DEVASTATING FIRE AT INDIAN OIL CORPORATION OIL

DEPOT (JAIPUR - 2009)

Presented by :ANKIT KHICHARIYA (09)

KARAN KARNWAL () MANISH SANGWAN ()RAHUL AGARWAL (38) SAMEER SHARMA (46)

THE INCIDENT• Date : 29th October, 2009• Time : 1830 to 1930 hrs

• Operation :

Transfer of Petrol from tank No. 401 C to M/S BPCL through pipeline

THE FACILITY• Receives petroleum products (Class A & Class B type ) including

Kerosene, Petrol & Diesel from Baroda refinery• The terminal has 11 tanks with an aggregate storage capacity of

more than 1 lakh kilolitres.

Storage Capacity Tentative Closing Stock

(as on 29.10.2009)

Product Capacity

Petrol 60,000 KL 17,810 KL

Diesel 40,000 KL 39,966 KL

Kerosene 13,500 KL 2099 KL

Interface - 2809 KL

How It Started ?• At around 5:50 pm tank No. 401 A (5500 KL of Petrol)

was being lined up for transfer of product to nearby BPCL facility.

• The outlet was provided with three valves in series• MOV (Motor Operated Valve)• Hammer Blind valve• HOV (Hand Operated Valve)

• At 1810 pm on Oct. 29, 2009 the spillage of MS started

• Till 1930 pm Leakage of highly inflammable petrol about 1000 tons took place

• It resulted in formation of vapour cloud, which according to a computer simulated model of such an incident turned out to be around 15 – 20 Tons.

• At 1930 pm presumably a Vapour Cloud Explosion (VCE) took place in the vicinity of the terminal and thereafter all the 11 tanks caught fire in a series and continued to burn for next five days.

• The fire continued till 0600 hrs on Nov. 11, 2009.

Scenario - I

• MOV was in open condition before the start of hammer blind reversal job

Scenario – I

• MOV opened accidentally when the blind was being reversed

Possible Scenarios

Probable Cause• Immediate Cause:

• Non – observance of normal safety procedure

• The hammer blind was not closed properly which allowed the petrol to come out in large quantity through the opening of the hammer blind.

Standard Operating Sequence Likely Sequence

1. Ensure MOV and HOV are closed2. Reverse the position of Hammer Blind Valve3. Open the HOV4.Open MOV (initially inching operation to

establish no leakage from Hammer Blind Valve body)

1. MOV opened first.2. Hammer Blind Valve opened3. Leakage started.

Root Cause:• Absence of site specific written operating procedures

• The safety audit report conducted by in-house experts of the company in February 2009 was SILENT about the ABSENCE OF SITE SPECIFIC SOP in the installation.

• Absence of leak stopping devices from a remote location• The audit team also observed that “emergency and disaster

management plan” are well defined but FAILED to indicate that this plan DOES NOT CONSIDER A MAJOR MS LEAK resulting in a large vapour cloud and the measures needed to deal with it.

• Insufficient understanding of hazards, risks and consequences• The Disaster Management Plan (DMP) booklet was undated and

appeared to be generalized and not specific to the site.

Source of Ignition

Trevor Kletz, the renowned safety professional has said “the vapour cloud formed does not worry about the

source of ignition; it will get it from anywhere”.

• The ignition energy required to ignite the vapour cloud is quite low (~ 0.2 mj)

• Probable source inside the terminal :• Electrical apparatus like lamp post, friction of material or any

other electrical equipment or vehicle.

• Probable source outside terminal:• Spark during starting a vehicle • Spark from other industries

Consequences of Incident• 6 consecutive Explosion

• Intensity of First Explosion was 2.3 on the Richter Scale.

• Fire in 11 storage tanks

• 11 Personnel Died

• 150 personnel seriously injured

• Pollution in Environment

• 5,00,000 people shifted to safe location

Consequences of Incident• Production in surrounding Industries affected

• Power cut losses to other Industries

• Cracks developed in the Houses close to depot

• Student living in nearby hostels taken to safer place

• Education in Schools & Colleges closed for several days

• About 30 establishments located around the terminal have been severely damaged in the incident.

Major Losses• Repairing cost of damaged houses

Rs. 5 Crore

• 60, 000 KL Petroleum products consumed in fire

• Estimated loss Rs. 280 Crores

Impact on Environment• Huge quantity of Carbon Monoxide (CO),

Carbon dioxide (CO2), Nitrous Oxide (NO2), Sulphur Oxides and un-burnt hydrocarbons (smoke) escaped into the environment.

• Respiratory problems to people residing in the nearby areas.

• Smoke also hit agriculture in the surrounding villages which supply vegetables and food grain to Jaipur.

Fire Protection Measures• All the tanks were provided with Medium Velocity

Water Spray (MVWS) System and foam protection system as a fire protection measure as per the norms of Oil Industry Safety Directorate (OISD)

• Water storage tanks – 02 Nos – of 24, 60,000 litres capacity each

• Fire water pumps – 05 Nos – of 113.89 M3/Hr capacity each. All were diesel driven pumps

• Jockey Pumps – 2 Nos – of electrical driven and capacity 2.78 litres/min

• Foam storage tank - 10,000 Litres• Fire water network in the entire terminal• Foam pourer system for all tanks• Water sprinkler system• Hydrants and Monitors

Shortcomings in Fire Fighting Systems

• Only diesel driven pumps were available• Water cum foam monitor was not available on

the Fire• water network• Cooling water system did not work, which

added the risk of fire on the other tanks• Foam system of the first tank also did not work

from where evaporating the flammable mixture• Inter tank distance was not followed

Shortcomings in Fire Fighting Systems

• Location of Fire Water Pump House was very near to the tank farm area

• Portable or fixed type Gas detection system was not available

• Condition monitoring system was not available• Personal Protective Equipments like B A set, Face

Mask, Fire Entry suit was not available.• No trained officer was deployed.• No policy for deputing a trained fire officer.• Lack of effective co-ordination.

LESSONS

• Implementation of applicable Codes & Standards .• Fire adequacy study to be done for installations.• Work Permit System should be strictly followed.• Intensive Operational & Fire Safety Training to be

organized at per level of employees at installations.• Green Belt around the Hazardous Industry required

to be developed.• Training on use of PPE by the operational staff &

Fire Services personnel.• Analysis of any fire incident and overcome the

lapses.

LESSONS

• Effective co-ordination monitoring system to be implemented.

• Gas/vapour detectors required to be installed in the sensitive locations, leakage prone areas.

• Testing of Fire Safety Systems as per regulation should be mandatory, Third party inspection may be incorporated.

• Control of such incident should be in the hand of the professional people

SNAPSHOTS of the incident

Thank You