incident analysis simple (edc

8/3/2019 Incident Analysis Simple (EDC

1/21


2/21

Over All leakage Trend

EDC/VCM (Jan-June)

0

10

20

30

40

50

60

70

JanFeb

MarApr

May

Jun

51

4240

46

69

25

Overall Half yearly Incident bar chart

Jan

FebMar

Apr

May

Jun

Incidents in

months , 25

0

10

20

30

40

50

60

70

80

Jan Feb Mar Apr May Jun

NoofIncidents

Trend of Incidents over last 06 months

Jan 51

Feb 42

Mar 40

Apr 46May 69

Jun 25

Total 273

Months No Of Leakages

Most vulnerable month

Reason (Continuous

shutdown from Jan to may

summary pasted below till

may)

Shutdowns Summary

3 - 18 Jan (Fur / Oxy) (16 days)

1 - 30 Mar (Fur / Oxy) (30 days)

1 - 5 Apr (Fur / Oxy) (5 days)




4 - 6 May (FurA) (3 days)

4 May - 19 Jun (Fur B) (15 days)

Total65days shutdown prior to the month of MAY which lead to fatigue and other

factors leading to incidents and if may shut down also included it goes to more then

100 days of shutdown

In next slide we will see the break down of theses incidents which will give a better

insight of the problems


3/21

EDC-VCM Incidents Monthly TrendJan Feb Mar Apr May JunNear misses 47 38 37 41 64 23

FAC 1 1 1

MTC 1

Process release 1 1

Operational upset 1 1 1

Process Incident 4 2 2 2 1

Fire 2

Env release 1

Total 51 42 40 46 69 24

0

10

20

30

40

50

60

70

Jan Feb Mar AprMay Jun

51

4240 46

69

25

No

ofIncidents

No of month

0

10

20

30

40

50

60

70

JanFeb

MarApr

May

Jun

47

38

3741

64

23

1

11

11

1

1

1

1

4

2

2

2

1

2

1

No

ofIncide

nts

Months

Incident Monthly break down To Types

near misses

FAC

MTC

Process release

operational upset

Process Incident

Fire

Envc release

Incidents Trend

High no of near misses are due to higher no

of leakages in the plant

May has highest no incidents then any other

months due high leakages in this month also for

reference see section of leakages latter

There are 03 operational upset in last six

months 01 cause shut down which was in April

rest of the 02 were in startup phase


4/21

45

46

47

48

49

50

51

Jan

47

1

1

1

1

operation

al upset

Process

release

MTC

FAC

near

misses

35

36

37

38

39

40

Mar

37

1

2

process

incident

operation

al upset

Nearmiss

38

39

40

41

42

43

44

45

46

Apr

41

1

2

1

1 FAC

process

release

process

incident

operational

upset

near miss

61

62

63

64

65

66

67

68

69

May

64

2

2

1

FAC

Fire

Pricess

Incident

Near miss

22

22.5

23

23.5

24

24.5

25

Jun

23

1

1

Env

Process Incident

Near miss

36

37

38

39

40

41

42

Feb

38

4

Process

Incident

near

misses

Incidents break down per month


5/21

0

10

20

30

40

50

60

70

80

90

Ops Maint Inspection I&E Others sharedresponsibilites

18

37

78

52

88

NoofIncidents

Incidents distribution on basis of dept responsible

6%13%

29%

19%

33%

Incidents distribution

w.r.t departments

Ops

Maint

Inspection

I&E

Others(multiple

discpline)

06 % of the total incidents that

were purely operation related

(which has 03 operational

upsets 01 process incident)

Most of the incidents are based on leakages at different points which led to a higher no of incidents in inspection department which has 78 no of

incidents (29%)

Rest others include shared responsibilities of misc group

2nd most vulnerable department in case of incidents is I&E which shares 19% of all incidents that took place at EDC/VCM plant

Pure operational related incidents are fewer then any other department but are critical as well room of improvement is there


6/21

1%

1%

1%

4%

1%

Nearmiss;

