LEARNING FROM INCIDENTS: A PERSONAL JOURNEY OVER DECADES OF MANUFACTURING

HAZARDOUS SUBSTANCES

RDC PRIOR

SHEXELLENCE CC, SOUTH AFRICA

MAY 2019

OUTLINE OF PRESENTATION• INTRODUCTION

• SEVERAL PROCESS INCIDENTS –DIRECT / INDIRECT INVOLVEMENT

• ABSENCE OF SIGNIFICANT PROCESS SAFETY INPUT

• PROCESS SAFETY DISCIPLINE STARTING TO DEVELOP

• LEARNING THE “HARD WAY”

• THE INCIDENTS• A RUNAWAY EXOTHERMIC REACTION

• A DANGEROUS START-UP OF A STANDBY BOILER WATER PUMP

• A HAZARDOUS ENTRY INTO AN ACID MIST PRECIPITATOR

• USE OF A FILTER ON A AMMONIUM NITRATE SOLUTION LINE

• MODIFICATION OF A NITROGLYCERINE SEPARATOR

• DEALING WITH AFTERMATH OF A MAJOR NG EXPLOSION

• CONCLUSIONS

INTRODUCTION• 1968 – 1998 : 30 YEARS MANUFACTURING HAZARDOUS SUBSTANCES

• PEROXIDES, ACIDS, AMMONIA, AMMONIUM NITRATE, EXPLOSIVES

• IN THIS PERIOD I WAS INVOLVED DIRECTLY AND INDIRECTLY IN A NUMBER OF SIGNIFICANT PROCESS SAFETY EVENTS

• RISKS WERE TAKEN (AS YOU WILL SEE)

• WITH HINDSIGHT – UNDERSTAND WHY DECISIONS WERE MADE

• NO REAL PROCESS SAFETY IN PLACE

• WITH TODAY’S KNOWLEDGE & EXPERIENCE WOULD DO VERY DIFFERENTLY

• BY ANALYSING 6 INCIDENTS, I WOULD LIKE TO DISTILL:• LEARNING POINTS THEN AND HOW THE INCIDENTS WOULD BE APPROACHED NOW

• HOW MY OWN GROWTH IN SAFETY TOOK PLACE

• HOW THE METHODOLOGY OF PROCESS SAFETY WAS DEVELOPING OVER THE PERIOD

• EXCUSE THE RECKLESSNESS EXHIBITED AT THE TIME – YOUTH & LACK OF KNOWLEDGE

1970 – LEARNING ABOUT RUNAWAY EXOTHERMIC REACTIONS

• IN UK, REACTING OLEFINS WITH H2O2

• SOAP INTERMEDIATES

• 1 TON BATCH REACTOR – GLASS LINED

• COOLING JACKET

• BLAST PROOF BUILDING - REMOTE

• MINIMAL INSTRUMENTATION –TEMPERATURE INDICATION

• ADDED ALL INGREDIENTS TOGETHER

• EVEN WITH MAXIMUM COOLING –TEMPERATURE RUNAWAY (SO DID WE)

• CONTENTS EJECTED ONTO BUILDING SURROUNDS – NO EXPLOSION

1970 – LEARNING ABOUT RUNAWAY EXOTHERMIC REATIONS

• DISCOVERED A PINHOLE IN THE GLASS LINING – IRON FROM THE STEEL CASING CATALYSED THE DECOMPOSITION

• PROCESS SAFETY AT THE TIME• NO SPECIFIC LEGISLATION• ICI WAS STARTING TO DEVELOP SOME PRINCIPLES OF TECHNICAL SAFETY e.g.

HAZOP• BUILDING DESIGN REFLECTED SOME UNDERSTANDING OF EXPLOSIVE

CONSEQUENCES• IN MY WORK – ONLY SAFETY CONSIDERATION WAS TO WEAR PPE• PERSONAL – I WAS MORE CONCERNED ABOUT THE OUTPUT THAN SAFETY ISSUES

• PROCESS SAFETY NOW – WE WOULD CONSIDER :• ASSET INTEGRITY (DESIGN, DETECTION OF LEAKS)• PSSR• SAFE PRACTICES IN ADDING MATERIALS INTO A BATCH REACTOR• EMERGENCY PLANNING

