P.K. Singh, DGM (EMD)K.C. Sajan, Mgr (SED)P.K. Singh, DGM (EMD)K.C. Sajan, Mgr (SED)

PROCESS S AFETY

CASE STUDYBHILAI STEEL PLANT

(Steel Authority of India Ltd)

Safety Culture 

Generative Proactive ReactiveCalculative Pathological

“Who cares as long as you don’t get caught”

“Safety is only an issue if something happens”

“Safety is managed by procedures & 

documentation”

“Safety is managed by workforce 

involvement”

“Safety is how the 

business is run”

PS Approach

Weak  Strong• Assigns little value to PS • Integrates PS into the core values of 

the organization• Has poor sense of PS vulnerabilities • Focuses on potential failures to 

understand the risk & means of controlling it

• Devotes minimal resources to PS • Provide resources proportional to the perceived needs

• Overlooks small indications of  PS  problems

• More emphasis on learning from mistakes to prevent future problems

• Accepts or normalized increasingly poor safety performance

• Put efforts to continuously improve PS performance 

• Relies solely on few individuals or management to determine PS hazards & risk management activities

• Employees of all levels are involved in hazard identification and riskmigation. 

Management Leadership & Commitment

Operating Procedures & Safe Practices

Process TechnologyRisk Assessment &

Process Hazard Analysis

Management of Change

Quality Assurance

Pre Start Up Safety Review

Mechanical Integrity

Management of Subtle-Change

Training & Performance

Contractor Safety & Performance

Incident Investigation

Management of Change (P)

Emergency Planning& Response

Auditing

PSM Elements

PHA‐ Technique 

• Hazard Identification: Toxic, Flammable, Explosive, Chemical, Potential (Pressure, Thermal, Volume) etc

• Site Visits• Consequence Analysis: Direct Impact, Aloha (Gas Dispersion)

• Process Hazards Evaluation: What If analysis, FMEA, HAZOP, FTA, LOPA, Bowtie etc

• Risk Evaluation:   Risk = Consequence X Frequency

• Development Recommendations• Management Review• Follow‐up of Recommendations

“It is a Combination of Science and Skill”

Blast Furnace Gas Exposure at Pump House -2 :WMD

Bhilai Steel Plant

Case Study

Brief of Incidence

12th June 2014, main feeding water line of GCP’s ruptured in Pump House‐2 of WMD

6 Fatal

Semi cleaned BF gas leaked in the M/C hall of P/H

Time: 06.00 PM, ‘B’ Shift

Pumps tripped & Water Line depressurized

BF‐GCP Layout

BF

Dust Catcher

Scrubber

Venturiatomizer

ESP ESP

Raw BF Gas

Septum valve

Semi cleaned gas

Clean BF gas

Water seal

‘U’ seal

PVSV

Water line-1

Water line-2

From Pump House‐2

ENTRANCE

CDI

MACHINE HALL P/H‐2

STAIRS STAIRS

SUB STATION‐4

Layout Plan of P/ H ‐2GCP‐3 & 4 Radial 

settling tank

C/ROOM

RMP‐1PP‐1

ROAD

Radial settling tank

ENTRANCE

Pump House‐II Details

Minus 12 Mt

Minus 8 Mt

Ground levelGCP Pumps

GPG Pumps

BF Pumps

Pump House‐GCP Layout

COLD WATER SUMP

131415

1617

4647 5455Line

‐I Line‐II

GCP‐I GCP‐2 GCP‐3 GCP‐4 GCP‐5 GCP‐6

Dia 400 mm Dia 400 

mm

Dia 400 mm

Dia 400 mmDia 400 

mm

Dia 400 mm

Ruptured

Dia 1000 mmDia 1000 mm

Dia 1000 mm

Dia 1000 mm

Dia 600 mmDia 600 mm

Dia 1000 mm

Gas Cleaning Plants 

Pump House‐2

Scrubber Layout

Raw BF gas

To AtomiserWater Nozzles

Scrubber

Syphon Valve

Total water Flow: 900‐1000 M3/HrWater Pr: 4.5 ‐5.5 Kg/Cm2

Raw gas Pr: 0.6 ‐1 Kg/Cm2  

Gas Flow: 120 X 103‐220X103

Drain Valve

Secondary Valve

Primary ValveLine‐I

Line‐II

Water Gas

GasL‐I L‐II

Dia30

0 mm

Water Line is always under positive pressure

Ruptured Pipe line

• Blast Furnace Gas passed through the Scrubbersof GCP’s to the Pump House (via water pipelines)and leaked through the ruptured portion.

