work
at height, etc., shall be a.rranged by the safety depa.rtment. Also, on
system of PTW, JSA training shall be a.rranged.
• Entry of duly tested Iifting machines, Iifting tools and tackles shall
ouly be allowed at complex, and the record shall be closely monitored.
These equipments shall be subjected to physical check for safety
before entry in the premises by the mechanical depa.rtment.

• To ensure the use of only standard PPEs, the contractors shall submit
a sample each ofPPEs used to company's safety officers for approval.
The approved type shall only be used at site by the contractor.
• All equipment erection sball be carried out as per the approved
erection plan. Compliance of PTW and JSA sball be the backhone of
safety at the work site.
• Safety monitaring shall be intensified at sites to ensure safety
compliance.
• All other equipment used at site, such as band tools, welding machine,
cutting and drilling machine, sball be checked and certify for their
fitoess before being used. Such certificate may be valid for one month.
• Duly certified scaffolds with GREEN TAG only sball be used for the
work.
• The safety department of complex shall coordinate closely with safety
officers of contractors to improve safety compliance at work sites.
In case of emergency shut-downs, the planning may not be possible in
advaoce. The existing safety systemshall be followed for carrying out the job
safely.
2.17 Plant start-up after shut-downs

On completion of shut-down after boxing up of all equipment and removal
of surplus materials/scraps/debris, closing all the work permits, the 'Pre-
Start-up Safety Review (PSSR)' is to be carried out by all departments in
a prescribed format. Departments need to certify that all planned jobs have
been carried out and the equipment is checked and found ready for start-up.
For proper line-up of pipeline and equipment, refer drawing/procedure to
ascertain, as any unnoticed blind in the system can cause a major accident,
or vice versa.
Safety department will also carry out safety checks as per checklist, which
will necessarily preclude all fire proteetion facilities and safety system be in
place, that all permits are closed, that the unit is free from all surplus materials,
scraps and debris and all temporary facilities for shut-down. These include the
removal of all mechanical and electrical equipment, contractors shed, their
manpower from unit battery arealhazardous zone. All observations by various
departments need to be addressed by plant manager, before allowing the plant
to go for start-up.
This procedure may not be followed, when the unit is being started up
after idling but where no maintenance job has been carried out during shut-
down. Not implementing the PSSR bad led to disaster in the BP refinery,
Texas, during start-up of ISOM unit in March 2005. (Refer case study on
disaster.)
There are many cases of tray disladging in distillation columns due to
water ingress in feed, poisoning of catalyst due to sulphur slips, fires due
to flange leaks or thermal shocks and coke formation in heater tubes due to
overheatiog, even leading to heater fire.
Start-up ofa process unit aller majorturn -around, is a very critical activity
for smooth operation and safety of plant. All the persans attached to the plant
have to be very alert in following the procedure for line-up, replacing of air
from system, raising the system temperature slowly, keeping constant watch
on any leak, skin temperature of heater tubes, abnormal rising of pressure in
any vessel, establisbment of flows as expected. Observing and contiouous
logging all these parameters are very important and the in-charge needs to
keep an eye on these observations. Any abnormalities noticed at this stage
need to be rechecked and confirmed, and corrective measures must be taken
immediately.

Chapter3
Case studies
There are many case studies available, but we have

selected only a few to demonstrate the types of
accidents in industries. We have analysed their root
causes, and the manner in which they occur? The
questions we have asked ourselves are: why and how
do these happen? And what are the consequences:
what are the damages and losses? We hope the
readers will get a fair idea from these case studies
and on their own, research more and more such case
studies easily available on industry websites and
circulated by safety departments in their bulletins in
various Organisations.
Chapter3
Case studies
Case studies
In the following pages, I would like to narrate some incidents and my learnings
from them. These incidents are from my own collection, incidents in public
domain, and the rcviews arc wbat I made during my forty years' worldng
experience. I have given my analyses and rccommendations, but these should
be treated ouly as broad guidelines. They may bave to be revised on case-to-
case based on the actoal situation and type of industry.
3.1 Pump house fire

I bad just completed my moming round of the unit and reached office when
suddenly, I heard the fire siren. The phone rang urgently to inform me about
a fire in the atrnosphere uni! (CDU). On reaching the site, I found that the
residue pump was on fire and the fire-fighting teamwas trying to extioguish it.
Reason: Atrnospheric residue pump is pumping bot residue from column
bottom to run down, as the product (around 300 oq is at more than its auto-
iguition temperatore. As soon as there was a leak from the flange, it caught
fire.
Learnlng: The pump was under commission after maintenance and the
flange starlad leaking. It seemed that the gasket used io the flange jointwas
not sultable for such bot service. Hence, after the temperatore was increased,
the gasket failed, leadiog to the fire.
We need to be very careful in selectiog the right/good-quality gasket.
A small detail like this can Iead to huge production loss, as the unit has to
shutdown for a whole day.
3.2 Fire at crude oil heater due to leakage in outlet

flange
A leak from flange joint in transfer lioe from the Heater to the column was
noticed. The crude oil io the coils was replaced by diese!, he transfer line was

opened and the heater was left for cooling. Suddenly, there was fire at the
outlet flange as the diesei inside got heated up (even though firing was cut off,
the box was hot) and reached its auto-ignition temperature. The fire increased
as the operator opened the steam into the coil (a normal procedure in case of
fiunace fue due to leak in coil, hydrocarbons are pushed to the column by
steam).
Heater
Economiser
Radiation
section
Steam
Fire spot
Outlet
Crude oil
inlet
Reason: By exposing the coil to steam, the diesei in the coils got pushed
out to the atmosphere and this aggravated the situation. The operator should
have known !hat in this particular case, he was only poshing the hol diesei out
and hence doing the wrong operation.
Learning: One should take a moment to analyse the situation fully and
only then take action. The operator should have taken into consideration the
fact that if there is a fire in the heater due to tube leak, the oil is pushed
out by steam. Blindly following nurmal procedure, without factoring in
deveiopments can, and often will, aggravate the probiem.
3.3 Avoid shortcut

A technician working with a construction contractor started walking from
the fabrication area, having decided to take his lunch in the shade along the
Gase sludies 31
boundary wall of the refinery. When he reached point A, he thought to take a
shortcut and cross the drain by walk:ing on the water pipe line instead of going
over the bridge. While crossing in this manner, he lost his balance midway
and fell. His head struck the sidewall ofthe drain. He was taken to the hospital
but was declared brought dead.
Learning: Shortcuts are dangerous and hence should be avoided.
3.4 Never allow anyone under the influence of

alcohol inside the premises
I have come across two such cases where the operator under the influence of
alcohol came on duty and met with an accident.
Incident A: Operator X was a habitual drinker. One night he came on
duty. He was working in the refinery's oil movement and storage area. The
shift in-charge sent him to start the pump in order to Ioad diesei into tank
wagons. While walk:ing to the pump house, in his stupor he did not notice
the danger board which had been placed in front of an open manhole, kept
ready for cleaning, and fell into it. Since that area was deserted, no one could
hear him calling for help and he lost consciousness. After a while, the shift
in-charge came searching for him and found him lying in the manhole. Fire-

fighting crew and ambulance was called. He was taken to the hospital but
due to inbaling too much hydrocarbon vapours in the manhole, he could not
survive.
Incident B: A similar incident took place in another petrochemical plant,
when an operator in drunk condition climbed a taok wagon for loading the
product but lost bis balance and fell down on the ground. He succumbed to
head injury in the hospital.
Product loading gantry
Accident spot
Man had free fall to ground
Reason: Under the influence of a!cohol, a person's reflexes are not good
and the body balance is not under bis control. Hence, malring mistakes under
such circumstances is very normal.
Learning: A person under influence of alcohol can put his life and the
lives ofhis colleagues and the plant area io danger. Such persans should not be
allowed ioside the factory/industry premises. In many locations, it is normal
practice to carry out the breath alcohol test for everyone at the entrance. When
I was CEO in Mombasa Refinery in Kenya, even I had to go through this test
while entering the refinery.
Also, there should have been a proper barricading around the manhole to
avoid any such incident of person falling inside.
3.5 Kerosene over flow due to no supervision

Incident: In one industry, one sulphur dioxide bullet came back aller
maintenance. After a hydro-test, the water was drained out. In order to make
the bullet completely moisture free, kerosene was being filled in it. A single
Gase sludies 33
operator was supervising the operation. He remernbered some urgent job in
the bank outside the premises and thought he would be able to be back in time
and left the site unattended. After completing the bank job, he wen! to the
canteen for lunch. In the meantime, the bullet was full and kerosene started
overflowing. lt found its way into an open drain. F ortonately, the fire and
safety group came for a routine round and noticed the hydrocarbon smell
along the open drain. Immediately they cordoned off the area, brought the
foam tender and spread foam over the top layer of the water level/kerosene to
avoid Iire. With the help of sand bags, the flow of the drain going out of the
complex was stemmed. After great effort, the kerosene was removed from the
drain and a major Iire averted.
Reason: Negligence on part ofthe operator could have resulted in a major
emergency. Ifthere was some urgency for him to leave the site, he should have
closed the kerosene inlet valve to the bullet to avoid overflow. lt was a case of
gross negligence.
Learnings:
• In the work permit/SOP, there should be a condition for a person to be
continuously present at the site for stringent Supervision ofthe job.
• The storm water drain connection to open drain should be closed
while doing such operation to avoid the flow of oillchemicals into an
opendrain.
3.6 Cleaner sleeping under a truck

Each industry has truck loading or unloading facility in the premises. Safety
is a big challenge while regulating the movement of so many trucks in a day.
Training of drivers and cleaners for safe operation is one of the essential parts
to maintain safety; still, accidents happen due to some negligence or the other.
It is a fact that most accidents have occurred while trucks are reversed.
Inddent: One afterooon, when the truck loading operation was stopped
for shift changeover, one cleaner decided to take rest for a while under the
parked truck. In no time, he fell asleep. When he operations resumed in the
second shift, the driver started the truck and reverseditto align it to the loading
bay. He was not aware of the person sleeping undemeath the truck; as a result,
the cleaner was crushed under the wheels and died instantaneously.
Learnings:
• There should be a proper rest room for drivers and cleanerslhelper.

• Driver should always Iake the help of cleaner/helper before reversing
the truck.
• Cleaner/helper should guide the driver from rear side while reversing
the truck.
3.7 Risks in crane operation

In day-to-day operations in all industries, sometimes accidents take place
which are difficult to envisage, despite precautions already Iaken.
Incident: During one of the oil unit's shutdown, one chemical dosing
pump was tobe rcmoved as pre-start-up activities were in progress. This was
a pulley-driven pump. The boom of the erane lifted the pump to a great height,
and before that, the area around the crane bad been fortonately cordoned off
for safety reasons. Suddeuly, due to the heavy pul! of rope on the cast iron
pulley, the pulley broke into several pieces, and these sharp-edge pieces fell
down.. One such piece fell on a worker who happened to be on the reactor
platform. This piece managed to pierce through his helroet but could not do
much harm. THE HARD HAT SAFETY HELMET HAD SAVED illS LIFE.
pump
Vessels
Pump lifled for loading in trolly
Gase sludies 35
Learnings: The incident indicates that mere cordoning off the area
at ground Ievel is not adequate. We need to ensure that no one is present
anywhere, at any height, t within the reach of the crane boom.
• Some warning system should be used before starting such an
operation.
• While tying the rope around aoy equipment to be lifted, ensure that
this is not putting pressure on some breakable part.
• The worker's life could be saved because he was wearing a safety
helmet; hence, it is imperative to wear hard hat helmets in the plant
area.
• The sling of the crane should be checked for its condition and Ioad
test.
• There are cases where the boom of the crane itself falls so the
worthiness of the crane should be checked before its use.
The crane should always be parked with boom in lowered condition
and brakes properly applied.
3.8 Static electricity causing fire due to and

improper earthing
One evening, there was an explosion inside a refinery. The fire siren went off
ed and fire tenders rushed to the spot. Fire had started in a tank lorry loading
motor spirit. The driver and the cleaner had died on the spot.
Incident: The truck bad been parked in the loading Gantry or tanker
loading platform to the Ioad motor spirit. As soon as the cleaner opened the
valve to Ioad the truck, the spirit inside the truck caught fire and exploded.
Learning: investigation revealed that the cleaner had forgotten to connect
the earthing clamps to the body of the truck. Hence, as soon as the liquid
motor spirit started flowing, the generated static electricity could not flow
down to earth in the absence of an earthing connection.
Static electricity is an invisible source of explosion and fire, and hence,
everyone has to be extra careful in ensuring that any vessel and equipment
receiving hydrocarbons is properly earthed.
It is the job of the Supervisor at the loading Gantry wbo must ensure
that proper earthing connections have been made before giving clearance for
loading.