1972 -DANGEROUS START-UP OF A STANDBY BOILER FEED WATER PUMP

• NEW SULPHURIC PLANT – PYRITES BURNT IN ROASTER

• WASTE HEAT BOILER

• POOR ONLINE TIME – PRESSURE TO PRODUCE

• BOILER FEEDWATER PUMP FAILED WHILE I WAS IN CONTROL ROOM

• NEEDED TO START DIESEL STANDBY PUMP IN 3-4 MINUTES

• POSSIBILITY OF STEAM EXPLOSION IF DELAY OCCURRED

• AFTER 5-6 MINUTES, OPERATORS ASKED ME WHAT TO DO

• WITHOUT ANY ANALYSIS I INSTRUCTED THEM TO START

• THEY DID SO AND NO DISASTER ENSUED

• FAILURE TO ADD WATER – BOILER TUBES MELTED – 6

MONTHS DOWNTIME

1972 -DANGEROUS START-UP OF A STANDBY BOILER FEED WATER PUMP

• UNDERSTANDING OF MAJOR RISKS – STEAM EXPLOSIONS

• INADEQUATE TIME TO ASSESS RISK

• NO COMPANY REQUIREMENT TO DO RAs & NO TECHNIQUES

• I COMMITED A SAFETY VIOLATION (COUNTER PROCEDURE)

• NO PROCESS SAFETY KNOWLEDGE OR LAWS AT THE TIME

• IF CURRENT PSM STANDARDS WERE APPLIED• FEEDWATER FAILURE WOULD HAVE ANALYSED (HAZOP)• AUTOMATIC START UP OF STANDBY PUMP / PUMP TESTING• SOME FORM OF TRIP MIGHT HAVE BEEN SUGGESTED – LOPA STUDY• BETTER UNDERSTANDING OF MAJOR RISKS • AT THE TIME RISKS WERE MANAGED BY “GUT FEEL”

WAS I BEING A COWBOY?

1973 - UNSAFE ENTRY INTO AN ELECTROSTATIC MIST PRECIPITATOR

• SAME SULPHURIC ACID PLANT – SAME PRESSURE• EMPS WORKED WELL WHEN NEW – STARWIRES FAIL• MILD STEEL EATEN AWAY BY WEAK ACID, SHORT SECTION• PLUME OF S02/SO3 DEVELOPED, PROGRESSIVELY WORSE

WITH PLUME EXTENDING KILOMETERS – SHUT DOWN• POSSIBLE TO RUN EMPS IF SHORTED WIRES REMOVED• WITH PLANT STOPPED, I ENTERED THE CHAMBERS TO

PHYSICALLY REMOVE THE WIRES• WORE FULL ACID SUIT AND REMOTE AIR SUPPLY• HAD TO LIFT INTERNAL HATCHES TO GET TO WIRES• ACID LEVEL WAS AROUND MY UPPER LEGS• PERSON WAS ON STANDBY BUT NOT KITTED OUT • REMOVED THE WIRES• IF ANYTHING WENT WRONG – NO CHANCE OF ESCAPE

IDIOTIC ACT OR BRAVE ACTION?

1973 - UNSAFE ENTRY INTO AN ELECTROSTATIC MIST PRECIPITATOR

• DECISION MAKING AND PROCESS SAFETY AT THE TIME• NO PS LEGISLATION AT THE TIME• OCCUPATIONAL SAFETY ENTRENCHED AND GOOD STANDARDS IN SA• HAZARDOUS CHEMICALS RECOGNISED FOR OH IMPACT ON PEOPLE• MY DECISION TO ENTER EMPS WAS PLACING PRODUCTION BEFORE SAFETY• WAS TIME TO DO A RISK ASSESSMENT IF WE KNEW HOW & WHY• PTW SYSTEM WAS IN PLACE BUT NOT APPLIED TO PS TASKS

• IF CURRENT PSM STANDARDS WERE APPLIED:• APPLY PTW SYSTEM AND DO A RISK ASSESSMENT• SHUT PLANT DOWN COMPLETELY• ISOLATE THE EMPS ELECTRICALLY AND PROCESS – WISE• DRAIN THE ACID • OPEN THE EMP AND VENTILATE• ENTER AS PER CONFINED SPACE RULES• HAZOP / FMEA MAY HAVE EXPOSED ISSUES – BETTER MATERIALS