• Presence of BF Gas in the pump house wasunexpected. Persons attending to the breakdown, never envisaged gas in the pump housearea.

• All persons working in the area got exposed to BFgas.

Cause of Accident

Technology:• Process Technology: No provision of NRV in the water‐gas intermode.

• Risk assessment and Hazard evaluation wrt gas was neverenvisaged.

Facility :• Quality assurance and Mechanical Integrity: of the piping wasnot properly addressed.

• No gas detection system was available in the area.Personnel:• Employees not trained for such type of eventualities• Contractual people werenotfamiliar with the process & area.• EPP was not available for such type of incidence.

PSA Elements ‐ Missing

• NRVs should be installed at suitable location in watersupply lines to scrubbers for each GCP.

• Electrically operated valves with facility for remoteoperation from Control Room should be installed in waterinlet lines in each GCP.

• Adequate No. of exhaust fans should be installed in PumpHouse‐2.

• Hot lines for quick and proper communication• CC TV shall be provided in Critical Pump houses for

monitoring.• Making mandatory for employees to have portable gas

monitors in underground & vulnerable locations

Recommendations

Contd‐

Contd‐

• Installation of fixed CO gas detection system at strategiclocations like sub zero level installation, cellars, enclosedspaces and vulnerable locations with Indication & alarm

• Separate Lubrication System for GCP group pumps should beinstalled to ensure their operation even during flooding ofGPG & BF cooling group pumps.

• Power supply for each lubrication pump should be from twodifferent sections.

• NDT of pipe line to be done periodically

• HAZOP study to be done for toxic and explosive gaseousinstallations

Bhilai Steel Plant

• Identification of Hazard and Consequence analysis done for most of the shops

• HAZOP studyconducted for the critical areas

• Subtle changes in the process are criticallyreviewed

• SOP/SMP’s are updated as per modificationin the process parameters

Technological Improvement

• NDT/ inspection of pipelines is done periodically.

• Action plan made for the replacement of damaged pipelines

• Fixed CO monitors are installed in the plant

• CCTV camera provided at important locations

• Hot line facility provided at critical      locations

Facilitating Actions

• Senior level Executives are trained in PSM• Portable CO monitors are provided in the C/Rooms• Breathing Apparatus are kept in the C/Rooms• Gas Safety training given to Employees/Contractors• Quantitative Risk Assessment conducted for MAH units by NSC• Approved On‐Site Emergency Preparedness Plan made for 

all the factories• Mock Drills are conducted twice in a year for MAH units • Comprehensive Safety Audit of BSP conducted by NSC, 

Mumbai as per IS‐14489:1998• Disaster Plan developed for the Plant by NSC, Mumbai

Personnel Initiatives

Paradigm Shift…

• Zero tolerance• Zero injuries• Zero spills• Zero financial Loss• Zero …..

SAFETY Performance can be managed.

AC C I D E N T S happen, Things

go wrong

Aim towards Excellence!

Paradigm Shift…

• Of accidents.• Of Failures• Of productivity

problems.• Of complaints• Of …..

Accidents & Incidents are investigated so that we can learn.

Find out the Root cause!

Fatal cases and Serious injuries are investigated as it is

reqd by law.

Paradigm Shift…

• Initiative• Operational discipline• Personal responsibility• Using proper PPE’s• …..

Safety Performance can be improved

From Reactive to Preventive!

Safety performance is by Chance or by

Luck.

Paradigm Shift…

• Value Customers• Tap the employees

capabilities.• Empower people• …..

Employees must be educated and

empowered so that they perform.

Focus on People!

Employees Supervision is

must so that they comply.

Conclusion

Accidents are generally due to thefailure of Management ControlSystems. It is a management functionto control all activities in its Physical,Technological and Human Aspects.

Thank You