3.9 Presence of mind can avert a crisis
Incldent: In a unit handling liquid sulphur dioxide, a leak developed at a point
upstream of its pump discharge valve, and this toxic gas started spreading
rapidly. If not controlled in time, the whole area around the unit and its
neighbourhood would have been affected. Operators were afraid of entering
the gas cloud but one brave operator took up the challenge. He put on the PPE
equipped with air breathing apparatus, rushed to the pump, closed its suction
and discharge valve and put it off. This combined presence of mind, courage
and knowledge prevented a dangerous situation from developing.
Leaming: We should know how to use various PPEs available in the plant.
This leaming can save both the plant and human lives.
Training in proper use ofPPEs is required regularly, and field staff should
be confident of using these in cases of emergency.
3.10 Safety culture is driven from the top

As I mentioned in my introduction, safety is everyone's responsibility but
initiative and push are required from top Ievel. People generally try to avoid
wearing basic safety gear like safety shoes and helmets. When this is allowed,
chances of accidents are higher and people working in such orgauisations are
not safe. However, once the management decides to impose discipline, the
situation can be improved in no time at all.
I know one industry where when the new CEO joined, he saw employees
inside the battery area coming in chappals and moving around the plant without
their hard hats. He wanted to issue a circular proclaiming that strict action
would be taken against those who did not wear safety shoes and helmets. The
production chiefwas scared that the Uuion might not like this circular and
agitate against it.
The CEO called a meeting of Union and Officer 's Association
representatives and discussed the matter. He explained that safety shoes and
helmets are given to employees free of cost for the sake of their safety and
that of the plant. Everyone had to use them while on duty and he needed their
co-operation in creating safe working conditions. All agreed to the CEO's
proposal. A notice was issued with a waming that after a month, if anyone
was caught without safety shoes and helmet in the field, he would be fined.
Gradually, the percentage of compliance started increasing, and within two
months, 98% compliance was achieved.
Gase sludies 37
At the construction site, a nurnber of workers were observed to be
working without safety shoes. The CEO ordered that safety shoes ftom stock
lyiog in stores be issued to the contractuallabour free of cost. Hard hats were
also issued free on a one-time basis. Any replacement was to be done on the
payment.
The CEO started talring moming rounds to shop-floor Ievel to address
the employees about safety, productivity and punctuality. The efforts brought
a significant improvement in the attitude of the employees towards these
aspects. At the farewell of their CEO, one and all appreciated his dedication
to the safety and well-being ofthe employees and their families.
3.11 All petroleum product tanks on fire

This is the case of a marketing terminal storing products like motor spirit,
diese!, ATF/kerosene. This was a well-designed terminal with a Iot of safcty
measures and interlocks in place. The incident that happened was very
unexpected and difficult to envisage even at the design stage and in the
HAZOP study.
Incident: At around 5 pm one day, two operators were given the job of
lining up one full taok of motor spirit to be purnped to the customer's tank,
which was connected by a pipeline. However, one of them decided to first
go to the canteen, and other operator entered the taok dyke alone for what is
technically koown as the de-blinding operation. The horror that followed as
this: as soon as this operator loosened the nut bolts of the hammer blind to
reverse the position, and line up the taok outlet to pump inlet, the motor spirit
gnshed out like a fountain and drenched the operator. The operator tried to
call the control room to shut the body valve of the taok (electrically operated
valve), but the engineer on duty had gone to witness the taok dip along with the
customer's representative. Within no time, the operator became unconscious
due to suffocation by motor spirit vapours.
The flow of motor spirit from the hammer blind continued uncontrolled
creatiog a vapour cloud. The second operator came back ftom the canteen and
tried to remove the unconscious operator from the site. But by this time, the
whole taok farm was flooded with so much motor spirit liquid and vapours
that he also suffocated and fell down unconscious in the dyke area. As time
passed, the pool of liquid motor spirit kept on building up in the dyke area
and an unconfined vapour cloud started spreading in the terminal. It being
evening and most people off duty, no one was around to notice this alarming

condition. The Production Engineer, meanwhile returned after the tank dip,
and noticing the strong hydrocarbon smell, arrived at the site. He also started
feeling nauseous and rushed to the hospital. By now, the message bad reached
senior officers but when they reached the terminal gate, they found it was
impossible to enter, as the whole area was filled with hydrocarbon vapours.
It was only a matter of time before the vapours were ignited s aod caused
ao explosion. resulted in huge explosion aod fire. The whole terminal was so
damaged !hat even the fire-fighting facilities became redundant. Soon,, all
petroleum product taoks were on fire. The only option was to keep the product
tanks cool by spraying water on their external surfaces aod Iet the product
burn inside, in a controlled condition to avoid tanks exploding and spreading
the fire even further.
There were a number of casualties in this accident and enormous loss of
products. The terminal was totally destroyed.
Cause and contributing faetors:

• The root cause of the iocident was negligence by operator who did
not ensure complete closing of tank body valve before opeoiog the
hammer blind. Since the tank was full, the high liquid head in tank led
to profuse flow of MS from the tank ioto the dyke area.
• The operating personnel who tried to control the leak were not
wearing adequate PPEs.
• All operating personnel were overcome by MS vapour. There was no
one to control the situation.
• The MS leak continued and the vapour cloud spread further. It could
have got ignited by ordinary light fittings io the administrative
building or by even a vehicle. This led to massive unconfined vapour
cloud explosion.
• Entire termiuals" was on fire, and there were multiple casualties.
Decision was taken to allow the product in the tank to burn till the
entire product s burnt out. The pipe connections of the fire-fighting
facility were badly mutilated due to the explosion.
Learnings!Recommendations:
• Hammer bliod valve io the tank outlet should be replaced by Double
Ball Bleed Valve (DBBV). The valve should be located outside the
dyke. In this arraogement, no reversal ofblind is required for lioe up.
Gase sludies 39
• The first body valve of tbe tank should be tbe Ren10te-Operated Shut-
Off Valve (ROSOV). It should be fail-safe and fire-safe type, and
operated from control room, The operating switch should be located
outside tbe tank dyke.
• A Radar gauge should be provided in each Class-A petroleum tank
in addition to tbe existing positive displacement-level indicator/
control. High-level alarm from radar gauge and a high-level alarm
from separate tap should be installed.
• Hydrocarbon detector near potential leak sources for Class-A and
Class-B petroleum products such as tank dyke, tank manifold, and
pump manifold should be provided.
• Area should be covered by CCTV ca.mera.
• Sitc-specific Standard Operating Procerlure (SOP) should be prepared
and implemented.
• Availability of PPEs (includiug self-contained breatbing apparatus
and fire suit) should be ensured, and training on use should be given.
Each terminal should have emergency kits witb necessary emergency
handling items.
• Shift manning should be maintained as per tbe schedule.
• Extensive fire and safety training to employees, regular contractual
employees and security personnel should be given.
• Rim seal fire protection system should be provided in each Class-A
petroleum tank.
• Tanks should be protected witb high-volume long-range foa.m monitor
(variable type) for fighting tank fires.
• The fire water facilities with adjoining petroleum installations should
be interconnected to improve reliability.
• Medium expansion foa.m generator should be provided on tank dyke
to suppress vapour in case of any spillage.
• Interna] safety audit should be strengthened for meaningful findings.
3.12 Escape of toxic vapours from chemical plant

(This case in India is well known, though the na.me of company and the place
ofincident are undisclosed here.) It was one oftbe rnajor disasters ofits kind
where thousands of people died or beca.me disabled. The incident showed that
how a minor mistake by an operator can play havoc.

This chemical factory was running for a number of years and producing
chemieals to be used in agricultural sector. The intermediate product known as
Methyl-Iso-Cyanite (MIC) is highly lethal in natore. It was stored in a bullet
of araund 80 KL L capacity. There was regular monitaring of temperature and
pressure.
To process
Nitrogen vent header
To relieve valve vent

Header (RWH)
'---'---J.it;:::rj--Rupture disc
To scrubber PI
MIC storage bullet
Simplefied sketch of MIC storage tank
The pressure relief system consisted of a rupture disc before Pressure

Safety Valve (PSV) to ensure that PSV was not exposed to MIC vapours all
the time. Vapours coming out ofthe PSV discharge were routed to ReliefValve
Veot Header (RVVH). The veoted material was routed to vent gas scrubber for
neutralisationldetoxification. After neutralisation, the gas from scrubber was
routed either to a stack for releasing to atmosphere or to a fiare header to burn
there.
The MIC tank, which was idle, bad around 40 tonnes ofMIC. Everything
seemed to be normal during the day. During mid-night, the MIC vapour
escaped the plant un-neutralised. This chemical is very toxic and can will
affect everyone in the surrounding area. As a result, many any people in near
by areas died in their sleep itself, and many became disabled/seriously ill.
It seems that some operators by mistake connected a water hose to the
idle bullet. Water reacted with MIC, and due to exotherrnie reaction, MIC
vapourised. This resulted in pressure built-up in bullet, leading to the ruptore
of disc and opening of PSV. The vapours travelled to the scrubber, but since
Gase sludies 41
the rate ofvapour generationwas very much more than what the system could
handle, MIC (untreated) escaped into the atmosphere. Unfortunately, the fiare
was also under maintenance on that day.
Cause of incident:
From the investigations, only apparent cause of incident appeared to be the
introduction of water in MIC tank by some operator without knowing the
gravity of the darnage it was to cause. However, had the fiare been operating
that day, the MIC would have burnt safely.
Learnings:
• Storing of minimurn quantity of toxic chemieals inside the plant.
• Training people in the plant about the dos and don'ts.
• Carry out process 'safety management study' and HAZOP.
• Disaster management plan should be known to key operating
personnel and conduct mock drill for on-site and off-site disasters.
• The production units dealing with such Iethai chemieals should be
located away from inhabited areas.
• in off-site disaster management plan, a support system from local
administration, police and health authorities, should be included.
diagram.
3.13 Fire in lPG truck loading/unloading facility

Incident: There was a heavy leak of LPG from a loaded LPG truck in a LPG
bottling plant, followed by vapour cloud formation. The unconfined vapour
exploded after coming into contact with a source of ignition, leading to a
major fire in a LPG Tank Truck Decantation Facility.
Reason: On investigation, it was revealed that one truck was unloading
LPG in a LPG bottling plant with proper fiange connection at unloading point.
Due to a push from another truck which happened to be reversing, there was
tension on the fiange connection. This caused a profuse leak of LPG, and
the whole area was engulfed by LPG vapours in no time. The vapours were
ignited from the DG set in the premises and resulted in a major fire.
Learnings:
• There should be enough space between the adjacent loading/unloading
points so that any operation going on at the adjacent point does not
cause any push-pull effect on the operatiog point.