1980 -UNEXPECTED EXPLOSION IN INLINE AMMONIUM NITRATE FILTER

• NEW CAN PLANT – MANY DESIGN / OPERATING PROBLEMS• I WAS ASKED TO HAVE A GO AT IMPROVING PERFORMANCE (A STRENGTH?)• MOLTEN CAN SOLUTION PUMPED TO PRILL TOWER TOP – PRILL TOWER SPRAYS CHOKES• OVERSIZE CALCIUM CARBONATE PARTICLES• I DESIGNED AN INLINE STAINLESS FILTER WITH MESH SIZE AROUND 2mm • FOR THREE WEEKS HAD A RECORD PRODUCTION BUT ON A NIGHT SHIFT THE FILTER EXPLODED – NO

INJURIES BUT DAMAGE - FILTERED OUT OIL (RECYCLED AN) AS WELL – OIL BUILD UP

1980 -UNEXPECTED EXPLOSION IN INLINE AMMONIUM NITRATE FILTER

• DECISION MAKING AND PS AT THE TIME• NO PS REGULATIONS IN SA (OR UK, USA)• GENERAL AWARENESS OF AN HAZARDS BECAUSE OF MANY EXPLOSIONS• BELIEF THAT DILUTED AN (28%N) WAS SAFE - IRELAND, SOUTH AFRICA• AFTER FLIXBOROUGH AN AWARENESS OF MOC WAS EVIDENT BUT NOT LAW• NO REAL KNOWLEDGE IN SA. • CHANGE SEEMED LIKE A GOOD IDEA BUT NO RA. INFORMAL DISCUSSIONS

• IF CURRENT PS STANDARDS WERE APPLIED• LATER TESTS BY SOME COMPANIES / MILITARY SHOWED COULD DETONATE• FULL MOC WOULD BE DONE• HAZOP MAY HAVE IDENTIFIED THE OIL RISK BUT PERHAPS NOT• MODERN PRACTICE IS TO AVOID RECYCLING• STRICT CONTROL OVER ANTI-CAKING AGENTS – EXPLOSION RISK NOT EXPLICIT

1982 - MAJOR NG EXPLOSION FOLLOWING A MODIFICATION TO A SEPARATOR

1982 - MAJOR NG EXPLOSION FOLLOWING A MODIFICATION TO A SEPARATOR

• PLANT NOT UNDER MY CONTROL BUT MY INVOLVEMENT DEVELOPED

• NITROGLYCERINE MADE BY REACTING GLYCERINE AND MIXED ACID

• NG SEPARATED FROM THE SPENT ACID IN A SEPARATOR (SG DIFFERENCE)

• TWO STREAMS LEFT SEPARATOR AT TWO SEPARATE POINTS

• SPENT ACID WAS RUN DOWN TO 6X80 TON TANKS AND PUMPED TO THE CHEMICALS AREA (MY PLANT) ABOUT 1.5km AWAY.

• WHEN THE OPERATOR STARTED THE DESPATCH PUMP, THE PUMP & LINE EXPLODED KILLING HIM

• THE NEXT DAY A TEAM OF 8 PEOPLE AT THE SPENT ACID TANKS WERE CAUGHT IN A MASSIVE BLAST AND DIED

• INVESTIGATION SHOWED THAT THE RIGID PVC LINE AT THE SEPARATED OUTLET HAD BEEN REPLACED WITH A LAMINATED PVC SECTION. THIS HAD DELAMINATED DUE TO THE NG BEING PRESENT & NG EXITED WITH THE ACID

• IN THE CHEMICALS AREA I WAS PRESENTED WITH 320 TONS OF THE SAME ACID AND HAD TO DEAL WITH THIS IN A VERY INNOVATIVE WAY – STORY FOR ANOTHER DAY!

1982 - MAJOR NG EXPLOSION FOLLOWING A MODIFICATION TO A SEPARATOR

• DECISION MAKING AND PROCESS SAFETY AT THE TIME• TWO SIGNIFICANT DECISIONS a) REPLACE PVC PIPE b) EXPOSE 8 PEOPLE TO RISK

• DECISION TO REPLACE PIPE MADE ON COST

• DECISION UNKNOWN TO PRODUCTION / MAINTENANCE STAFF

• NO MOC SYSTEM IN THE EXPLOSIVES DIVISION – THEY WERE “DIFFERENT”

