Learning From Risk Control System Failures. Mike Jones
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1 Learning From Risk Control System Failures Mike Jones
2 MIKE JONES Chief Consultant CRA Industrial Process Assurance Process Safety/Technical Safety Consultant 43+ years experience in Industry/HSE/Consultancy Operations, Operations Management, Control Systems HSE Specialist Inspector (Process Safety)
3 MIKE JONES HSE Experience Involved In about 40 investigations including: Gas explosions Fuel explosions (including a fatality) Dust explosions Deflagrations Fires Near asphyxiation Uncontrolled exothermic reactions Rapid degradation of containment
4 ABOUT YOU How many of you are Chemists Chemical Engineers Mechanical Engineers Safety Engineers Other Disciplines Regulators or ex Regulators
5 THIS EVENING S TALK We will examine three incidents Outline the circumstances leading up to the incident. Identify the immediate causes. Identify the immediate consequences. Examine the causes/failings. Identify the learning.
6 Any questions?
7 PITMACHIE GARAGE What do you know about waste engine oil? Contains heavy metals Usually very dirty Combustible May contain 0.5% to 2.0% petrol Present in many garages
8 PITMACHIE GARAGE Events of the afternoon of Friday 18 th June 2010 A 23 year old experienced mechanic was cleaning up after finishing the weeks work He was collecting old car parts (mainly brakes) and putting them in drums He was someone who on this occasion didn t follow advice and training The first task involved cutting the tops off old drums so they could be filled
9 PITMACHIE GARAGE Events of the afternoon of Friday 18 th June 2010 Cutting the tops off old drums
10 PITMACHIE GARAGE Events of the afternoon of Friday 18 th June 2010 One drum lid had been successfully removed using a pneumatic hacksaw Colleagues complained that the saw was noisy The second drum lid was removed a different way
11 PITMACHIE GARAGE Events of the afternoon of Friday 18 th June 2010 A thermic lance was used
12 PITMACHIE GARAGE Events of the afternoon of Friday 18 th June 2010
13 PITMACHIE GARAGE Investigation Inverurie Police Station
14 PITMACHIE GARAGE Investigation The drum lid had been forced off by the internal pressure in the drum There had been an explosion What had fuelled the explosion? Why wasn t there a subsequent fire?
15 PITMACHIE GARAGE Investigation People can and do make mistakes when under peer pressure Rushing causes mistakes Even a tiny amount of petrol can kill you under the wrong circumstances how much? This was between 5 and 10ml. There are usually around two fatalities a year involving exploding drums or small tanks. This information is given during apprenticeships
16 WASTE ENGINE OIL
17 ANY QUESTIONS?
18 METHANE What do you know about methane? Gas at ambient conditions Highly flammable Flammable limits (~5-15% in air) Lower density (lighter) than air Rises rapidly Low minimum ignition energy MIE <0.2mJ Used at home
19 LARKHALL, GAS EXPLOSION Pre 1970
20 LARKHALL, GAS EXPLOSION 1970s Medium Pressure (2barg) Ductile Iron Gas Main
21 LARKHALL, GAS EXPLOSION December 1999
22 LARKHALL, GAS EXPLOSION 22 December hrs
23 LARKHALL, GAS EXPLOSION
24 LARKHALL, GAS EXPLOSION
25 LARKHALL, GAS EXPLOSION
26 LARKHALL, GAS EXPLOSION
27 LARKHALL, GAS EXPLOSION
28 LARKHALL, GAS EXPLOSION Immediate Causes Medium pressure gas main failed. Gas tracked into solumn of house. Ignition of flammable natural gas-air mixture. Ignition source not determined Switching on an appliance Lighting a cigarette Static Almost perfect gas/air mix Whole family of 4 died in the blast House obliterated Whole roof tiles up to 400m away
29 LARKHALL, GAS EXPLOSION Failings Medium pressure gas main corroded. Ductile iron pipe thought to be polyethylene (from plan). Pipe replacement had not taken place. It was known that ductile iron corrodes unpredictably due to carbon inclusions during manufacturing. Pipe had been in place for 25+ years. Use of land had changed over time. Rubble under houses was capped with clay.
30 LARKHALL, GAS EXPLOSION Learning Always try to recognise change, No matter how slow it may seem. Always try to question change. No matter how insignificant it may seem.
31 LARKHALL, GAS EXPLOSION Any Questions?
32 BITUMEN What do you know about bitumen? Residues/Heavy ends from crude oil processing Highly viscous fluid, may be solid at ambient conditions Combustible, supports fire Has to be processed at high temperatures (c.300c) to become fluid enough for handling.. Widely used on roads
33 NYNAS REFINERY, DUNDEE Bitumen Production CRUDE KERO NAPHTHA ATM VAC HFO J303 BITUMEN
34 NYNAS REFINERY, DUNDEE Bitumen Production Heavy Crude feed (e.g. Venezuelan) to bulk storage Crude transfer (50-100C) Atmospheric Distillation to remove light ends (Naphtha) Reduced Crude transfer (300C) Vacuum distillation to penetration spec. Some blended into emulsions for cold processing. Bulk blending and distribution.
35 NYNAS REFINERY, DUNDEE J303 Reduced Crude Feed Pumps A & B
36 NYNAS REFINERY, DUNDEE 01:35a.m. on 10 th November 2010 Plant operating at 900 t.p.d. External call received to report smoke/steam on Nynas plant. Operator investigates area around J303 pumps Hears crackling sound. Sees liquid between pumps Does not see smoke Decides not to change over pumps and walks away Sees a blue flame and fireball Seal failure on pump diagnosed
37 NYNAS REFINERY, DUNDEE J303 Reduced Crude Feed Pumps A & B
38 NYNAS REFINERY, DUNDEE Incident Plant tripping Tayside Fire & Rescue Service called and on site Fire alarm activates via smoke detector Alarm sounders silenced ESD valve manually shut No one injured
39 NYNAS REFINERY, DUNDEE Incident - Foam System Foam pouring system did not automatically activate Foam pouring system failed to operate when manually activated Diesel fire pump manually started, still no foam Back up foam supply from containers used by TSFR to address incident
40 NYNAS REFINERY, DUNDEE Post Incident Foam System Typical zoned foam pouring system fed by diesel pump Loss of air pressure (quartzoid bulbs) activated system Six monthly external maintenance by TYCO MOU by pass found open MOU by-pass now locked closed
41 NYNAS REFINERY, DUNDEE Post Incident Foam System Single point of failure Disabled whole plant system MOU MOU By-pass
42 NYNAS REFINERY, DUNDEE Post Incident Fire suppression J303 Reduced Crude Feed Pumps A & B
43 NYNAS REFINERY, DUNDEE Post Incident Fire suppression How can fire be suppressed at these pumps? Steam snuffing system fitted Used a convenient steam supply nearby Not seen as a plant modification No risk assessment
44 NYNAS REFINERY, DUNDEE Post Incident Steam snuffing system What are the risks here?
45 NYNAS REFINERY, DUNDEE Post Incident Steam snuffing system risks High process temperature (>300C) Potential for condensate in steam no traps fitted Condensate in process could cause internal explosion Potential for injury/fatality of operator (in area) System isolated (advice)
46 NYNAS REFINERY, DUNDEE Incident J303 pumps Pump changeover manual Not identified as a particular risk System in excess of 300C during changeover Only a single mechanical seal on pumps Risk?... Revised procedures and assessment
47 ANY QUESTIONS?
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