• The DG set should be located at a safe distance, besides ensuring it
has a spark-free operation.
• Automatie fire-fighting system with deluge valve sprinklers should
be installed. These should be equipped with a gas-sensing signal. This
should operate immediately, and spray water on the facility to protect
it from severe damage.
• The operation and movernent of trucks should be regulated at a safe
distance, without disrupting or disturbing other activities.
• Whenever we are handling LPG in open areas like LPG bottling
sheds and LPG storage areas, we must ensure that there are no cable/
pipe trenches in the area as LPG vapours are heavier than air. These
settle in lowlying areas and can be a cause of big fires sparked by
some iguition source. If such trenches do exist, fill them with sand.
• As compared to LPG, natoral gas (CNG/PNG) is much lighter than
air, and in case of any leak from the system, it gets dispersed in the
atmosphere. So, it is safer than LPG.
• We have come across many instances of leaks in LPG road tankers.
Ministry of Petroleum and Natural Gas has given clear instructions
to Oil Marketing Companies to train their TT crews how to handle
minor leaks. Io case any help is required, they should contact the
nearest refinery or LPG bottling plant of any company, to control the
leak and safely transfer the LPG to another tanker.
• Ensure adherence ofSOPs for unloading operations by operators and
drivers.
• Breakaway couplings of TLD arms installed in all LPG plants must
be tested for efficacy in both forward and reverse directions of the
movernent of the bulk tank trucks.
3.14 Fatal accident due to asphyxiation inside a

vessel/confined space
These types of accidents usually happen in a runuing refinery/chemical
industry when during shut-down the vessels go for intemal cleaning. One
such accident took place in one of the refineries where I worked.
Iocident:
The reflux drum of distillation unit bad been given for cleaning. The drum
was steamed and left open for cooling down and entry of air.. The blinds were
Gase sludies 43
inserted on the flanges connected to the column, outlet nozzle, etc. After tool
room talk on the precautions to be taken, contractuallabour was permitted to
enter the vessel by the Production Department, after due work permits were
issued.
The first operator was found unconscious inside the vessel within a few
minutes of bis entry. Anther operator went inside to rescue the first operator
but soon he also collapsed. The third operator smelt e hydrogen sulphide gas
inside the vessel and raised an alarm. The two operators were brought out aod
rushed to hospital but withio a few days both lost their lives. A committee was
set up to probe and analyse the reasons, which were as under:
Reasons:
I. It was a clear case of asphyxiation inside the vessel (non-availability
of sufficient oxygen in the vessel). There was one fuel gas conoection
of one inch diameter coonected to the vessel, which was suspected to
be in unblinded position at the time of accident through which fuel
gas containing hydrogen sulphide gas could have entered the vessel
aod since this gas is toxic in natore, could have caused the operators
to lose consciousness.
2. The other possibility was the entry of nitrogen through a hose
(mistaken for an air hose) kept for maintaining the fresh air supply
inside the vessel as both air hose and nitrogen hose were very similar.
Both were conoected to pipes which were unmarked, thereby giving
rise to confusion about their services.
3. The operators did not use proper breathing apparatus while entering
the vessel.
4. Before entering the vessel, Production Department should have
checked the oxygen percentage inside the vessel, which should
ideally be above 19 percent.. U sing Gas Meter, the absence of Hß,
etc. should also have been ensured for safe entry into vessel aod
supported by fresh air supply through air hose.
Learnings:
• Before issuing a work permit, operation group should identify
• hazards in carrying out the cleaning activity of the vessel from inside.
The operation group should clearly show the blind position in the vessel
drawing, aod ensure !hat the blinds have been inserted at right positions. This
should be re-confirmed before giving the entry permit.

Such jobs should be carried out under supervision. One person should
be deputed to stay outside. The person who enters the vessel first should
have some whistle or a bell to alarm the person standing outside, so that an
immediate rescue operation can be arranged.
There should be clear colour codes to demarcate differences in hoses used
for oxygen and nitrogen and proper display boards to be put up at the tap-off
points for easier identification of the service.
• It is very critical to ensure that the vessel is free of hydrocarbon and
any other gas. The oxygen content in the vessel should be more than
19 percent.
• Suitable respiratory apparatus should be used before entering the
confined space.
• SOP should be kept ready for such operations, and one should ensure
that the procedure is being followed religiously.
3.15 Fire due to electric short circuit

Fires due to short circuit are common in countries with hot weather. In India,
summers are very hot and, in certain regions, the air can also be rather dry.
Continuous use of electrical appliances Ieads to overloading often,and the
electrical wiring gets is heated up. The high ambient temperature adds to this
problem. Insulation weakens, short circuiting takes place, and fire results. If
such fire breakouts are noticed immediately, and prompt action taken, the fire
can be controlled by using CO, extinguishers and by cutting off the supply
from the mains.
Normally, when such short circuiting takes place at night time or on
holidays, it results in big fires in offices, shops, warehouses and substations,
etc. Very frequently, we hear such news on TV and read in the press about
such fires, leading to a number of fatalities and huge darnage to property.
Learnings:
• Only good quality wiring with ISI mark should be used.
• The rating ofthe cableslwire should be selected based on the highest
Ioad expected, and keeping some safety margin.
CO, extinguishers should be placed at easily accessible places, and
people should be trained to use them.
• In case of fire, the electricity connection is to be cut from mains
immediately.
Gase sludies 45
• No water or foam should be used to fight electrical fire.
• Time-to-time checking of the condition of cables is advisable to
prevent such incidents.
• In closed system, there should be some ventilation provided to
facilitate the dissipation of heat on a continuous basis.
• Overloading of the systero is always dangeraus and should be
avoided.
3.16 Accident due to wrong line-up

Correct line-up for commissioning a process uoit is most critical. It can make
all the difference in the prevention of a prospective shut-down/fire/explosion.
During start-up activities, a normalline-up is done. This is basically achieved
by removing the blinds which were inserted for isolation, ofien reversing the
blind position at many locations, dropping or replacing the spool piece into
its original position, etc. I have seen cases where the unit bad to be shut down
again due to one blind not being removed by oversight.
Incident:
The atmosphere unit was in start-up mode. After the displacement of the air
by steanting and fuelling gas back-up in the systero, emde oil was received in
the main column. Through cold circulation, the water-draining exercise was
completed, after which, burners were put on to raise the teroperatore. Slowly,
as the temperatore went up, the product started coming in the side draw-off
vessels, beginning with naphtha, kerosene and diese!. Once enough Ievel was
built up in the diesei vessel, the pump was started to send it to the run-down
tank. Diesel was coming to the pump at more than 200 °C, pump pressure was
increased to its shut-off pressure. One blind on the discharge side had not been
removed. Suddenly, the gasket that follows the discharge valve gave way, and
there was a sudden splashing out ofhot diese!, followed by a fire. Immediately,
the unit was shut down, and the fire brought under control. The system had
to be cooled down again, the gasket was replaced, and the culprit blind was
removed. Ooly then the unit could be restarted safely. This shows how a small
slip in line-up can cause a hazardous sitoation and loss ofproductivity.
Learning: in the above case, there was ouly a small fire, which could be
controlled immediately, but there was a loss oftwo man-days.
I remernher another similar incident where there was explosion and fire
due to some mistake in line- up before start up. In most of the Hydrocarbon

and chemical industries, it is very crucial to make the entire system air free
and waler free before start up. The air left in the system can form an explosive
mixture when the oil is healed and produces light fractions of hydrocarbons.
Similarly, small amount ofwaler, on heating can convert to steam and increase
the system pressure in no time.
This incident happened in one of the refineries when FCC unit was ready
to start. All the start up activities were going normal when all of a sudden
there was explosion in the slurry settler vessel. The explosion was so strong
that parts of this vessel flew away and hit the piping and vessels. The impact
was so strong that it sheared the connecting pipelines and punctured some
vessels. There were fires at no. Of places and the oil and gas coming out from
these openings aggravaled the situation to great exlent. The structures and
vessel supports were badly damaged and it took many days to re-built the unit
and make it operational.
The Enquiry commitlee came to the conclusion that the explosion in
slurry settler took place due to presence of some waler in the vessel bottom
which either could not be completely drained due to chocked bottom drain or
condensale accumulaled de to entry of some sleam through sleam connection,
specially provided for de- chocking of the bottom drains. With heating of the
oil in vessel to araund 300 degree centigrade, water got evaporated suddenly
and built up excessive pressure (many times more than design pressure)
resulting in to rupture of this vessel. Delay in evaporation of water must have
been due heavy and viscous oilleading to slow rale of heating of waler lying
in some comer of vessel bottom and as the temperature increased it evaporaled
ina surge.
The above stody clearly explain the importance of Standard Operating
Procedures, special atlention and care of all during start up and training of
staff to caler to emergency situations.
3.17 Fire due to line vibration

Samelimes we treat the situation ligbtly, not realising the repercussions of
negligence. In one refinery, there were two hot naphtha purnps. The normal
procedure was to operale one at a time. It so happened that operational pump
'A'" was shut down due to some vibration problem. Pump 'B' was then put
into operation, but it also started tripping aller just one day. To keep the unit
running, Pump 'A' was put into service despile the vibration issue. There was
a half-inch diameler pipeline connecting from discharge to suction side of
Gase sludies 47
pump with a needle valve in between. Pump 'A' continued to operate for 24
hours, then due to fatigue, the joint of this half-inch diameter line gave a
way, releasing hot naphtha vapours, which then caught fire, and the whole
pump house was on fire. This resulted in damage to a !arge number of pumps,
motors, electrical and instroment cables. The unit was shut down for a week
for repairs. So, in industry, we should not overlook the indication of any
weakness in the system as it can result in major accident, loss of life and
financiallosses.
3.18 Accident during excavation

Incident: Outside one refinery, excavation was being done in order to lay a
product pipeline. In the work permit, it was clearly stipulated that the earth
removed was not to be dumped at the edge of the dug area and that there
was to be proper barricading by tin sheets and bamboos, so as to prevent the
earth from caving in. Unfortunately, due to Iack of Supervisionandin order to
save time, the labourers did not follow any of these instructions. When the pit
became about two metre deep, all of sudden the wall caved in and the whole
heap of loose earth fell into the pit. Two labourers got buried under this heap
of loose earth, and before help could be arranged for their rescue, both died
due to Iack of oxygen.
Learning: We must ensure that the said contractor adheres strictly to all
the conditions stipulated in the work permit Had the contractor arranged to
remove the loose earth alongside the digging and erected the barricading, this
fatal accident could have been avoided easily. lt is also essential to appoint a
knowledgeable Supervisor on-site to take care of all safety regulations.
3.19 Handling of oil at auto-ignition temperature

Auto-ignition temperature of any substance is the spontaneaus (self-ignition)
temperature at which the substance catches fire without any extemal ignition
source. Generally, heavier petroleum products have lower auto-ignition
temperature. Products with vacuum residue and long residue can self-ignite at
a temperature of araund 200 °C, while gasoline (petrul) ignites at a temperature
of around 250-280 °C. Hence, refiners and other users of petroleuro products
have to be extra cautious while dealing with these products. Any leak in the
system, where product temperature is more than its auto-ignition temperature,
will immediately catch fire.