• MOC IN PLACE IN CHEMICALS OPERATIONS – SOME PS ELEMENTS APPEARING

• NO LEGAL REQUIREMENT FOR MOC IN SA

• FUNDAMENTAL PRINCIPLE IN EXPLOSIVES – MINIMUM EXPOSURE AT ALL TIMES

• EXPLOSIVES REGULATIONS APPLY THE SAME PRINCIPLE

• GAP OF HOURS BETWEEN EXPLOSIONS – LED TO BELIEF ALL IS WELL

• NO FURTHER EXPLOSIONS EXPECTED

• NG WAS AND REMAINS UNPREDICTABLE

• CIMAH IN UK – 1984, NO PS LEGISLATION IN SA

1982 - MAJOR NG EXPLOSION FOLLOWING A MODIFICATION TO A SEPARATOR

• IF CURRENT PS STANDARDS WERE APPLIED• IT IS UNDERSTOOD TODAY THAT PS IS APPLICABLE TO ALL PROCESSES INVOLVING

HAZARDOUS CONDITIONS AND SUBSTANCES. COMPARE DEEPWATER HORIZON!

• A MOC / RISK ASSESSMENT WOULD BE CARRIED OUT. THE EXPLOSIVES INDUSTRY IS VERY SENSITIVE TO ALL CHANGES INCLUDING VERY SMALL ONES

• STILL CONCERN TODAY THAT SUPPLIERS AND PURCHASING STAFF ARE NOT FULLY ONBOARD WITH MOC.

• HOPEFULLY, THE SENSE OF “CHRONIC UNEASE” WOULD BE STRONG AND REMIND MANAGERS TO TAKE THE CONSERVATIVE ROUTE

• EXTREME CAUTION SHOULD BE TAKEN IN APPROACHING LARGE QUANTITIES OF THE SAME MATERIAL THAT HAD EXPLODED THE DAY BEFORE.

• THE 320 TONS OF THE SAME MATERIAL WAS DEALT WITH THE NEXT DAY USING A “HYPER-DEVELOPED” SENSE OF UNEASE AND CONCERN.

1994 - DEALING WITH THE AFTERMATH OF A MAJOR NITROGLYCERINE EXPLOSION (7 FATALITIES)

• AS PRODUCTION DIRECTOR – WAS DIRECTLY RESPONSIBLE

• ABOUT 1 TON DETONATED (FULL TUB) – NO CAUSE FOUND BY US OR DOL

• AS A MANAGER, I FOUND THE MULTIPLE AREAS OF THE AFTERMATH EXTREMELY CHALLENGING AND DIFFICULT.

• NONE OF THIS IS TAUGHT IN ANY COURSE

• HAD DETAILED EMERGENCY RESPONSE PRACTISED PLANS

• “CHRONIC UNEASE” WAS WELL ESTABLISHED

• COMPLEXITY & EXTENT OF RESPONSE / DEMANDS FROM AFFECTED SECTORS WENT FAR BEYOND ANY OF OUR PREDICTIONS

• THE DIAGRAM ON THE NEXT SLIDE SHOWS THE SECTORS THAT HAD TO BE MANAGED

1994 - DEALING WITH THE AFTERMATH OF A MAJOR NITROGLYCERINE EXPLOSION (7 FATALITIES)

1994 - DEALING WITH THE AFTERMATH OF A MAJOR NITROGLYCERINE EXPLOSION (7 FATALITIES)

• CUSTOMERS• MAJOR CUSTOMER ANNOUNCED 50% OF BUSINESS GIVEN TO COMPETITOR• SUDDENLY SEEN AS UNRELIABLE • MARKETING TEAM VISITED AND SOLD THEM SOUND ALTERNATIVES• UNEXPECTED DEVELOPMENT

• WORKFORCE• 3500 WORKFORE WENT ON IMMEDIATE STRIKE – DEMAND FOR DANGER PAY• COMPETENT SENIOR MANAGER LED TEAM TO NEGOTIATE WITH UNION• MILITANCY – SOME INFRASTRUCTURE DAMAGE• ADRESSED A MASS MEETING – VERY DIFFICULT & SENSITIVE QUESTIONS• GOT AN AGREEMENT – NO EXTRA PAY – DIFFICULT ATMOSPHERE FOLLOWED• DID NOT PREDICT THIS – NOT IN EMERGENCY PLANNING – 7 WEEKS STOCK!

