WHAT IS BROKE? The Story So Far – Unrelenting Tragedies

This Presentation

• In 20 minutes we can only touch the surface and not an in-depth analysis.

• But the purpose is to provoke thought, discussions and create awareness.

• Points to possible areas for attention.

• Bottom line:

“WE ARE NOT DOING IT RIGHT! BUT WE CAN!”

09/02/2015 3

Unrelenting Tragedies.....over 40 years

Seveso 1976 Flixborough 1974

Bhopal 1984

Norco, Louisiana 1988

Grangemouth 2000 Humber Oil Refinery 2001

BP GOM Macando 2010

Texas City 2005

Pasadena, Texas 1989

Longford 1998

Buncefield 2005

Piper Alpha 1988

Henderson, Nevada 1988

Alon 2008

Skikda 2004

Pembroke Chevron Refinery 2011

Kaohsiung Gas Line 2014

Petro China Gas Field Explosion 2003

Guadalajara Pipeline Explosion1992

Georgia (USSR) Gas Explosion 1984

Tanker Truck Fire Chennai India 1994

Nigeria NNPC Oil Pipeline Explosion 2008

Propane explosion Indiana 1983

LPG Truck Explosion, Thailand 1990

Oil Tanker Explosion, Ireland 1979

Paraguana Refinery Complex, Venezuela 2012

Bridger Pipeline Failure Yellowstone 2015

35 Years Failure Snapshot: 1965 - 2000

Source: DNV

Major Property Loss 30 Years: In Oil Gas & Process Industries

5 From TWI, UK

TANKS AND PIPELINES The Same Story. Little improvement

Tank Major Incidents Statistics*

*Based on Compilation by James I. Chang & Cheng-Chung Lin, Taiwan Extracted from Journal of Loss Prevention in Process Industries

0

10

20

30

40

50

60

70

80

90

1960-1969 1970-1979 1980-1989 1990-2000 2000-2003

Pipeline Incidents Data - USA

Extract: “The Blaze” blog

No Respite!

The Human Cost Year Reference Location Dead

1984 Bhopal 20,000

2003 Petro China Chuangdonbei 234

1992 Guadalajara Gas Line Leak 206

1984 Gas Explosion, Tbilisi, Georgia 200

1995 Chennai Petrol Tanker Truck 110

2008 NNPC Nigeria Oil Pipeline Explosion 100

1982 Western Ranger Oil Platform, Canada 84

1963 Indiana, USA, Propane Explosion 74

1990 Bangkok, Thailand LPG Tanker Explosion 63

2014 Sinopec Pipeline Explosion 63

1980 Ortuella, Spain. Gas Explosion. 49

2012 Paraguana Refinery Complex, Venezuela 48

1984 Petrobras Campos Basin Explosion 36

2013 Qingdao, East China 35

Bhopal 1984 20,000 deaths

Sinopec Pipeline 63 Deaths 2014

The Human Cost Year Reference Location Dead

1974 Flixborough Disaster, England 28

2004 LNG Plant Explosion, Algeria 27

2004 Gas Explosion, Belgium 24

1989 Phillips Plant Incident, Pasadena, USA 23

1997 Hindustan Petroleum Refinery 22

1966 Propane Sphere Explosion, France 18

2005 Texas City Refinery Isomerisation Unit 15

2013 West Fertilizer, USA 15

2014 Taiwan Gas Pipeline 14

2010 Deepwater Horizon 11

2000 El Paso Pipeline Explosion, USA 10

1983 Gas Explosion. Lodz, Poland 8

2010 Tesoro Refinery H.E. Explosion. 7

2007 Xcel Energy, Colorado, USA 5

Texas City 2005: 15 deaths

Tesoro Refinery: 7 deaths

More Codes, Standards,

Regulations, Inspection

Technologies. Yet Frequency of

Major Incidents continues!

Not Enough! Something else is missing!

What Are We Getting Wrong?

“AGEING”...ONLY MAKES MATTERS WORSE.

Is my plant too old to function reliably?

It’s Not About

Year of Construction.

Images from 121clicks.com

It is about how well was

It cared for*.

.

