Safety Alerts

Safest Plants are the ones you design, as if your son or daughter would be working one day in them

Safety Alerts: A few lines extracted from lengthy reports. Excluded: Fabrication/ commissioning Incidents

“Organisations have no memory. Only people have memory and they move on”. “Accidents are not due to lack of knowledge, but failure to use the knowledge we have” - Trevor Kletz

Visit regularly

https://www.csb.gov/ Incident Reports and simulated incident videos
https://www.hse.gov.uk/eci/incidents.htm Incident Reports
https://ccps.aiche.org/process-safety-beacon Monthly Process Safety Beacon
https://www.icheme.org/membership/communities/special-interest-groups/safety-and-loss-prevention/resources/lessons-learned-database/ Incident Reports

Read

Read ‘100 Largest Losses in Hydrocarbon Industry - Marsh’
BP Process Safety series (https://icheme.myshopify.com/collections/bp-process-safety-series)

Why Accidents Happen

Read http://www.aiche.org/sites/default/files/cep/20140728 Are There “Gorillas” in Your Plant?

Tasks that demand high attention, impair our ability to recognize a rare, unexpected and potentially hazardous and catastrophic situation.

And the 3 AM syndrome. An operator is woken up in LQ, handed a walkie talkie and asked to go fix something. Sure to start the wrong pump or close the wrong valve! (Thanks Natanael Bonicontro, for all the Petrobras-18 discussions!).

Marsh report: In the first 10 years of a plant, failures are operations related - learning curve. In older than 30 years plants, more due to mechanical integrity - corrosion/ thinning. Thickness may not meet updated standards.

EPSC (European Process Safety Centre) route cause analysis attributes 14% to design; 35% to mechanical integrity - corrosion/ thinning and 51% to operations. They recommend focus on 18 areas of operations, viz. Apply Double Isolation, Empty and De-energize before line-breaking, Monitor an open drain, Manage overrides of safety critical systems, Walk the Line, Verify leak tightness after maintenance work, Avoid working behind a single valve, Verify the condition of flexible hoses, Operate within safe limits, Control utility systems connected to a process, Report deficiencies on Safety Critical Equipment, Unplugging of equipment, Stay out of the Line of Fire, Control (Un)loading, Check atmosphere in fire box before igniting the burners, Avoid splash loading, Avoid run-away reaction, Report process safety incidents. See: https://www.epsc.be/documents/ps-fundamentals

Extracts from BP Process Safety series are marked BP. Extracts from IChemE Reports are marked IChemE. Extracts from “What Went Wrong”, Trevor Kletz are marked WWW.

Design Engineers: Check and ensure your design is safe. Add Caution Boxes in P&IDs. Some of the incidents are not caught by Hazop scenarios. E.g. Opening a sour service vessel results in Pyrophoric Fire.

Plant Engineers: UUpdate P&IDs and Operating Manuals with Caution Boxes and Start-up Tips. As people move on, their insight should not be lost. A well informed operation team is the Best Asset.

Wellheads & Flowlines

Choke Failure: P in/out =220/23 bar. Downstream check valve blocked with Ca(CO3)2 scale. High downstream pressure + blocked piston balance ports inside choke. Actuator ejected. Fatal injury
Wax deposits in flowlines: Flush with hot diesel/ water + heat tracing/ insulation
Water Injection: Hydrocarbon back flowed and brought H2S in sour fields. Injury and fatality. Show caution while opening/ breaking joints for maintenance
Waterflood pump plunger broke (blocked outlet?) releasing H2S laden water. H2S detectors were not regularly tested and didn’t alarm. Personal H2S detector was not used. Pumper fatally injured. Better ventilation of pump house or open-air installation of pumps
To avoid a shutdown, worker manually drained 2 vessels inside an insulated building into a bucket. He left the building to check other locations. The drained hydrocarbons vaporized inside the building and displaced oxygen. When he returned after 20 minutes, he was asphyxiated. Poor ventilation. No gas detectors. Personal gas detector was in his truck. CSB
Gas-lift: Small bore annulus PT tubing downstream of SDV failed and released HC. SDV closing was no use. Fittings, instrumentation and smallbore tubing on wells are subject to movement due to thermal growth or wave motion. Fit Wellhead SDVs close to wellheads. Shut SDVs with the same signal as SSVs
Riser ESDV Failure: 180 cases. Prime causes - corrosion, age and seizure/sticking. Analyze root causes before routinely bringing back ESDVs into service just by cycling/ lubricating
Riser ESDV Failure: Due to corrosion actuator bolting mechanism failed. Plate and spring impact on pipe and structure
HP Gas Well at 211 bar. ⅜” SS tubing not tightened to recommendation. Leaked. Instead of depressurizing first, operator attempted to tighten, releasing HP gas. Lung damage
HP Gas Well: Gas from a well at 316 bar was used to pressure test at 17.6 bar casing of another well, using a digital PG and a HP hose. The casing rated for 115 bar ruptured. Gas release. Fatality. (1) Such a pressure test done for the first time without any procedure (2) No PCV or RV on supply line (3) Dual rated digital PG, both in psig and bar, could have led to higher pressure
Gas well blow out: Gas with H2S gas released. 30m high gas cloud. 234 fatalities and 1,000+ injuries. Mountainous topography led H2S to populated low level locations
Static: Casing fluids bled into a plastic drum caught fire. Static build-up in the plastic drum. Read ‘HSE-RR804 Plastic Containers for Flammable Liquids, Hazardous Areas, Electrostatic Risks’
Hydraulic Oils: Under pressure in small bore pipes, subject to rupture. Fire hazard
Natural Gas Liquid Storage Cavern: Wellhead lockdown screw was removed instead of tightening by a battery-operated wrench left in reverse. Gas release and ignition. Use only hand tools on cavern wellheads. Vent to a flare system. CSB
Oil well control lost. Failed blowout preventer. Blowout - oil and gas release. Fire and explosion. Massive oil spill

Pipelines

European Gas Pipeline Incident Data Group: External interference (35%), construction defects 16%, corrosion 14% and ground movements 13%. Read their ‘Gas Pipelines Incidents Report’
Pressure in a buried HP pipeline was lowered and ground excavated for maintenance. Excavation damaged wall thickness by 75%. On pressure restoration, pipeline exploded. 250-450m high flame
14” Subsea pipeline severed by dropped anchor. Pipeline didn’t shut as PSLL was set very low. SDVs on 2 incoming lines were in branches
Ineffective anti-corrosion coating + poor cathodic protection of gas pipeline. Exploded
20-year old gas pipeline leak was clamped. On pressurization, the pipeline burst around the clamp point, weakened by clamping action
Gasoline pipeline routed around an oak tree. Bent section got punctured by excavator while installing an adjacent water pipeline. Released gasoline ignited by water pipeline welding
Condensate leak between Gas and NGL plants. Line ownership issues delayed isolation. Fire. 3 Crude units + 2 reformers damaged
Sour crude oil pipeline was cleaned with compressed air and a pig. Detonation. BP
For pig trap installation, a cold cut was made on an export gas pipeline. Leak. Fire. Platform destroyed
Crude Oil leak from 2 pipelines. Fire and explosion. Massive spill into the sea. Cause? Improper injection of desulfurizer, an oxidizing agent after a tanker unloaded oil
After a 30” pipe bend was cut, pipe support became unstable and the pipe bend rotated. Crushed the welder against the adjacent pipe. Serious injury. BP
A contractor instead of cutting an emptied propylene pipeline, mistakenly cut a butene pipeline. HP butene ignited and damaged other pipelines nearby. Fire and explosions

December 2025 Next

Page updated

Google Sites

Report abuse