• ONGOING OPERATIONS• STRONG COMMUNICATIONS WITH THE LIMITED ONGOING OPERATIONS• TRIED TO MINIMIZE CONCERN AND SENSE OF UNCERTAINTY

1994 - DEALING WITH THE AFTERMATH OF A MAJOR NITROGLYCERINE EXPLOSION (7 FATALITIES)

• REGULATOR AND PUBLIC ENQUIRY• WRITTEN AND PHYSICAL EVIDENCE COLLECTED BY DOL• LIST OF MANAGERS AND WORKERS TO BE INTERVIEWED IN EQUIRY• PUBLIC ENQUIRY HELD BY MAGISTRATE• LEGAL REPRESENTATION FOR MANAGERS, WORKERS, UNIONS, FAMILIES• BRIEFED ON WHAT / WHAT NOT TO SAY• 2 DAYS SPENT ON PROVING WORKERS WERE TRAINED• 1 WEEK ENQUIRY – NO FINDINGS• UNPLEASANT EXPERIENCE – LAWYERS TECHNICALLY INCOMPETENT• NEVER RECEIVED ANY TRAINING FOR THIS ASPECT OF THE JOB

• INTERNAL INVESTIGATION• DOL LOOKS AT BREACH OF LAWS, COMPANY NEEDS TO GET TO ROOT CAUSES• PARALLEL INVESTIGATION LEAD BY ONE OF MY MANAGERS• INTERNAL INVESTIGATION HAD MORE INFORMATION – NOT OFFERED TO DOL• VERY DIFFICULT SITUATION – DOL ACCESS TO INTERNAL INFO• THIS INVESTIGATION FAILED TO FIND ROOT CAUSES OF THE INCIDENT

1994 - DEALING WITH THE AFTERMATH OF A MAJOR NITROGLYCERINE EXPLOSION (7 FATALITIES)

• HEAD OFFICE• LOCAL HEAD OFFICE VERY SUPPORTIVE AND HELPFUL – MATERIAL & MORAL

• OVERSEAS HEAD OFFICE ONLY REQUIREMENT “KEEP US INFORMED”

• LEARNT LATER THAT THE FIRING OF MYSELF AND / OR THE MD WAS CONSIDERED

• A TECHNICAL TEAM AUDITED OPS – SOME SYSTEM DEFICIENCIES

• TOTALLY UNPREPARED FOR THE POLITICS OF THIS SITUATION

• SELF• HAD TO ENSURE WE MANAGED ON ALL FRONTS

• HAD SOME COMPETENT MANAGERS WHO HELPED CARRY THE LOAD

• MOST SERIOUS CHALLENGE IN 30 YEARS OF MANAGING

• BECAUSE OF THREATS – HAD 24 HOUR BODYGUARDS

• VERY HIGH STRESS LEVELS – POOR SLEEPING – NO TRAUMA COUNSELLING

1994 - DEALING WITH THE AFTERMATH OF A MAJOR NITROGLYCERINE EXPLOSION (7 FATALITIES)

• NO AMOUNT OF PLANNING COULD HAVE PREPARED FOR THIS

• MUCH MAKING IT UP “ON THE RUN”

• EXPERIENCE AND AN ABILITY TO MAKE QUICK DECISIONS

• ROBUSTNESS A KEY ATTRIBUTE – THE “EYE OF THE STORM” IS NOT A COMFORTABLE PLACE TO BE

• ORGANISATIONAL SUPPORT CRITICAL

• PERHAPS A “CASE STUDY” APPROACH COULD BE USED TO GIVE PEOPLE A TASTE OF THE REAL THING.

BOTTOM LINE – DO ANYTHING (FOLLOWING GOOD PROCESS SAFETY PRINCIPLES) TO PREVENT A MAJOR INCIDENT – YOU MAY NOT SURVIVE

ONE AS A SENIOR MANAGER

CONCLUSIONS

• HAVING A CAREER MANUFATURING HAZARDOUS MATERIALS OVER MANY YEARS – YOU WILL BE EXPOSED TO MANY INCIDENTS

• IN MY EARLY YEARS – FOCUS ON PRODUCTION AT THE EXPENSE OF SAFETY

• COMPANIES AND MYSELF GRADUALLY EVOLVED INTO A BETTER UNDERSTANDING AND PRACTIONER OF THE ELEMENTS 0F PROCESS SAFETY

• THE CASE STUDIES ILLUSTRATE HOW THE INCIDENTS WOULD BE HANDLED TODAY. IN MANY CASES THE INCIDENTS WOULD HAVE BEEN PREVENTED!

• MY PERSONAL LEARNING INCLUDED TECHNICAL AND PEOPLE/ SYSTEMS ASPECTS – HOPEFULLY YOU LEARNT A THING OR TWO

• WE DO NOT ALWAYS KNOW EVERTHING ABOUT HAZARDS WE MANAGE - THERE CAN BE SURPRISES!