* HSE UK: Managing Ageing Assets

Guideline

Beating the Curve

Critical Care

Intensive Care

Life Extension Strategy

Curve from ABB, Teeside. All animated indicators: KB

The FEMI*: Causes of Ageing

FEMI – Fixed Equipment Mechanical Integrity

Principal Cause of Ageing: Metal Degradation due to

Corrosion & Stress

Ageing – The Main Reason: Metal Degradation

Ageing Mechanisms STRESS WEAR/

EROSION THERMAL

STATIC CYCLIC Time Based Metallurgical Transformation

CORROSION SCC₁ CF₂ Corrosion-Erosion

Creep Embrittlement TF₄

Examples of Plant affected components >>

•Stainless parts: Valve Springs, H.E.Tubing

H.E. Tubes •FCCU Slide Valve •Piping at support

•Heater Tube •Furnace Fittings

•SS Heater Radiation

Reflection Cone

•Heater Tube supports •HE Tubes •GT parts

1: SCC - Stress Corrosion Cracking

2: CF - Corrosion Fatigue

3 TE - Temper Embrittlement

4. TF – Thermal Fatigue

The E/I&C Challenge of Ageing Plants

What To Look For

o E/ C& I – equipment which impact on Major Incident Prevention.

o Installed to act as ESD

o Trips, Alarms

o HLA and ESD in Storage Tanks.

o SCADA Systems in Pipelines.

o Obsolescence in ageing plant I&C.

After Static Equipment: The Second Most Important Asset Class

The 50’s: Obsolete?

If our state-of-the-art

system in NOT working, Then

we are back to the 50’s!!

The HSE Report (UK)

50% of European Major Hazard LOC’s₁ arose from technical failures primarily due to ageing plant mechanisms.

o Erosion

oCorrosion

o Fatigue

oC&I Related events.

What if we could mitigate these risks by a “Find-and-Fix” by LES ?

1 - HSE Guideline for Managing Ageing Assets

Ageing Can Be Arrested and The Ageing Curve Re-Routed

BUT

WHAT WE ARE GETTING WRONG!

1. Failing to retain or build Competency on the site.

2. Savings with no Risk Evaluation.

3. Failing to practice LFI as a structured exercise: Can it happen to us?

4. Failing to categorize High Risk Assets: Tanks in hazardous service,

pipelines, process piping, Process Safety-Critical I&C

5. Underestimating the Human Factor.

6. Turning MOC and RCA into a tick box exercise.

7. Failure to Communicate.

A few points from past failures

SAVING COSTS WITHOUT RISK ASSESSMENT Asset Management Budget: Risk Based Cost Cutting

Historical Oil Prices

The Start of the “Cost Savings” Era

Saving On The Wrong Priorities

“Cost cutting was not carried out as a

structured, managed and measured process”

From the Independent Baker Report into the BP Texas City Accident.

Must be based on Expert Risk

Evaluation

REPEATING MISTAKES Over and over and over again.......

We are not learning. Keep repeating the same mistakes!

Do NOT save on low cost high risk assets!! Following cases of overfills leading to disaster:

• Union Carbide - Bhopal

• BP Texas City – Houston

• Caribbean Petroleum – Puerto Rico

• Buncefield – U.K.

• Overfilled tanks globally killed 29 persons and caused devastating fires.

Technical Causes Repeat Themselves

Immediate Causes

Alpha Piper LOC: Final: Overflow.

Texas City LOC due to malfunctions LI = Overflow + Human Factors+ Others

Buncefield LOC by Overflow due to Inadequate SIL design. Single LI not working + Human Factor. Poor Auditing.

Taiwan Pipeline 2014 Corrosion.

China Pipeline 2014 Inadequate inspections; undetected Corrosion.

Chevron Fire 2012 Corrosion. Misguided Savings to avoid alloy change.

Bhopal Avoidable through design. Overflow: LOC.

Caribbean Refinery T/Farm, Puerto Rico

Overflow of tank. Non-functioning C&I system.

Thailand ARC tank farm fire

Overflow. Defective C&I and wrong response to alarm.

Tesoro H.E. Explosion Corrosion. Error in Data Interpretation in Code.