3.20 Pyrophoric iron on fire
Pyrophoric iron is a self-igniting substance, which ignites the moment it
comes in contact with air. Nonnally, it is formed in oil tanks. The rust, formed
by corrosion of the inner surface of the oil tanks, reacts with sulphur in the
crude oil, in the form of hydrogen sulphide gas, to then form iron sulphide,
which is pyrophoric. This compound when exposed to atmosphere on dryiog
self-ignites and catches fue.
I remember, one day, I got a call from the oil movement and storage area
of a refinery, informing methat the sludge removed from an imported crude oil
tank (containing sulphurous crudes) bad caught fue. This refinery was using
indigenous crude oils since its inception. These were sweet crude oils and
no such incident had taken place thus far. It bad, however, started processiog
imported crudes after the iostallation of a new distillation unit a few years ago.
The crude oil tank contaioiog these imported sulphurous erndes was beiog
cleaned for the :first time. The dryiog sludge began to burn, and caused and
explosion.. The staff had forgotten that this product could cause explosion
duriog the unloading of a crude oil tanker, if exposed to air.
Learnings:
• To protect it from ignition, always keep it wet or surround it with a
nitrogen atmosphere.
• The sludge removed from tank should be kept under a layer of water
and buried at a safe place, or bumed under controlled conditions.
3.21 Oil-soaked insulation on fire

To transfer heavy and viscous products through pipelioes, these are pumped
io heated condition, and to maintaio them in fluid state, iosulation is done
around the pipelioe. In some products, steam tracers are also laid along with
the pipelioe, and over the tracers, iosulation is done to keep the product
heated. When there are a number of pipelioes running together on pipe-racl<,
sometimes due to a minor leak, the iosulation of one pipelioe may get soaked
with the prodnct. Depending on the auto-ignition temperature of the leakiog
prodnct aod temperature ofthe lioe on which it has been falliog, the oil-soaked
iosulation catches fue. The only way to extingnisb this fue is to remove the
effected oil-soaked iosulation completely and put a Iot ofwater on it to cool it
down. Many time, the iosulation may catch fire again as the oil present io the
inner layers seeps out slowly aod catches fue again. So, we have to be very
careful while taclding the iosnlation fue.
Gase sludies 49
3.22 Accidents during turn around of processing
units
Canying out maintenance work in a refinery is often more unsafe than the
project site. Even though the columns, pipelines and connected vessels are
made hydrocarbon free by draining and steaming, some oil or gas remains
trapped in some remote comer of the vessels. Giving any entry permit for
inspection or hot work in vessels is very risky under such circumstances. One
must ensure by meter-check of explosives and gas meter tests that the vessels
are absolutely hydrocarbon free. For the sake of safety, one person should
always be present outside the vessel to provide immediate assistance to the
person inside. I have come across casualties by asphyxiation inside the vessel,
or due to explosions triggered by the presence of some oil/gas pocket inside.
This cautionary measure is especially necessary for products like LPG, gas,
naphtha, motor spirit and kerosene, etc.
In a unit shut-down, many agencies work in a small area and are under
a Jot of pressure to complete the shut-down in a minimum number of days to
mioimise production loss. This increases the risk factor.
In one of the refineries, I applied some innovative methods in consultation
with the maintenance team:
1. I had seen small extemal cranes being used in civil construction sites
to carry both material and manpower to higher levels. We installed
a similar Iift against the main column platform with intermediate
connections at 3-4 Ievels. This saved us a Iot of time in moving the
scrap from higher Ievels and in the Iifting of fresh material to the
desired Ievels. The Iift was also used to transport manpower up and
down so that they were not tired out..
2. Normally, after water washing and steaming, the columns/vessels are
hot and stuffy. We installed cold air blowers in the bottom manhole of
the main column to provide fresh and cool air to manpower working
inside.
3. To prevent manpower leaving the columns, or coming down from
working platforms, arrangernent was made to provide tea, snacks and
waterat the work-spots. These measures saved us a Iot ofproductive
time.
4. The Iift facilitated the safety, inspection and maintenance manpower
to frequently make visits and supervise the job closely.
5. To work on pipelines, instead of erecting scaffoldings at a number
of locations, we developed a moving platform on wheels, which

again saved us time and effort of erecting a number of scaffoldings at
different locations.
6. Proper communication system was providcd to establish an easy
communication channel between people worldng at elevation and
ground Ievel.
I am happy to say hcre that in this total refinery tumaround of about 50
days, there was no lost-time accident.
3.23 Chlorine gas cylinder leak

Chlorine is used in many industries as bleaching agent, solvent and in water
treatment plant, etc. Chlorine was used in the paper mill whcre I worked for
few months. It comes in cylindcrs weighing about 650 kg, which is stored
in a segregated area. It is yellowish in colour, heavier than air and has very
pungent smell and suffocating odour. The prolonged symptoms intolerable
to patient might lead to possibilities of pulmonary embolism, and in case of
acute exposure, it may lead to acute lung injury and in some cases leading to
dcath.
Chlorine was being used in the paper mill to bleach the pulp so as to give
paper its white appearance and to remove 'Iignin' an element of wood fibre
that yellows paper when exposed to sunlight.
One day, a chlorine gas leak emanated from a cylindcr and started
increasing rapidly. There was panic in the mill as gas, being heavier than air,
started spreading in other parts of the paper mill. No one had the courage to go
near the leaking point and plug it.. Management advised people to stay away
and use a handkerchiefto cover their noses and advised the fire-fighting team
to spray lots of water on the cylinder and gas to prevent it from spreading
everywhere. Spreading of foam on the leaked compressed gas finther reduced
the evaporation. The cylinder was then lifted with the help of a crane and put
in the neutralisation pit containing solution of caustic soda. This brought the
situation under control and normal activities could resume after a struggle of
sixhours.
Do's and Don'ts for handling gas leak emergency

• People should stand in upwind direction
• Ventilate the closed space
• Immediately call emergency numbers of the region
• Isolate leak area for at least 100-200 m in all directions by putting
road blocks
Gase sludies 51
• Don 't panic and keep a handkerchief on the mouth; keep breathing
normally
• At least two persans should go to attend/arrest leak. The use of Self-
contained Breathing Apparatus (SCBA) is essential prior to going
towards the leaking point
• If all efforts to control the leak fail and leakage continues, neutralise
the chlorine by passing it into a solution of caustic soda or soda ash or
hydrated lime through a suitable pipeline with a perforated distributor
• Standard proteelive equipment, emergency equipment, standard first
aid and emergency health management procedure should be attempted
The industry must have a chemical disaster management system
to tackle a major leak, which may even affect the neighbourhood
community.
• A well prepared standard kit to attend chlorine cylinder body leak and
koob leak should be kept ready at all times.
3.24 lmproper stacking of pipes

The refinery industry needs large-diameter pipes for transportation of raw
water, cooling water, effiuent and at some places even for the feed and
products. Staclting ofthese pipesinan orderly way is very important from the
safety point of view.
/ Pipestack
~~
'LGround
Ievei
Stoppers to avoid
Rolling down of pipes
In one refinery project area, the 12-inch-diameter steel pipes were

stacked. One crane was lifting pipes from the stack and loading them into
a truck parked nearby. The techoicians were putting the sling on the pipe
and co-ordinating with the driver to Iift it. One contractual Supervisor was

standing near the stack. Suddenly. the stack got disturbed and the dislodged
pipes started rolling down. The supervisor tried to run and save bimself but
still some pipes bit him in bis foot, which was badly hurt. Had be delayed even
a bit, he might have been crushed under tbese pipes.
Learnfngs:
• In stacking of pipes. we must use some stoppers at eacb stage to avoid
any rolling down
• Chaining of pipes after two rows of stacking will also help in
preventing the rolling
• At the bottom of the sta~ we should put some stoppers. in case
rolling starts (the stopper is a solid pipe ofaraund four-inch diameter,
whicb stands two feet in the ground and tbree feet above tbe ground
and located around two met:res away ftom the stack)
• All the persons working in that area should be on the side of stack or
beyond the stoppers
• Wearing of safety shoes is a must in tbis area
Timber protector 100
100 mm x 100 mm 100mmx50mm mm xSOmmx
hardwood block lull cleats secured by length or pipe, und er
length or pipe two 100 mm nails to a pair of chains and
per pipe stringers tensioners
Thls ls the correct procedure for loadlng of plpes on trolly
3.25 Explosion and fire in gas processing plant

Brief description:
Recently, an explosion followed by major fue occurred near Oily Water Sewer
(OWS) in a gas p:rocessing plant at Maharashtra, leading to the death of four
Case studiea 53
persons. Heavy rain in area led to an overflow of OWS pit in the plant and
spread ofhydrocarbon (HC) vapour. Vapour exploded, a major fire followed,
leading to four fatalities and darnage to the plant.
On the day of the incident, heavy rain had fallen. Security personnel
noticed the distinctive smell of hydrocarbon near the OWS pit area. There
was HC vapour in storm water channel, which bad overflowed. A fire-fighting
crew equipped with SCBA sets were engaged alongside operators to identify
the source ofthe HC leak. Suddenly, there was an explosion in the HC vapour
followed by the eruption of a major fire. The unfortunate incident led to four
fatalities. The plant was damaged badly. Fire was extinguished within a few
hours by the fire-fighting team ofplant with mutual-aid partners.
The gas processing plant bad been receiving gas from offshore pipelines.
Pigging operation (a form of :tlow assurance where pipeline pigs are used to
clean pipelines to keep them running smoothly) in this gas line was carried
out a few months back, but no pig was found after opening the barreis at
plant end. About a fortnight days prior to the incident, high condensate/muck
:tlow was observed inside the gas pipeline due to sudden pig movement. This
unexpected event resnlted in a huge amount of condensate/muck routed to
process units. In many units, OWS pits were reported to be choked with muck.
This muck was collected in drums, and filter elements choked with oil-laced
muck were also reported lying in unit area.
The plant bad provision of routing storm water from gas processing units
to OWS pit, if contarninated with oil. All the associated units storm water
drain was lined up to OWS pit at the time of incident. OWS pit Pump-A
was out of order. Pump-B was pul on load but no reduction in pit Ievel was
observed. Trend of OWS pit showed pit overflow.
Detectors were detecting HC and giving alarm intertnittently in one ofthe
gas process units on the day of incident. Probable causes of the presence of
HC in this unit conld be the release ofHC from the muck due to heavy rain or
leakage from pump/process equipment.
At the time of incident, there was condensate in storm water channel due
to overflow of OWS pit. The team of fire-fighting as weH as operation was
trying to identify the source ofleakage.
At around 07.00 hours, there was explosion followed by major fire. The
fire extended outside plant area as weil as to around 1.2 km open channel to
sea. Fire was extinguished within few hours.
Fire darnage was observed in security cabin, parked vehicles at incident
site, around OWS pit area, overhead cable trays, storm water channel of
connected unit, etc.

