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