cf lecture 8 incidents - loss of containment
TRANSCRIPT
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Incidents
Loss of Containment
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Learning from Accidents
A wise man learns from his own mistakes. A wiser
man learns from those of others. (Anon)
We learn wisdom from failure rather than from
success. He who never made a mistake, probablynever made a discovery. Samuel Smiles 1812-1904
Those who do not learn the lessons of history are
doomed to repeat them. George Santayana 1863-1952
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Incident
• Any undesired circumstance or occurrence which gives rise to, or couldgive rise to, ill health or injury, damage
to property, plant, products or theenvironment
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Accident
An undesired event, which results inphysical harm and /or property damage,usually resulting from contact with a
source of energy above the ability of thebody or structure to withstand it.
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Near-miss
An unplanned / undesired event which
has the potential to result in personal
injury, or damage to property, or harmto the environment
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ACCIDENT MODEL
THE LOSS
THE EVENT
THE IMMEDIATE CAUSE
THE UNDERLYING CAUSE
THE MANAGEMENT SYSTEM FAILURE
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THE LOSS
FATALITY
INJURY
PROPERTY DAMAGE
ENVIRONMENTAL SPILL
FINANCIAL LOSS
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THE EVENT
IMPACT
COLLISION
FIREEXPLOSION
LEAK
SLIP OR FALL
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IMMEDIATE CAUSES
SubstandardConditions
Substandard
Acts
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SUBSTANDARD CONDITIONS
• Inadequate guards or barriers• Inadequate or improper protective equipment
• Defective tools, equipment or materials
• Congestion or restricted action
• Inadequate warning systems
• Poor housekeeping
• Noise exposure• Radiation exposure
• Toxic material exposure
• Operation of equipment with isolated alarm orprotective system
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SUBSTANDARD ACTS
• Operating equipment without authority• Failure to warn others of known hazard
• Failure to operate equipment at theappropriate time
• Operating at improper speed• Making safety devices inoperable
• Removing safety devices
• Using defective equipment
• Failing to use personal protective equipmentproperly or at all
• Under influence of alcohol or drugs
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UNDERLYING CAUSE OF THE ACCIDENT
• Individual FactorsInadequate:
•Capability
•Knowledge
•Skill
•Motivation Inadequate:
•Inspection
•Engineering
•Maintenance
•Equipment
•Work Standards
Lack of Procedures
Inadequate LeadershipUnsafe work conditions
Unsafe systems of work
Job Factors
Organisation Factors
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MANAGEMENT SYSTEM FAILURES
• INADEQUATE LOSS PREVENTION PROCEDURE
• INADEQUATE LOSS PREVENTION STANDARDS
• INADEQUATE COMPLIANCE WITH LOSS
PREVENTION STANDARDS
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MANGEMENT SYSTEM FAILURE
• Inadequate loss prevention procedure• No operating procedure
• Inadequate loss prevention standards
• No system for reviewing operating
procedures• No system for checking standards are set
• No programme for hazard identificationduring design
• No work permit system
• No modification procedure• Inadequate compliance with loss prevention
standards
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Management System Defects
Incident
Root or Underlying Causes
Immediate Causes
Contact
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Loss of containment events
• Range from minute leaks to massive releases
• Can be liquid or gas
• Commonest defect in many industries, and
hence often ignored
• Majority occur during normal operations or
maintenance
• Often the trigger for larger events such as fireor explosion
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Piper Alpha 1988
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Transco pipeline failure USA
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Buncefield explosion and fire
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Where do releases occur?
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Which pipe do you mean?
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Offshore Christmas Tree
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I Chem E study into releases in chemical plantsand refineries found:
•Work systems 26%
•Mechanical damage 19%
•Internal corrosion 12%, external corrosion 6%,stress corrosion 3%
•Material problems 9%
•Freezing, vibration, thermal fatigue, water
hammer accounted for 8% and
•17% other or unclassified
Why do releases occur?
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HSE Hydrocarbon Database
• Set up to record release types and causes.
• 55% were gas releases, 17% oil, 15% condensate,and 13% were non- process.
•6% major, 55% significant and 39% minor.
• Equipment with highest leak rates wasinstrumentation, especially on turbines andcompressors which are subject to vibration.
• 6% of all releases ignited
• Mechanical was the highest failure mechanism.
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Work system failures
• Often occur as underlying cause or managementsystem failure.
• Inadequate design, fabrication, understanding of systems, planning or control of work, or
training/competency.
• Non existent or inadequate procedures, poorequipment, weak leadership
• Overall the biggest cause of incidents and
accidents e.g. Piper Alpha, Texas City, Buncefield,Flixborough, Bhopal, HCC Pasadena
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Mechanical damage
• Impact on piping or vessels during mechanical
handling
• Excavation without prior investigation
• Dropped objects
• Ship impact on pipeline risers
• Overstressing of components, overpressure
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Digger ruptures pipe
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Bombay High North platform
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Fake extended stud bolt
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Corrosion/material problems
• Corrosion and material failures together accountfor more leaks than any other cause
• Often due to inadequate understanding of process fluids composition, changes in
temperature/pressure/flow regime
• Often not observed e.g. corrosion underinsulation, or internal corrosion/erosion of pipes/vessels
• Deliberate/misunderstood use of inferiormaterials
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Failure during hydro test. Inadequate materials
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Other failure mechanisms
• Water or hydraulic hammer. Rapidly flowing
fluid hits elbow or valve. Very high pressures
generated.
• Pipe contents freezing and expanding.• External sources of heat.
• Vibration. Oscillation of pipes by wind or
flowing water. Inadequate pipe support.
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Novel pipe support
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Exploding aerosol can left in car on a sunny day
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Fractured pipe on vibrating compressor outlet
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Summary
• Loss of containment is probably the largest
cause of dangerous occurrences in the
chemical industry
• Often occurs on small or less significant lines• Can rapidly escalate to fire/ explosion or toxic
poisoning incidents
• The largest cause of fatalities in refineries and
offshore