20,000* dead; 200,000

Blinded and Injured

The Worst Industrial Disaster in Human History

* Wikipedia

The Aftermath At Humber

13 Dead; 100+ Burnt and Injured

BP Texas City Refinery 2005

BP GOM Deep Water Horizon, Macando Field April 2010

o Claimed 11 lives o Discharged 4.9 Million bbls. Of Oil o Oil flowed for 87 Days o Biggest Marine LOC in History o $ 5.0 Billion in Fines. o Damages budgeted to cost $30 Billion.

Tesoro Heat Exchanger Fire 2014

Hydrogen Attack

7 Dead

Material Failure

Sinopec Crude Oil Pipeline Explosion 2013

Oil leaked into

Municipal Grid

Similar to Guadalajara,

Mexico

Tanks Overfill and Ignite Fatalities From Tank Overfills

Buncefield 2005

Caribbean Petroleum Refinery Puerto Rico Disaster 2009 – 4 Years after Buncefield!!

Company goes into

Bankruptcy

Repetition of

Buncefield!

Why do we keep making the same mistakes? Fix the Underlying Causes or else the Recurring Immediate Technical Causes will continue to cause Accidents!

The “Eerie Similarities in Underlying Causes” The Underlying Cause of

Failure

The Texas City

Refinery

Incident

The Buncefield

Terminal

Incident

The Deepwater

Incident

1 Design and layout mistakes. Or,

lack of redundancy in critical

equipment.

X X X

2 Poor Risk Assessment. HAZID X X X 3 Cost savings driven without

Risk Assessment X X

4 Poor communication between

contractor and client X X X

5 Failure to learn from other

incident reports (LFI) X X X

6 Time savings driven without

Risk Assessment X

7 Lack of application of

Management of Change process X X X

8 Not following up on

maintenance of safety critical

equipment

X X

9 Operational shortcoming /

Procedural error/ Lack of

control.

X X X

10 Human Factor issues.

Incompetence. Exhaustion.

Lack of Supervision, etc.

X X

COMPETENT PEOPLE ARE A MAJOR INCIDENT BARRIER Why Codes, Standards and Prescriptions Cannot Save Us.

Point to Ponder

“The key to good decision making is not

knowledge. It is understanding. We are

swimming in the former. We are desperately

lacking in the latter.”

Malcolm Gladwell, Blink: The Power of Thinking Without Thinking

API 580 (RBI RP): Introduction

“Users of this RP should not rely exclusively on

the information contained in this document.

Sound business, scientific, engineering, and

safety judgement should be used in employing

the information contained herein”.

Emphasis: KB

“Good occupational health and safety

performance of an asset does not guarantee good major incident prevention. ....additional technical skills and competencies are needed to manage Major Incidents Risks”.

Pg.3 Health & Safety Executive (UK) Guideline for managing Ageing Assets (Emphasis:kb)

Warning from the OGP Asset Integrity Guideline

HR Policies must Support AIM

• Knowhow walking out the door – too aggressive and not risk assessed head count reduction.

• Mixing up information with knowledge and knowledge with understanding. Not the same thing.

• Saving on specialist technical training which are critical to Process Safety – bad economics! One right decision can save you millions and may be even lives.

Easier said than done! The Competency Challenge

1. The Missing Generation of engineers, technicians, tradesmen and operational managers.

2. Failure to have a succession plan. “Ageing assets have ageing managers!”

3. Wisdom walking off the job ....no knowledge capture or replacement.

4. Process Safety-Critical jobs not identified. Should be a

“No-Lay Offs- Zone”

5. Excessive dependency on contracted expertise without being intelligent consumers. One needs the other

6. Attracting talent back – recruiting experience

AIM AS AN INTEGRATED MULTI-FUNCTIONAL MANAGEMENT RESPONSIBILITY. The basis for an AMS Approach

Everyone must do their part The Holistic Nature of AIM

AIM

HR

Finance

IT

Operations

Engineering&

Inspection

Contracts & Procurement

Managing Assets is a multi-functional activity, led by the Business Leadership

WHAT NEXT?

Life Extension Review For Ageing Facilities

• Independently led –reporting to Top Management

• Supported by Plant’s Technical Team

• Each Recommendation Risk Evaluated.

• Detail a Life Extension Plan with Cost & Schedule.

• “Find-and-Fix” basis to avert Major Incidents

For complete presentation contact;

Kiriti Bhattacharya bkiriti@yahoo.com Mobile: 1-868-749-2449

Land: 1-868-223-9502