Cause of explosion!Fire:
Root cause of explosion and fire was primarily due to the loss of primary
contaimnent caused by:
• Failure of both the OWS pit pumps during monsoon period, leading
to overflow of light condensate from pit.
• Presence of HC muck in the unit because of which rain water was
diverted to OWS pit. The fire got further spread due to the presence
ofHC-laced muck in storm water cbannel.
• Suspected leakage from one of the units where HC detectors had
activated intermittently prior to incident.
Conclusion:
OWS pit receives condensate from process units and pumps it out to Effluent
Treatment Plant (ETP). In OWS pit, Pump-A was out of order and no reduction
in Ievel was observed when Pump-B was put on Ioad. Storm water cbannel
ofthe respective unit was also lined up to the OWS pit. Heavy rain and non-
availability of pumps resulted in an overflow of the OWS pit. Condensate in
storm water cbannel was also a result ofOWS pit overflow. As observed from
CCTV footage, the fire started with the engine of the vehicle parked at the
incident site starting or while fire-fighting crewentered their vehicle.
Recommendations:
• Pit pumps of OWS pits should be maintained in healthy condition.
• In case ofHC leak, no vehicular movement should be pennitted and
affected area should be condoned off.
• Adequacy study of storm water system should be carried out.
• HC muck should not be stored in the plant area and should be disposed
off as quickly as possible.
• In the absence of OWS pit pumps, an alternate arrangement for HC
removal from the pit should be provided.
3.26 Fatal accident due to harmful gas in an eastern

sector refinery, lndia
Brief description:
A fatal accidcnt of a ficld operator occurred in the Sour Water Stripper Uuit
(SWSU) of a refioery due to the inhalation of hydrogen sulphide gas.
Gase sludies 55
At the end of a night shift, in early moming hours, the field operator went
inside bis unit to collect thc samples of sour watcr, stripped watcr, rich amine
and lean amine from the sampling point. He did not come back with samples.
The morning shift field operator went in to check on the operator.. He rushed
back to the control room as his personal H,S monitor started showing the
presence ofH,S gas (20 PPM) near the sample collection location and he did
not have respiratory protection equipment. After putting it on and retuming to
the location, he found the uight shift operator lying in unconscious condition
near the sampling location. He informed the shift-in-charge. Subsequently, he
pulled the unconscious operator away from the site. The victim was shifted to
hospital, where the doctor declared him brought dead.
In SWSU, sour water from FCC, CDU and DCU are received in degassing
drum. The drum fioats with acid gas fiare system. Depending upon the Ievel
of hydrocarbon separated in the reservoir of degassing drum, as per extant
practice ofthe refinery, oil is drained time to time in OWS through a funnel.
Sour watcr is fed to sour water stripper column for the removal of H,S. The
stripped water is consumed in de-salter of CDU. The excess quantity, if any,
is drained to OWS.
There were occasions when stripping was found inadequate, which is
corroborated by Iabaratory results !hat indicate the presence of Hß beyond
the stipulated Iimits. Hydrocarbon from degasser drum was also drained into
OWS funnel instead of CBD. However, the liquid drained overflowed from
the OWS funnel, indicating choking in the line.
Other lindings at the site include:

• H2S Ievel in vicinity was in the range of 40-50 PPM.
• The reading of the Ievel transmitter draiuing water on the degassing
drum was found at zero (-2.9). Undersuch circumstances, ifthe valve
is left open. H,S inevitably would escape.
• The H,S detector, near the HC drain funnel, was found non-functional.
• The operator who had gone for sampling did not carry H,S personal
meter.
Cause of incident:
The abnonnalities and root causes were as follows:
• Occasional increase ofH,S Ievel (>lOPPM) in the stripped water due
to improper operation of stripped sour water system.
• Draining of water from degasser drum or any H,S-contamioated
water to OWS manhole, fitted loosely with meta! box-type cover.

• It was possible that H2S might have escaped to OWS system from the
degasser drum since the Ievel of drum was zero; the drum floats with
acid flare gas.
• Lot of H:,S gas escaped through OWS system, since the drain line was
choked.
• Operator did not carry personal H,S monitor.
• The H,S detector alann in DCS was either overlooked or kept at the
bypass mode.
Learnings:
• The feed to sour water stripper is based on LIC control and must be
changed to FRC control system to ensure a steady flow of water to
stripper.
• No H,S-contaminated liquid should be drained into the open system;
instead, it should be drained to CBD. On these lines, any access-
stripped sour water should be drained to CBD only.
• Entry in process unit with H,S personal meter should be strictly
implemented.
• Additional H,S detector should to be provided near OWS manhole.
• Whenever any operator goes to the unit, he should ioform hls CO-
operator in advance.
• Safety interlock should be made functional and kept on the line.
• H,S alann must be acknowledged by control room, and appropriate
action taken.
3.27 Fire and explosion in flixborough (UK)

The case stodies I have discussed so far are mostly from Indian industries.
I have taken up a few in order to pointout the general mistakes that cause
accidents/fires and explosions.
I have gone through some case studies and videos of accidents that took
place abroad. The Flixborough incident was also similar to the other incidents
described thus far. There were six reactors through which cyclohexanone bad
to pass through at high temperature and pressure in order to get converted to
caprolactum. Cyclohexanone is highly inflammable; any leak was dangeraus
and prone to catch fire.
Gase sludies 57
Out of the six reactors, one reactor was pul on by-pass for repair work
and a 20-inch-diametcr by-pass line Gumper) was provided to keep the unit
running.
There were frequent upsets in the unit due to severalleaks in a short span
of two months. Due to several thermal expansions and stresses, the by-pass
line failed, and there was a massive explosion followed by huge Iire.
The main cause found was the design mistake in putting the 20-inch
by-pass line between the two reactors, which was not adequately supported,
and the frequent leaks in units caused the fatigue and failure of this piece.
Learnings:
• Management should recognise the vulnerability in critical manpower
changes.
• Any modification in plant should be designed, constructed, tested and
maintained by the same standards as the original plant.
• All pressure systems containing hazardous material should be
inspected by the inspection department after any significant
modification and before the system start-up
• The system should be tested at about 1.3 times the relief valve
pressure setting.
• The by-pass was tested pneumatically. In such systems hydraulic
testing should be made obligatory.
• HAZOP is required to be carried out at regular intervals or whenever
any modification is carried out to understand the risk involved.
• Proper supports should be provided even if the line is put temporarily
to avoid vibrations/stress and ultimate failure.
• There should be a proper policy for 'management of change' 'to take
all precautions and carry out checks at each stage'.
A similar case occurred in another refinery where explosion and Iire
took place due to a failed outlet pipe of llare knock-out drum, releasing
massive hydrocarbons into the atmosphere. This formed an unconfined
vapour cloud, which found a source of ignition and exploded. It seems that
due to malfunctioning of control valve for pumping out the bottom product
from column A to column B, the column A got filled with liquid. This liquid
found its way to llare the knock-out drum, and due to an increase in pressure
and llow, the weak point in llare header failed and the hydrocarbon vapour
escaped.
In this case, it is very clear that the operator could not understand the
magnitude ofthe problern looming in the plant..r. In fact, it was safer for him

and the plant unit tn shut down and analyse the problern and restart tbe unit
after resolving it. The learning from this case study would be:
• The operatnr should know how to carry out simple volumetric and
mass balance check.
• Staff should be trained based on assessment of tbeir knowledge and
competence on handling operations and emergencies.
• There should be a proper inspection plan to check tbe health of
pipelines and vessels.
• Time to time checldng of Ievels and pressure, etc are tn be followed
by operatnrs in tbe field.
3.28 Explosion and fire in olefins production unit of

formosa plastics corporation in point comfort,
texas
Brief description:
On 6.10.2005 at about 3.05 PM, tbere was an incident ofrelease ofpropylene
from olefios unit-II ofFormosa Plastics Corporation, Texas, as a trailer being
tnwed by Forklift snagged and pulled a small drain valve out of the strainer
in a liquid propylene system. Escaping propylene vapourised, forming a !arge
vapour cloud. At about 3.07 PM, tbe vapour iguited creating an explosion.
Explosion knocked down several vessels and bumt two (one seriously)
operatnrs present in tbe unit. Flames from fire reached more tban 500 feet
higher in air. The fire in unit continued for five days. Because of massive fire,
evacuation started from sites. Fourteen workers sustaioed burn injuries. Due
to extensive damage, unit rernained under shut-down for five montbs.
The olefios unit-II uses furnaces to convert eitber naphtba, or tbe natural
gas derived feedstock, intn a hydrocarbon mixture contaioing metbane,
etbane, propane, propylene and various higher hydrocarbons. Distillation
columns tben separate tbe hydrocarbon mixture. Some of tbe separated gases
liquified and sent to storage, while otbers are used as fuel for tbe fumace or
recycled intn feed stuck.
Relief valves protects various process equipment from overpressure.
These valves discharge into tbe fiare header system, where tbe hydrocarbons
can be safely burned.
Incident sequence:
• A worker driving a fork truck towing a trailer under a pipe rack
backed into an openiog between two columns to turn around.
Gase sludies 59
[
i
i
'
i
.
~
'5.
0
Y sb'ainer and drain
,.",.
Remal.ely operat&d
contrnl valve
~------ ~A ----~"f -------------t><J- -----t><J--------r:J<J----t~------t><l -----•To slorage
l_____ _ I Le~point
I '->
IKXf--+4
7:J
I,
l_/
,II
Propylene prudu: '-vo-----_j C><J Manual gate vaJve

~\ N Check valve
'-~) ---v-- Y stralner
Propylene product flow
• When the worker drove forward, the trailer caught on a valve

protruding from a strainer in the propylene piping system.
• The trailer pulled the valve and associated pipe out of the strainer,
leaving 1.9-inch-diameter opening.
• Pressurised liquid propylene escapes through the opening and
partially vapourised creating both a pool of propylene and a rapidly
expanding vapour cloud.
• The fork truck driver and other contractors saw the leak and evacuated
the site.
• An operator also heard and saw the release and informed the control
room. The control room operator also saw it on CCTV and began to
shut down the uuit.
• The field operator attempted unsuccessfully to reach and close manual
valve to stop the leak. They operated the fixed water monitors.
• Control room operators shut offpnmps from MCC and closed control
valves to slow the leak.
• The vapour cloud ignited.
• Field operator left the uuit.
• Control room operators declared a site-wide evacuation. On getting
propylene smell, they evacuated the control room.
• A large pool fire burned under the pipe rack and sides of an elevated
structore that supports various process equipment, such as vessels,
heat exchangers and relief valves.
so Safety in industry - leam from experience

• Company Emergency Response Team (ER1) arrived and took
command of incident response.
• After thirty minutes into the event, the side of the elevated structure
collapsed. crimping emergency vent lines to the flare header.
• Crimping pipes and steel, softened from fire exposure. led to multiple
ruptures of piping and equipment and loss of integrity of the fl.are
header.
• ERT isolated fuel supply sources where possible, and allowed small
fires to bmn the mcontained hydrocarbon.
• It took five days for the fire to be extinguished.
4" Propylene
product line
Pipe nipple
Pipe and valve arrangement
Lapses and eause of lneldent:

1. Vebide lmpaet proteetlon
The propylene piping involved in this incident was protruding outside
into the open, yet it was not given any impact protection.
Company bad administrative safeguards for vehicle operation in the
unit, including a plant-wide speed limit, a vehicle-permitting process,
Case studiea 61
and a crane-use procedure. However, these safeguards did not specify
where vehicles were to operate within the unit.
The plant design drawings desiguate specific access paths for vehicles;
however, these were not physically demarcated in the unit itself. The
area where the impact occurred was not a desiguated access pathway,
but was !arge enough for vehicles to pass through.
The guidance manual dealing with the protection of control stations,
pipelines, and other grade-levelplant equipment was not specific, but
it did state that proteelive measures should be in place to prevent
impact.
During facility siting analysis, the hazard analysis team discussed this
aspect. They judged the consequeuce as 'severe' and probability as
'very low', resulting in 'low overall risk range'. Because of lowrisk
rating, the team considered !hat existing administrative safeguards
were adequate and did not recommend additional traffic protection.
2. Fire proofing of structural steel
During the Iire, part of the structure supporting the relief valves and
emcrgency piping to the flare header collapsed. The collapse caused
several pipes to crimp, it was likely this prevented flow through the
pipes, leading to the rupture of major equipment and piping !hat only
added fuel to the Iire.
Fireproofing was done on only three, out of four support column
rows, and the column !hat supported the PSVs and emergency vent
piping had no fireproofing. The bare steel column bent over, while the
fireproofed columns remained straight.
API publication 2218, 'Fireproofing practices in Petroleum and
Petrochemical Plant' (July 1988) recommends that steel supporting
important piping such as relief and fiare lines be fireproofed.
3. Remote equipment isolation
The leak occurred between manual control valves and remotely
operated control valve. While a check valve and remotely isolation
valve downstream of the leak prevented the backflow of propylene
from the product stage, operators were unable to reach the manual
valves capable of stopping the fiow from the distillation column. The
operators were also unable to reach the local control station to turn off
the pumps supplying propylene, although they eventually turned off
the pumps at the MCC located in the control room bnilding, slowing
the rate of propylene feeding the Iire.