92%

Distribution of incidents type

Env Incident FAC

Fire MTC

Operational upset Process Incident

1, 4%

3, 13%

2, 9%

1, 4%3, 13%

11, 48%

2, 9%

Percentage of Incidents excluding Nearmiss

Env Incident

FAC

Fire

MTC

Operational upset

Process Incident

Process release

0

2

4

6

8

10

12

1

3

2

1

3

11

2

Env Incident FAC Fire MTCOperational

upset

Process

Incident

Process

release

No of leakags 1 3 2 1 3 11 2

Incidents bar graph as per type

Distribution of Process w.r.t

dept responsible

Near misses accounts for almost 92 percent of all incidents which lead to

other critical incidents needs to be control in future to a lesser extent

If we exclude Near misses largest no of incidents that took place are Processincidents total 11 (48%) out of which 08 are related to I&E and 03 to

operations

8

3

I&E Ops


7/21

Inadequate , 4

Proceduer not

followed, 17

Not available , 21

4

10

2

4

6

8

10

12

14

16

18

Inadequate Proceduer not followed Not available

No

ofIncidents

Category

Total (alldept.)Ops related

0

5

10

15

20

25

Inadequate Proceduer

not followed

Not available

4

17

2

1

4

1

Ops related

Total (alldept.)

4, 17%

Proceduer not

followed, 74%

2, 9%

Inadequate

Proceduer not followed

Not available

Procedure related Incidents

16%

Proceduer not

followed, 67%

17%

Procedure related incidents distribution(Operation )

inadequate

Proceduer not

followed

Not available

Procedure related incidents distribution

On analysis its shown that training on procedures and its ease of availability

is required to over come the not following part and already emphasis on internal

grooming is being taken care at EDC/VCM Plant

74% are the incidents related to procedures which are not being followedsimilarly 67% is the share in ops distribution of these incidents

Procedure not followed has a

huge share both in ops and all

other departments forincidents related

No of incidents comparison of

ops vs other departments


8/21

11-20% 20-36% 50-65% 70-85% 90-100% 105-120% 125-135%

27

11

161

48

10 7 3

Incidents distribution on the basis of score

allotted

11-20% 20-36% 50-65% 70-85% 90-100% 105-120% 125-135%

10%

4%

60%

18%

4% 3% 1%

Pie chart showing percentage of most

incidents as per rated score

11-20%

20-36%

50-65%

70-85%

90-100%

105-120%

125-135%

Almost of all the total score given to all incident lies in

the category of 50-60% and 70-85% which contributes

almost 78% of the all the incidents that occur during

last 06 months

High percentage of

incidents score lies in the

middle to top score

category which is alarming

as 88 % of all the whole

incidents lies in category in

between50-100%

Above charts indicate to have strong analysis of all those incidents lying in this score and formulating a way to minimize them and

their reoccurrence should not occur at any stage

Need to focus on major part of these incidents which is the middle portion also safety department to give feedback on these


9/21

0

2

4

6

8

10

12

14

16

Careless act Judgement Lack of

communication

16

11

13

2

3 3

Chart Title

All dept. Ops

0

10

20

30

40

50

60

70

80

90

100

normal

Operation

Plant start up Plant shutdown Commissioning

100

13

31

1

7

16

1

Events at which incidents occur most

Misc dept Ops

Incidents distribution on personnel behavior

Personnel issue(requirestraining)

Carless act

Judgment error

Lack ofcommunication

Most of the incidents that are

related to plant shutdown are

indicative of physical and mental

tirdness which includes slipping of

blind, injuries etc

Normal operation has high no

of incidents due to leakages

involved thats why score of

other dept is high as compared

to ops


10/21

0

10

20

30

40

50

60

70

PSI PHA O&MP SWP PSSR MI QA PT&P E&RP auditing

5

10

55

38

7

68

33

21

1 12 1

8 8

0 0

6

1 1 1

Total (all dept)

Ops

PSI2%

PHA

4%O&MP

23%

SWP16%

PSSR3% MI

29%

QA

14%

PT&P

9%

E&RP

0%auditing

0%

PSRM basis distribution of incidents (All dept)

