Summary Bullets
Failure to understand risk leads to 2 fatalities and 8 injured
Heat exchanger ruptured releasing a flammable vapor that exploded
Reliance on system software negates individual safety responsibilities
Background
A plant sustained a small leak on the process side of a heat exchanger. Action was quickly taken to repair it, but during the shutdown, the coolant dropped the exchanger temperature dangerously low, embrittling the metal.
As the process restarted, the heat exchanger ruptured, releasing a flammable vapor cloud. The vapor cloud traveled 170 meters before finding an ignition source. The massive gas cloud exploded and then caught fire, killing 2 workers and injuring 8. Because the plant was the sole supplier of natural gas to the region, the entire region had no gas for cooking, and factories employing 250,000 workers were left idle.
As the process restarted, the heat exchanger ruptured, releasing a flammable vapor cloud. The vapor cloud traveled 170 meters before finding an ignition source. The massive gas cloud exploded and then caught fire, killing 2 workers and injuring 8. Because the plant was the sole supplier of natural gas to the region, the entire region had no gas for cooking, and factories employing 250,000 workers were left idle.
What Happened
A corporate audit of the plant conducted just 6 months before the incident declared the plant’s process safety management system was in order. However, the incident investigation team found (Ref E.3) significant deficiencies in process hazard analyses, training, documentation, workforce involvement and communication, and management oversight.
The Royal Investigation Commission noted the company had a world class computer-based system to manage its process safety programs, but concluded the company’s use of it was flawed in that personnel over-relied on checking the boxes specified by the system rather than assuring actual safety, effectively failing to empower individuals to successfully fulfill their safety responsibilities. What other culture gaps might have contributed to this incident?
What culture factors led the Process Hazards Analysis team to fail to understand the hazards and risks they were evaluating and develop insufficient actions? Was failure to ensure open and frank communications and foster mutual trust the cause of the observed poor workforce involvement, communication, management oversight, and training?
The Royal Investigation Commission noted the company had a world class computer-based system to manage its process safety programs, but concluded the company’s use of it was flawed in that personnel over-relied on checking the boxes specified by the system rather than assuring actual safety, effectively failing to empower individuals to successfully fulfill their safety responsibilities. What other culture gaps might have contributed to this incident?
What culture factors led the Process Hazards Analysis team to fail to understand the hazards and risks they were evaluating and develop insufficient actions? Was failure to ensure open and frank communications and foster mutual trust the cause of the observed poor workforce involvement, communication, management oversight, and training?
Safety Culture Focus
A questioning environment supports a more thorough hazards analysis process.
Open, effective communications promotes greater awareness of risks and mitigation strategies.
Over reliance on software programs can undermine individual responsibility for safety.
Safety Culture Focus Note
**Only 54% of those surveyed indicated risk planning was a strength in their organization.**
Source File
E.29.pptx
(326.09 KB)