Had a remotely actuated valve been installed upstream ofthe pumps,
this incident would likely to have ended quickly.
This was in line with designer (M/s Kellogg) philosophy. However,
Health and Safety Executives (HSE) (1999) recommend that !arge
vessels aod columns with hazardous inventories be equipped with
rapid isolation capability.
4. Flame-resistant clothing
Flame-resistaot clothing will Iimit the severity of burn injuries to
workers in plants where flash fires may result from uncontained
flammable Iiquida and gases. Neither of the two operators burned in
this incident was wearing FRC: had they been, their injuries would
likely have been less severe.
The OSHA as well as NFFA has guidelines ofthe use ofFRC.
Learnings:
• Hazard review:
When performing a Hazard analysis, facility siting analysis, or
pre-start-up safety review, vehicle impact and remote isolation of
catastrophic releases should be investigated. Such critical projected
equiprnent should have a permanent impact guard.
• Flame-resistant clothing
In process plants with !arge flammable liquids andlor gas inventories,
mechanical failures can result in flash fires that endaoger workers.
The use of FRC may Iimit the severity of injury to employees who
work in plants with !arge inventories offlammable gases and liquids.
• Use of current standards
Evaluate the applicability and use ofcurrent consensus safety staodards
when designing and constructing a chemical or petrochemical process
plant. This should include reviewing and updating earlier designs
used for new facilities.
3.29 Fatal accident in a petroleum refinery during

hydro-jetting operation
Brief description:
A fatal accident of a contractor workman took place on 1.10.2013 during
hydro-jetting operation in a refinery for removal of debris from OWS manhole/
Gase sludies 63
lines and ensuring thoroughness. During the job, the self-propelling nozzle of
machine came out abruptly from. OWS manhole. Tbe water jet and nozzle hit
the neck of the worker standing by side of manhole. He was badly injured.
Later, he succumbed to bis injuries.
What led to this fatal accident? Let us analyse the incident. Tbe truck
mounted hydro-jetting machine with four workmen (including a supervisor)
reported at site for de-choking of OSW manhole (Depth: about 21 feet) and
ensure tboroughn.ess between two manholes. Job was started after tool box ta1k
and obtaining work permit (cold work) and continued till1.30 PM, ti11 a leak
developed in discharge line of tbe hydro-jetting pump. The job discontinued,
and the truckwas sent out for repair by contractor.
Trock-mounted hydro-jetting machine bad a pump driven by truck engine
through a Power Take-Off (PTO) unit for hydro-jetting. The pressure for
hydro-jetting was controlled through a Iever on rear side of the vehicle. The
discharge hose of pump was connected to a self-propelling nozzle.
High-trust conlcal head (self-

propellad) nozzle uaed for tne
purpoae had one hole in front
and five holes at ltle rear. Hole
in front is used fur de-chokingf
cuttingfcleaning, whereas holes in
tne rear provide the tt1 rust so ttlat
nozzle rnoves ln forward dlrecllon
automstlcally.
High-Thrust Conical Head Nozzle
After repairing the machine, the contractor started the job without
:in.forming the engineer in-charge, while talring clearance in work. permit on
the same day (aftemoon). Two contractorpersons were at the work. site. When
job was started, the manhole bad about three feet water and the OWS pipes
were not visible from the manhole top. During the job, one person was at
pump control (on rear side of vehicle), whereas another was trying to put
the nozzle in OWS pipeline (covered under water) by swinging the hose
under pressure (300-500 PSI) from top of manhole. Such nozzle with hose
has tendency to turn back" if it fin.ds an obstruction in the middle of the line,
provided there is sufficient space for tuming back. In this case too, nozzle
under water might have been obstructed under the water and turned back as
64 Safety in induslry -leam from experience

there was enough space for doing so. Thus, after tuming back, the hose, in a
swift motion, moved in the direction of the operator. Consequently, nozzle
with hose at a pressure of about 300-500 PSI hit the neck of the operator,
causing fatal injuries.
Lapseslcause ofiucident:
1. As the contractor personnel entered premises with a temporary gate
pass of a single day, they skipped the structored safety training. The
tool box talk given at site did not address the relevant hazards and
precautions.
2. Job was being done without supervision (from compaoy side as well
as contractor side).
3. Job was re-started without taking clearance on work permit for the
second shift.
4. SOP aod safety precautions for high-pressure jetting system issued by
OEM were inadequate aod not available at site.
5. SOP provided by the contractor for the jobwas not reviewed for the
content.
6. PPEs were not categorically identified for hydro-jetting.
7. Insertion ofthe hydro-jettiog nozzle inside OWS pipewas being done
by swinging the hydro-jetting hose, which s is an unsafe method.
'Why Why Analysis 'of Incident concluded that ignorance about the
hazardlrisk associated with the job by all concerned Ieads to the fatal
accident.
Learniugs/recommendations:
• System needs to be developed for assessing the hazardslrisks
associated for hydro-jetting of various process equipment/facilities.
• Compliance of work permit is to be ensured in line with OISD Std.-
105.
• For high-pressure system of contractors, the test certificate should
be obtained from contractor and all repair and maintenance work of
system should be subjected to lest, recommended by OEM, before
taking equipment ioto service.
• In-house competency needs tobe developed to supervise the execution
of such jobs safely. Contractor must depute a dedicated supervisor for
such critical jobs.
Gase sludies 65
• Existing access control system to be reviewed. All entry/exits of
visitors/employees/contractor personnel should be linked through the
access control system.
• Stroctured safety induction training sbould be made mandatory for all
contractors, coming for the execution of job inside refinery, even if
for one day or two.
• Training programme needs to be conducted for creating awareness
amongst permit signatories for critical operations such as using high-
pressure systems.
• For such specialised jobs, requirement ofPPE should also be identified
and arranged, and compliance should be ensured.
3.30 Fatal accident at a construction site in a

petroleum refinery due to fall of scaffold pipe
from height
Brief description:
On 11.11.2017, during the revamp job of the DHDS unit in a petroleum
refinery, a fatal accident of a contractor employee took place, when he was hit
on the head by a falling scaffold pipe from a great height.
During revamp of DHDS unit, two contractors were allowed to carry
out work at different eievatians in a reactor at a height of 5M at the lowest
platform and 27M at the top platform. The erection of reactor was already
completed. On 11.11.2017, one ofthe contractors, who was working at 27M
height, was carrying out stroctural work for platform/bracing on the southern
side. However, another contractual employee was carrying out hot job for the
erection of cable tray for laying instrument cable at SM level on the northern
side. 1\vo contractor supervisors were supervising the erection job of cable
tray at 5M Ievel from ground floor, standing below the job.
At the top platform of reactor, a !arge portion of the scaffold was jutting
out on an extended/cantilever platform on another side. Three vertical pipes
of scaffold were banging outside the top structure, supported with a scaffold
coupler. One of them loosened, slipped and feil from a height of about 27M.
The falling pipe struck the safety helmet of one of the contractor Supervisors,
who was standing direclly below, having breached the soft barricade on
the ground floor. The impact of scaffold pipe damaged the safety helmet
of Supervisor and caused a critical head injury. He was shifted to hospital
immediately, where he succumbed to injuries.

Lapses and cause of accident:
1. Original scaffold for work at 27M Ievel of reactor was erected from
ground Ievel. Later, some portions of scaffold were removed, leaving
part of the scaffold hanging from the respective beam of extended
platform/cantilever platform. These scaffolds were left hanging to
cany out localised jobs later. In horizontal pipes, beam clamps were
used, whereas for vertical pipes, scaffold couplers with bolts were
used.
2. A scaffold pipe of 3M (weight about 12 kg) loosened and fell down.
Why?
The scaffold pipes were kept hanging at this height since about two
months, and due to self-weight, wind Ioad and temperature effects,
the bolt on clamp might have loosedlthreads wom off, leading to
slippage of pipe from the location and falling down.
Neither the contractornor the Project Management Consultant (PMC)
had any record of scaffold pipe and coupler checkingftesting. Record
of certification and re-certification of scaffold were also not available.
In brief, the scaffold safety standard was not foUowed for erecting,
dismantling, testing and certification ofscaffolds.
3. The contractor as weil as PMC failed to follow and implement the
precautions mentioned in work permit and job safety analysis (JSA)
at work site. This also indicates poor supervision of job.
4. The supervisors of contractor for working at SM Ievel were standing
within the barricaded area, ignoring the safety waming.
Learnings/Recommendations:
• Scaffold safety standsrd is to be implemented at site by contractor
as weil as PMC in totality. Other safety precautions are also to be
implemented.
• Scaffold certificationlre-certification should be approved by either
PMC or independent scaffold inspector.
• Separate specialised agency/group is to be engaged for ensuring
compliance of scaffold safety norms, training of site personnel and
regular check of the fitoess of scaffold.
3.31 Explosion in BP retinery, texas

An unconfined vapour cloud explosion took place in British Petroleum
Refinery, Texas, oo 23rd March 2005 during start-up activity of Isomerisation
Gase sludies 67
(ISOM) process uni!, followed by massive fire and explosions, killing fifteen
workers, injuring about 170 others and severely damaging refinery. The detail
investigation report by Chemical Safety Board (CSB), USA, is available on
website www.csb.gov>bp-america-refinery-explosion.
Brief description of incident:

ISOM unit in refinery was meant for conversion of low-octane hydrocarbon
through various chemical processes into hydrocarbon with higher octane rating
that could then be blended into unleaded gasoline. The raffinate splitter of the
unit bad a 170-feet-tall splitter column, used toseparate lighter hydrocarbon
components from top of the column (mainly pentane and hexane), which
condensed and were then pnmped to the lighter raffinate storage tank, while
the heavier components were recovered from lower down in splitter and then
pnmped to heavy raffinate storage tank.
Two tumaround activities were taking place at the adjacent Ultra-cracker
Unit (UCU) and at the Aromatics Recovery Unit (ARU) at the same time.
After work bad been completed on the raffinate splitter, the start-up
activities began. One of the primary safety critical steps in the pre-start-up
process was the pre-start-up safety review procedure. This was not carried out
probably because the unit bad many serious safety issues.
Start-np activity commenced in the night of 22nd March with filling up
of raffinate column of unit. Later tbis was discontinued bnt re-commenced
at 9.30 AM on 23rd March. The Ievel transmitter of column was designed to
indicate the raffinate Ievel within 5-feet span from the bottom of the splitter
column to a 9-feet Ievel. Before re-commencing the column fill and circulation
process, heavy raffinate was drained from the bottom of the column via the
LCV into the heavy storage tank and was then shut off in a manual mode with
a 50% flow rate.
The Ievel in column started build up as there was no circulation and feed
to column continued. The defective-level traosmitter ofthe column continued
to show the Ievel at less than 100% (at 9 feet) and extemal sight g!ass was
opaque.
Further burners in the fumace heating the feed raffinate led to high
temperature and pressure in the column. The Ievel in column rose bad to 98
feet. At about 12.42 PM, the furnaces bad been tumed down and the LCV was
opened. The Ievel in the column wentupto 158 feet.Atabout 1.13 PM, all the
three PSVs were forcibly opened due to high pressure, and led to heavy flow

ofheated raffinate. Hotraffinate fiowed in to blow-down drum and stack, and
as it filled, some ofthe fluid started to fiow into the unit sewer systemvia a 6"
pipeline at base ofblow-down drum. HLA ofdrum also did not activate. After
sometime, the hot raffinate started falling from top ofthe stack and into the air.
The hot raffinate rained and spread, making pool of oil.
3 Excess vapor, typ1cally condensed and

cycled back mto tower, vented through
release valve dunng overpressure
6
Vent not fitted w1th ftare
system. burst vnth overflow
1
Flammable liquid release:
i 7,600 gallons
Release valve & / •

~
in 1.8 minutes
~·\
2 sp1ked the pressure

Overfilled tower ~~::[.4~~ tt/rt
-.rt
:-.;,~ l
t \\\
Distillation tower
51,900 gallons
Overflow
in 6 minutes
4 S1gmficant overflow over

short penod of t1me
Tofill piping
and equipment:
31,130 gallons
in 4.2 minutes
To sewer:
12,200 gallons
1 Vaponzed crude 011 wrth typ1cally

only 3-10ft of liqUid heavy 01ls.
5 Blowdown drum overwhelmed
enters tower from furnace
The sequence of events 1tlat resulted ln exploslon, Jgnlted by a near by truck.
The vapour cloud of hot ra:ffinate spread and reached a diesei pickup
truck trailer, located at about 8M away from the blow-down drum in start
position. Getting source of ignition, the vapour cloud exploded. The blast
pressure wave struck the nemby contractor shed, destroying it completely,
killing fifteen people and injuring about 170. The explosion was followed by
massive fire and further explosion. Incident led to severe damage to ISOM
unit and unit remaine<l out of operation for the next two years.
Cause and eontributory faetors leading to explosion:
Personnet responsible for start-up greatly over:filled the splitter column and
overheated its content, which resulted in an over-pressurisation condition.
Liquid was pumped into the column for almost three hours without any liquid
being removed or any action taken to achieve the lower liquid level mandated
by the start-up procedure.
Case studiea 69
The contributory factors were as follows:
I. Inadequate desigu
BP decision to continue operating with an atmospherically vented
blow-down stack in lieu ofthe widely available, and inherently safer,
:flare stackwas a contributory factor. The capacity of the blow-down
drum was also a limiting factor.
The splitter column Iiquid-level transmitters were not designed to
measure Ievels above the height of nioe feet, providing no iosight
ioto off-nomioal operating scenario. The column liquid Ievel reached
the estimated height of 138 feet ionnediately prior to the overpressure
event.
II. Non-compliance of operating procedure:
Lack of adequate traiuing and supervision of filliog and operating the
splitter column had contributed siguificantly. Fundamental procedural
errors Iead to overfilling the colunm, overheating, liquid release and
subsequent explosion.
Uuit supervisors were absent during critical parts of start-up and uuit
operators failed to take any effective action to control deviation from
the process or to sound evacuation alarms after PSV opened.
III. Deferred maintenance:
The start-up of the splitter column was authorised despite reported
problems with the Ievel transmitter, high-level alarm of column and
blow-down drum. These bad management approval. A key alarm
failure within the colunm and blow-down drum failed to warn the
operators.
IV. Trailer in hazardous zone:
Mostly, fatalities occurred io and around the trailer. Trailer was parked
io hazardous zone near to the stack and blow-down drum. This was
violation of facility siting policy.
Further, pre-start-up safety reviewwas not carried out, and hence, the
trailer and contractor sheds remaioed in operating area before start-up
activities.
Learnings/Recommendations:
• Ensure pre-start-up safety review before each start-up.
• Ensure that instrumentation and process equipment necessary for safe
operation is properly maintained and tested.

• Effective implementation and control system for splitter column such
as multilevel indicators and automatic control. Configure control
boards display to clearly indicate material balance for stripper
column.
• Carry out details PSM (including MOC and HAZOP) and ensure
tbeir iroplementations of recommendations.
• lntroduce system of Process Safety Performance lndicator (PSPI) for
monitaring of each leading and lagging process indicator.
• Ensure training and skill development of operators using simulators.
3.32 Explosion inside flammable solvent storage

tank due to static electricity
On 17.07.2007, a series of explosions followed by fire occurred in Solvent
Tank Farm at Borton Solvents Wiehila facility in Valley Center, Kamas, USA.
The incident destroyed tbe entire tank farm and led to eleven people being
injured. The area outside tbe premises was also evacuated. For details, refer
CSB website: www.csb.gov
Brief description of incident:

The tank farm handling inflammable solvent had 43 above-ground storage
tanks, ranging from 300 to 20,000 gallons capacity. 1n tank farm, tbe Varnish
Makers' and Painters (VM&P) naphtba, a fl.ammable solvent, was being
received tbrough tank trucks and being uuloaded tbrough pumps in storage
tanks.
The salient properties ofVM&P naphtba, which indicate fire hazard, are
as follows:
Flash Point 14"C
vapour Pressure 0. 7 kPa (5 mmHg) at20 •c
Flammability Limit 0.9-6.7% by volume in air
Conductivity to Static charge 3 pS/m Non-conductive
On the date of incident, tbe unloading of an above-ground storage tank

holding 15,000 gallons ofVM&P naphtba was in progressvia a pump from
a tank truck. The tank truck had tbree compartments. The uuloading from
tbe first-two compartments was completed and tbe unloading from tbe tbird
Gase sludies 71
compartment bad just begun. At this point, the first explosion oceutTed in
receiving naphtha, sending the tank rockering into the air, trailing a cloud of
smoke and fire from burning liquid. It landed approximately 130 feet away.
Within moments, two more tanks ruptured and released their contents in
tank farm. Aß the fire bumed, the contents of other tanb over-pressurised or
ignited, damaging tanks one by one.
VM&P naphtha tank Emergency pressure PressureNacuum valve

and photo of an relief device
example float
~
Gauging
viewglass
- ----"---
Grounding
Diagram ahowing VM&P naphtha tank wilh ftcating gauge arrangement
Cause of e:xploslon and contrlbutory factors:

• The tank contained an ignitable vapour-air mixture in its tank hea.d
space.
• Stop-start filling, air in the transfer piping, and sediment and water
(likely to have been present in the tank) caused a rapid static charge
accumulation in.side the VM&P naphtha tank.
• The pump fiow velocity was very high (4.6 M/second) for non-
conductive liquid. This helped in static charge generation.
72 Safety in industry- leam from experienoe

• The tank bad. a liquid-level gauging system float with a loose linkage
that most likely separated and generated a spark durlog filling.
• The turbulence and bubbling during stop-start transfer pumping,
in addition to creating rapid static charge accumulation, also in all
likelihood created slack to the float, causing the linkage to separate
and spark.
• The MSDS for VM&P naphtha involved in the incident did not
adequately communicate the explosive hazard.
(Side view)
Tape r
Fload body
Diagram showing float linkage and area where the spark likely occurred
Lesson learned:
• Add an inert gas such as nitrogen to the tank head space with consent
of manufacturer of VM&P naphtha, which will reduce the potential
for ignitable incident {explosion) as it renden tank head spaces
incapable of supporting ignition from static spark.
• Modify or replace loose linkage tank-level floats, so that floats with
Ievel measuring devices do not prompt spark inside the tank.
• Remove any slack in the tie connected to the float mechanism that
could allow a spark gap to form.
Case studiea 73
• Non-flammable Iiquida capable of forming ignitable vapour-air
mixture ioside tanks should be transferred at reduced flow (pumping)
velocity (IM/second) to minimise the potential for static ignition.
• Anti-static (conductivity-enhanciog) additives iocrease the
conductivity of Iiquida helpiog reduce static accumulation. This may
be added with consent ofmanufacturer ofVM&P naphtha.
• Coveriog 'earthiog and bondiog' agaiost static charges alone for
protection is not enougb io MSDS ofVM&P naphtha by manufacturer.
It should provide conductivity testiog data and specify the additional
precautionary measures that should be observed.
74 Safely in industry -leam from experience

Chapter4
Tips to maintain a healthy safety system
There are some safety tips for all working in industries

which are easy to remember and very effective in
improving the safety record of any industry. Many
such tips can be displayed at various strategic points
to catch the attention of staff moving in the field.
These are mostly based on experience gained is many
years.
Chapter4
Tips to maintain a healthy safety system
Here are some tips to be remambered to maintain a

good and healthy safety system in an organisation:
There is a saying !hat wise people leam from the mistak:es of others. In
the context of the subject of safety, past incidents will prove to be our best
teachers. Let us learn from past case studies and extract pointers to avoid
similar incidents in industry.
• There can never be any relaxation on safety. Wearing PPEs is must
for everyone in the field, with no exception to be made for top
management and visitors. Safety helmets must be properly secured
by tightening the straps over chins or tightening them using the knobs
at the back of helmets.
• Reporting of substaodard acts/conditions/near-miss incidents is the
responsibility of all. Through near-miss analyses, we can know which
areas need improvement and tak:e immediate corrective measures
accordingly.
• Leaming from one's own mistak:es is good but leaming from others'
mistak:es is wise. Hence, it is recommended that all case studies be
circulated to all concerned, along with leamings from past accidents.
• No visitor is allowed to go inside the plant area without being
accompanied by a representative from the host company.
• A drunken person inside the installation is a danger to himself,
aod others as weil as to the plant assets. Alco-meter test should be
conducted for all those entering the premises, even if they belong to
the top maoagement (my experience ofKenya Petroleum Refinery).
• Static electricity is most dangeraus in industries handlinginflammable
materials/products. Hence, all care must be tak:en to ensure proper
earthing of all vessels, tanks, pipelines aod wagons/tracks under
loading/unloading. Lack of earthing has been known to be one of the
main causes of fires and explosions in the industry.

