Recently the Indian chemical industry has been beset by a string of fatal incidents, all of them occurring when the plants were in the process of starting up after several weeks of lockdown. What can we learn from these incidents? Are there any lessons to be learned to avoid similar occurrences in the future?
Transient Process
These spates of incidents were not entirely unexpected. Starting up and shutting down a chemical plant has always been fraught with risk. Even with a template in place, the operators have to always expect the unexpected. Systems often don’t respond the way we would want them to and this can be very crucial in the transient process of startup and shut-down. Equipment and hardware which are at the end of their useful life can fail catastrophically during start-up. It is the period that requires the utmost attention and concentration of the human mind. Every start-up and shut-down presents unique challenges for the human mind.
Incidents
On 7th May, Styrene vapors leaked from a polymer plant in Visakhapatnam. It left 11 people dead; nearly 1000 people had to be evacuated. While this incident grabbed nationwide media attention because of the fatalities, other incidents that happened around this time evinced little interest. On the same day, 7 workers were injured in a power plant boiler explosion at Neyveli, near Cuddalore. Just hours before the Styrene leak, 7 workers inhaled some toxic gas in a paper mill, which was being readied for resuming operations after a protracted shutdown. Also on the same day, there was a fire in the packaging section of a pharmaceutical plant near Nashik. A couple of weeks later, there was a major
fire in a chemical plant handling ethanol and acetone near Pune. And soon after, 10 people
were killed in a major explosion in a plant at Dahej in Gujarat. At the time of writing this, a gas leak has killed the General Manager of a plant in Kurnool district. And just as were going to press comes the news of yet another incident, again in Andhra Pradesh, on the outskirts of Visakhapatnam, where benzimidazole gas leaked from a pharma unit. Two people died and four have been hospitalised.
Human Error
The fact that these incidents happened in close succession immediately after the relaxation of lockdown leads to the suspicion that the pandemic in some way or the other must have been responsible. These are extraordinary times for all of us. It cannot be denied that the pandemic has scarred our minds to varying degrees. While some people have been preoccupied with the security of their jobs and livelihood, others have been worried about the wellbeing of their near and dear ones. That these are stressful times would be an understatement. This series of incidents beg the question about the preparedness of the staff involved. Trevor Kletz, the grandfather of Process Safety, has famously said – All error is human error as people have to decide what to do; people have to decide how to do it; people have to do it. But he went on to add that blaming human error diverts attention from what can be done by better engineering. Prof James Reason eloquently summed this up – we can- not change the human condition, but we can change the conditions under which people work.
NDMA Guidelines
After the Styrene leak, National Disaster Management Authority (NDMA) has come out with a set of guidelines for restarting factories after the lockdown. The guidelines suggest that the first week after restart should be considered as a trial or test run during which companies should not aggressively ramp up production. Employees should be sensitized to identify abnormalities like sounds, smells, vibrations, leaks etc. Most of the ecommendations of NDMA are routine and would figure in the SOPs of major chemical companies, yet may not be in the playbook of some companies in the growing MSME sector. The guidelines call for a safety audit before the restart of the plant.
IChemE Good Practices
UK based IChemE has recently published a collection of good practices that will help businesses manage the extraordinary situation created by the COVID-19 pandemic. Top on the list is mental health. The guidelines warn that the current situation can adversely affect the mental health of its staff, either because of social isolation and loneliness or due to stress. Organizations should be aware of this and should develop programs that will promote the wellbeing and mental health of its employees. The white paper advocates that the management should “try to show a little less judgment about how others are acting and a bit more compassion for their circumstances, some of which we may not understand”.
CCPS Resources
US-based Centre for Chemical Process Safety (CCPS) has published 2 monographs giving helpful pointers on the unprecedented situation created by the COVID-19 pandemic. These monographs are freely available on their website. One contributor in the monographs interestingly draws a parallel between the present situation and the 2005 explosion at BP Texas City Refinery which was then operating with much-reduced staffing levels. Another parallel is in the 1998 Longford Esso incident, where the technical staff worked remotely from the plant site. The change in work culture and ethics due to some people working remotely from home needs to be fully understood. CCPS recommends “Activity mapping” to make sure that all tasks are fully covered in the event of understaffing.
Workplace Changes
The White Paper of IChemE has recommended some drastic changes for the shop floor to make sure the safety of the employees. Teams should be broken up into subgroups, so that one subgroup does not contaminate the other in the event of a fresh outbreak. Adequate backups should be ensured for critical roles. The entire shift should be segregated to avoid chances of cross-spreading. Physical distancing has to be observed while handing over shift. Workstations have to be regularly sanitized, while ensuring that the process integrity is not inadvertently altered and compromised. These practices could become permanent if the pandemic lingers on indefinitely.
Safety Science
It is a tragic fact that the science of safety advances mostly through hindsight. Each fatal incident, each near-miss, teaches us new lessons and adds incrementally to our knowledge. The Flixborough disaster of 1974 hastened the adoption of Hazop Studies and introduced the concept of Change Management. The Bhopal Tragedy of 1984 led to the Responsible Care movement. Following the attack on the World Trade Centre, businesses got alerted to the threat of terrorism and started preparing to counter it. The earthquake and tsunami at Fukushima in 2011 is another recent example. Even as recently as 2017, Hurricane Harvey taught us new lessons of how to respond in the face of an unprecedented deluge. The COVID-19 pandemic is another such “Black Swan” event which is making the industry introspect about their safety practices and test their robustness.
Readers’ responses may be sent to:
k.sahasranaman@gmail.com or
chemindigest@gmail.com