PSI

7%

PHA

3%O&MP29%

SWP

29%

PSSR

0%

MI

0%QA

21%

PT&P3% E&RP

4% auditing4%

Are high due to high

number leakages on

the plant and

Safe work practices are align with

operation and maintenance

procedure both PSRM violations

are high and critical also

operation related incidents

major contributor s

Ops distribution of incidents indicating

area of concern is procedures and safe

work practices

Ops distribution of Incidents on PSRM violation

PSRM wise distribution of incidents


11/21

0

20

40

60

80

100

120

140

Fire in

furnace B

Gr-301

Tripping

Gr-301

Tripping

Partial power

faliuer

Oxy leakage

inlet line

Gr-301

Tripping

Steam gasket

rupture Lp

header

High

Acetylene in

MS-304

High moisture

in MS-403

Partial power

faliuer

(Transformer

1 Tripping)Incident 135 125 125 120 120 110 105 105 105 105

135125

125

120

120

110

105

105 105

105

Incidentscore

Area 300

Cause

MI

Resp

ALL

Area 300

Electrical

Issue

Resp

I&E

Top 10 Incidents at EDC/VCM Plant on basis of Score

Oxyinletleakagecausing

shutdownofpla

nt

Area 300

Electrical

Issue

Resp

I&E

Area

300

Electric

al

Issue

Resp

I&E

Area 300

Ops Upset

TT-306B

MI issue

tube

failure

Resp Ops

Sub station

Electrical

Issue

Resp

I&E

Sub Station

Electrical

Issue

Resp

I&E

Area 200

Process

release

MI issue

Resp

ME /INSP

Area 400

Ops

Upset

At start

up of

Area 200

Resp Ops

Area

400

Ops

Upset

LT issue

Resp

Ops/I&E


12/21

54, 77%

15, 21%

1, 2%

Distribution Of Leakages As Per Identity

MECHNICAL

INSTRUMENT

MACHINERY

1. Total no of leakages 70 in last 04 months till 2nd June

2. Average leak per months 18

3. 77% (54) of leakages occur on mechanical part of the plant that is 54 out of 70

4. 21% are leakages are due instrumentation of plant that is 15 leakages out of 70


13/21

1% 1% 1% 1% 1%3%

3%3%

3%

4%

4%

4%

CONNECTOR , 6%

tubing , 7%FLANGES, 11%

VALVES, 15%

Piping, 30%

seal

RD holder

PG

vessel

Purge point

FT mainifold

Burner assembly

GLG

Switches

GASKIT

BELLOW

Head cover (Exchanger)

CONNECTOR

tubing

FLANGES

VALVES

Piping

Vulnerable parts prone to leakages:-

The most prone part where leakages occur is process piping including fitting T-joints elbows etc which accounts for 30% of the total

leakages

Second most vulnerable area are Valves where leakages report goes to 15% and subsequently flanges has 11% and instrument

tubing connector 7% of the total leakages that occur during past four months

Parts prone to leakages

Distribution of leak points


14/21

Service where most of the leakages occur during last 04 month are

1. EDC

2. HCL &

3. Mix of EDC/HCL/VCM

0

5

10

15

20

25

1 1 1 23 3 4 4

6

10

13

22

No

ofleakages

Chemical Released

No of leakages due to serviceMost leaking services


15/21

2% 1% 1%3%

4%

4%

6%

6%

9%

Mix of EDC HCL VCM

, 14%

HCL, 19%

EDC , 31%

CL2

waste water EDC

carbon material

VCM

HeaviesVCM HCL

Cautic NaOH

10% HCL

Low Ph water

Mix of EDC HCL VCM

HCL

EDC

Break of leakages as per

Service released1. EDC accounts for more then

30% of the leakages that

occurred during last 04 months

out of total 70 leakages 22

leakages occurred at EDC

service then most highly leaking

service is pure HCL which has a

share of19% of the total

leakages that is 13 leakages out

of 70

2. In addition both HCL and EDC

accounts for 50% leakages that

occurred in EDC/VCM plant

and if mix ofEDC/HCL ANDVCM is taken in account it goes

to 60%

Distribution of leakages as per service leak

Area of

concern

hl k d


16/21

Monthly Leakages Trend

Shut down

Period Furnace A/B&oxy both

(Thats why ratio of

leakages are

minimum)

Reasons for High no Of leakages in MAY:-

MAY has the most no of leakages and June has also potential for high no of leakages month,

May apart from furnace incident has been running normal there are 3 major reason for high no of leakages in MAY

1. Plant was running no major shutdown apart from furnace fire

2. April has seen no of shutdown startups which resultantly effect the operation of MAY and increase leakages

3. 11th may high CL2 after which 05 Leakages occur at wash train before that only 01 leakage was reported

4. June also saw an equal amount of leakages including area 100/200 and area 900 as bulk of it

Shutdowns Summary

3 - 18 Jan (Fur / Oxy)

1 - 30 Mar (Fur / Oxy)1 - 5 Apr (Fur / Oxy)

6 - 10 Apr (Fur / Oxy)

15 - 17 Apr (Fur / Oxy)