• The plant manager must do safety rounds of site daily to ensure tidy
housekeepinglno obstacle on exits or escape routes He must regularly
check the knowledge of operators about the use of PPEs and the
handling of every kind of emergency, besides keeping a check on
compliances in the case of of work pennit, etc.
• Keep a check on open drains of the installation. Any presence of oil
in them is very dangerous.
• The plant area needs tobe tidy, especially the pump/compressor area.
Any object on the way or oil on floor is adefinite routc to an accident.
• U se of standard safety harness must be ensured to avoid any free fall
while at height. No work at height in foggy weather/during rain and
storm is to be perntitted.
• Suitable safety notice boards displaying do's and don'ts are needed
in accideot-prone areas, like that of chemical handling and water
draining systems from crude oil tanks /product tanks and LPG storage
facility. Any negligence there can cause major emergency.
• Many accidents are reported due to failure of scaffolding. Standard
scaffolding material should be used. Once it is erected, it should be
certified as 'fit to use' by a competent officer.
• Regular health survey of process pipelines will help in controlling the
failure/ leakage of pipelines.
• Any leaky point/ dripping point should be attended to immediately.
• Don 't allow anyone to walk on pipelines!unsecured overhead platform
as any fall may Iead to head injury/fatality.
• In case of strong winds!cyclone conditions, the booms of all cranes
should be lowered down and brakes to be properly engaged to avoid
rolling of cranes (case in point: accident at one of the ports in eastem
India, when a heavy crane rolled down into the sea.)
• One has to be very careful (stand to one side) while lighting the cold
heater or boiler, as the llame usually backfires.
• While climbing onto the top of a lloating roof taok, one should ouly
walk on the platform and not climb onto the roof. Accidents have
been reported due to corroded and weakened roof plates falling inside
the taok when walked on.
• Safety-conscious people are always alert to danger and keep their
nose, ear and eyes always open. Any smell of gas!hydrocarbon
lips to maintain a healthy safety system 77

vapours should alert people about leaks and these must be attended to
immediately, to avoid any emergency-like situation.
• Heavy oils should not come in contact with hot surfaces like steam
lines or steam tracers as there are good chances of catching Iire. If
these products fall in droplets from overhead lines over a bot surface,
they can easily catch Iire due to their low auto-ignition temperatures.
• Repair work on electric poles during rainy seasons should be
avoided,as chances of electric shock, even electrocution, are great. In
cases of emergency where such work is unavoidable, extra precautions
must be taken.
Electrical short circuiting has been one of the common causes for
fires in plants. Standard and proper rated electrical fittings/wires/
joints should be used to avoid such accidents.
• Oily sludge taken out during tank cleaning, vessel cleaning, etc.
contains pyrophoric iron. This is highly inflammable and can catch
fire as soon as it dries . Hence, sludge should always be kept wet or
storedunder water to prevent exposure to the sun. This sludge should
be treated in line with environmental guidelines.
• Dry grass, can being easily iguited, its presence in the plant area is
dangerous. It should be cut and removed immediately.
• There should not be any tall trees in the plant area. During storms,
they can fall and darnage the process pipelines and power cables.
They can even obstruct the fire-fighting operation.
• Wet floors or any foreign materiallying in the plant area can Iead to
slip/trip and cause accident. Hence, proper and !arge caution boards
should be placed to alert passers-by.
• All manholes should have proper covers. Any manhole, kept open for
some job, should have proper barricading to prevent anyone falling
into it. Plant area should be welllighted.
• Training and refresher training of employees is the only way to make
them aware about safety and understand the proper use of safety
equipment during an emergency.
• Weekly trials of Iire water pumps and daily trial of emergency
sirens should be practised. Regular mock drills in various types of
emergency seenarios will bring out weaknesses in the system, and
enable corrective measures to be taken.

• Safety audits by multidisciplinary audit teams consisting of persons
drawn from different locations also helps in bringing out deficiencies
in the system and to plug thern. Most important is to monitor the
implementation of the recommendation, by top management in
monthly safety reviews.
• Head of HSE department has to be a dynamic Ieader, and he should
report to the location head for effective control.
• Regular and candid reporting ofloss time incidents to top managernent
should be encouraged. Any one trying to hide such incidents should
be liable for punishment.
• Monthly HSE meeting to be attended by all HODs and top
management; is a must to discuss and aoalyse safety breoaches, their
causes and decide on actions to be taken to improve overall safety
Standard.
• Safety showers and eye wash facilities are must in the chemical
handling areas.
• Limited vehicle movement should be allowed in plant area with strict
adherence to speed lirnit. Vehicles fitted with CCE-approved spark
arrestor should only be permitted as per requirement of hazardous
area classification. Extra care should be taken while material sbifting,
and banging objects should have a gnided movement.
• System should be in place to involve workers in safety management
system through lloor-level safety committees, safety meetings, safety
training, safety inspection and safety campaigns, etc.
• Safety bulletins should be circulated widely among employees. These
should cite case stndies, unsafe acts, near-miss incidents, accident-free
man hours/days achieved without a loss time accident vs the target.
Even some token awards for achieving specific targeted accident-
free days may be introduced to encourage the people to follow safe
practices.
• Safety performance should be one of the parameters in working
out the fonnula for the annual perfonnance incentives. Also, some
incentive schemes can be introduced to honour the employee who
does an exemplary job to avoid a major mishap due to his alertness,
knowledge and courage. I found it very encouraging when I tried this
in one of the refineries.

• All the areas with moving parts should have guards, and no one
wearing loose or flowing clothes should be allowed to enter the plant.
• During project stage/annual maintenance, the proper metallurgy of
pipes and bends being used should be ensured. Any wrong fitting may
rcsult in leakage and thereby, fire during plant operations.
• In project contracts, a clause providing incentives on achieving
milestone of accident-free man hours/man days as well as a penally
clause for each accidant in project area should be inserted.
• The contractor has to ensure the availabilily of a qualified safely
offleerat project work site to oversee safely compliances. It should be
the responsibilily of the contractor to provide PPEs to its workforce.
• The operating staff needs to be more careful when any interlock
control is put on the by-pass. This job should be attended to on
top priorily, and everyone on duly should be aware of this by-pass.
Approval of such by-pass should be done as specified in Management
of Change (MOC) procedure.
• The control room should not be left unattended under any condition.
• Predictive/preventive maintenance schedule of each running
equipment should be strictly followed to avoid sudden failure of
equipment. Similarly, any vibration in pipeline should be given
proper support to prevent its fatigue failure.
• Any standing instruction/special attention job should be explained
to operating people as soon as they join duly. (The reHever should
take full brief from the person in earlier shift, besides reading the
instructions.)
• Availabilily of the first aid box should be ensured at all work sites.
Also, an adequate number of 'first aid trained' people should be
available during operating hours. It has been experienced that if
timely first aid is administered to an injured person, chances of saving
bis life gets increased considerably.
• Ouly medically fit persons should be deployed for working at heights.
• Everyone should follow Standard Operating Procedures (SOP}-
shortcuts cannot be allowed.
• The staff should not be allowed to work if tired. Long working hours
without breaks or proper rest is unsafe. Uuless the person is alert on
the job, chances of mistakes are high.
ao Safely in industry - leam from experience

• Extra care is required for working in confined spaces/ at heights and
during excavation aod in aoy other high-risk job. Proper Job Safety
Analysis (JSA) should be done prior to the start ofthe job to identify
probable hazards and their mitigation measures to be followed.
• Work area monitoring with respect to noise and presence of toxic/
hazardous vapours should be practised regularly to avoid any
undesirable exposure to workiog staff.
• Regular health monitaring of workiog staff should be implemented to
assess the occupational health issues.
• All field and portable safety equipment for example detectors,
alarms, shut-down switch, and extinguishers, should be maintained
by periodic inspection.
• Any major accident can be avoided if the staff on duty is alert, knows
the job and trained to handle any emergency. Many times, simply the
use of common sense is very helpful in controlling the situation.
- Once there was fire in a Naphtha wagon under loading,
operators decoupled the rest of filled wagons aod pushed them
to a distance. Tbis averted a major fire.
- In one unit, sulphur dioxide leaked and caused panic in the
refinery. One operator used his presence of mind and entered
the gas cloud while wearing air breathing apparatus and closed
the valve to arrest the leak. Tbis action prevented a major
emergency.
The above tips will certainly be of help in reducing incident, in your
industry. I wish all of you and your colleagues a very safe workiog and
long&aod healthy life.

Bibliography
1. FrankE Bird Jr., Domino Theory

2. Kletz Trevor 'Still Going Wrong' 2003
3. OSHA Process Management Standard
4. Conoco Phillips Marine Pyramid (Incident)
5. ISO 45001: Occupationa/ Hea/th & Safety Management Systems
6. OISD GDN 206: Guidelines on Safety Management System in
petrochemica/ industry
7. Process Safety Management for Petroleum Refineries, OSHA
3908/3918
8. Safety & Health Guide for Chemical Industry, OSHA 3091
9. Investigation report of cases by Chemical Safety Board (CSB), USA
10. Case studies published in safety joumals and safety buHetins
11. Borton Solvents Investigation case, CSB news re1ease
12. API recommended practices 2003
13. Proreetion against ignition arising out of static lightening stray
currents, 7th edition 2008
14. Presentation 'Learning for process industry from the Bhopal gas
tragedy' Shri S.P. Chaudbary on 11-12 February, 2020 in New Delhi
15. COX J. (2005) Flixborough Revisited Chemical Engineering The
Chemical Engineer 26--28
16. The report of the US Refineries Independent Safety Review Panel
(Baker Panel) January 16, 2007
17. Fatal Incident Investigation report, Isomerization Unit explosion, find
report, Texas City, USA, British Petroleum, Mongford J.
18. Alkylation Unit Ginza Oil Refinery, James Town, NM
19. Report of the investigation by the health and safety executive into the
explosion and fues at Texaco refinery in July 1994.

Safety in Industry Learn From Experience (2023)

Uploaded by

Copyright:

Available Formats

Safety in Industry Learn From Experience (2023)

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Safety in Industry Learn From Experience (2023)

Uploaded by

Copyright:

Available Formats

Safety in lndustry

learn from Experience

Brij Mohan Bansal

CRC Press is an imprint of the

WOODHEAD PUBLISHING INDIA PVT LTD

1. Basics of safety and safety management system 1

4. Tips to maintain a healthy safety system 75

Truly the lirst safety book ofits kind •••••••

Industrial safety refers to the safety management practices which apply

Being myself,a chemical engineer experienced in handling all sorts of

Bansal gives to thereaders his entire life span of40years ofexperience,from

Vijay Kumar Soni

Director GFCL EV Products Ltd;

Firstjob in paper mill: Tea every two hours

Decision to leave paper mill

First impression of petroleum refinery

Exposure to safety norms

Safety - whose responsibilty

Safety: Not a one-time assignment

Near-miss incidents - not to be ignored

More than forty years' industry experience

The purpose of this chapter is to understand the

2 Safely in industry - leam from experience

1.4.1 lncident ratio study

Basics of safety and safety management system 3

At-risk behaviours and sub-standard condition.s are always symptoms of

SuiMitandard condlllons At·l1•k behavloure

4 Safety in industry- leam from experienoe

Sub-standard condltlons At-rlsk behavlours

• Placement hazard '" lmproper use of hands or body parts

Basics of safety and safety management system 5

Personal factors Job factors

• Physlcai/Physlologlcal capablllly • Leadership andfor Supervision

6 Safety in industry - leam from experience

Personal factors Job factors

" Mentai/Psychologlcal strass .1' Communication of safety and health

Basics of safety and safety management system 7

1.4.4 Safety management system

1.4.5 Process of managing risks

a Safety in industry - leam from experience

Basics of safety and safety management system 9

1o Safely in industry - leam from experience

Safety is taken into consideration in a process industry

2.1 Operational safety

A. Hazard Operability Study (HAZOP)

12 Safely in industry - leam from experience

Objectives of carrying out a HAZOP study:

B. Hazard identification (HAZID):

C. Process Hazard Analysis (PHA)

14 Safely in industry - leam from experience

Focus on anything that might impact the process, including:

Both the.frequency and severity ofeach process hazard must be analysed:

D. Layer of Protection Analysis (LOPA)

16 Safely in industry - leam from experience

2.2 Plant Iayout

2.3 Fire protection measures

2.4 Plant commissioning

18 Safety in industry - leam from experience

2.7 lnspection and Maintenance