28 - 30 Apr (Fur / Oxy)

4 - 6 May (FurA)

4 May - 19 Jun (Furnace B)

0

5

10

15

20

25

FEB MARCH APRIL MAY JUNE

0

5

10

15

20

25

JANFEB

MARCHAPRIL

MAYJUNE

20

16

9

16

21 21

Months 2011


17/21

Area -800

3%

Area -4004%

Area -200

12%

Area -600

11%Area -300

19%

Area -900

20%

Area -100

31%

Leakages distribution area wise

050 2281338214

14

8

Area 100 leakages break up

LTCA/B

periphery

wash train circuit

which contains

highest no of

leakages

AREAS HAVING HIGH RATE OF LEAKGES :-

1. A-100 is the most gray area where leakages has occurred time to time andparticularly wash train circuit which accounts for 63% of area100 leakages

2. Second most vulnerable areas include A-900 and A-300 which accounts for

20% and 19% of the total leakages combining these areas70% of the leakages

occur in A-100/300/900


18/21

0

5

10

15

20

25

Area -

100

Area -

200

Area -

300

Area -

400

Area -

600

Area -

800

Area -

900

22

8

13

3

8

2

14

Total

no of

leakages

Leakages at

AS-302 and its circuitLeakage on

overhead

circuit

13 7 (out of 0704 on Reflux circuit of

PP-302)

4 are on

over head

circuit

Total At Ko pots At backend

14 06

at ko-pots

06

backend area

Break up of Area-900 leakages

Break up of Area-300 leakages

(remaining 02 leakages at furnace side)

Remaining 02 leakages at burner assembly

2nd and 3rd most vulnerable areas are A-900 and A-300 respectively

Areas Most Prone to leakages and their break down

Top 03 most leakage

vulnerable areas

1. Area 100

2. Area 900

3. Area 300


19/21

0

1

2

3

4

5

6

7

8

9

10

HCL feed line toOxy Reactor tie in

leakage from PP101 B suction and

PP 101 A/B

common

discharge lines

and valve body

Heavy causticleakage gaskit

rupture

PP-302 A seal oilpot level grass

breaks

Bullet C SV upstream spool

clamped

leakage

Priming valve PP-302A (gland

leakage)

02 pin holes at PP101 A/B

circulation

line isolation

valve to MS 103

10m

8m

6.25m

5m

4m 4m

3m

Heavy leakages but

control without any

abnormality

Top Seven heavy leakages in EDC/VCM Plant

(last 04 months on the basis of extent of leakage)

Extentofleakage

Meter(m)

Description Of Leakage

A-200

A-100

A-100

A-300A-600

A-300

A-800


20/21

Recommendation of Analysis

Incidents that occur repeatedly should have high score then previously allotted for example

GR-301 Tripping on the same cause (control power issue) was scored 125 on all the three occasion

it occurred

1. 3-Feb -11

2. 7-Mar -11

3. 14-Jun -11 For such incidents Quality of B-report should also be check by Safety Department

(Resp Safety)

On the basis of these Incidents analysis Training on procedures and their availability to be ensured

(Resp All interfaces)

Refresher of SWP , OMP, MI and other high violated PSRM to be conducted

(Resp Safety, relevant dept)

PM plans and Inspection plan of all equipment to be shared and should address chronic and

problematic areas like A-100/800-900/300

(Resp Inspection)


21/21

Physical tiredness long shutdowns and continuous duties in these runs should be dealt with care in order to minimize the fatigueand mental tiredness of a employee esp. Maintenance person who works on 6 duty 1 rest Rota

On normal plant run leakages have been most choronic issue which led to high no of incidents where as shutdowns and start upseems to have process related issue as well as injuries issue

Most

21 TR done out of 70 leakages that is 30% of the total it is recommended to keep a close look at each TR done as in bullet C case atemporary repair was done on 11th April and after 8days a heavy leakage occur on bullet C same point from clamp, it is highlyrecommended to check integrity of such clamps and TR

Bullet C inlet manifold has 03 leakages during last 04 months which has a high probability of exposure to corrosive material asquench filters are deacon here all such circuits to be marked and highlighted and Inspection to be done

30% of leaks has occurred in process piping along with that other major 02 leak points are VALVES AND FLANGES there PM

plan to be revised and its effectiveness to be checked thoroughly as its is causing 26% of the total leaky points

THE END

incident analysis simple (edc

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