28 years after Bhopal accident - lessons not learnt by others

It is 28 years now after the occurrence of Bhopal accident on 2/3 Dec 1984. As is widely reported, it happened because of,

1. engaging no so well versed technicians at the time of the incident
2. no proper training to employees, local government agencies including health department, nearby residents
3. storage of excessive quantities of MIC
4. non-availability / switching off of safety systems, like, refrigeration to maintain at 2 deg C temperature, maintenance taken up for scrubber and flare systems
5. starting of cleaning of lines also during the non-availability of emergency systems
6. any safety permit was taken for cleaning of lines (is not known)

Murphy's law was proved in this accident. None of us learnt the lessons from this accident. Though, there was initial euphoria, it did not last long. Though the scale of the accidents is not like Bhopal accident, we read / learnt about occurrence of so many accidents.

We continue to engage cheap labour, without providing them any training. Most of the labour are daily workers. A person coming today may not be coming tomorrow or next week. The safety systems provided are not tested, or, they are only show pieces for regulatory agencies. The large number of accidents that appear in media is a proof of this as in many of the organizations in which accidents occur engage short term workers. The reasons for many of these accidents are also simple and are avoidable. It is not that some complex and unknown thing happened leading to such accidents.

We also continue to discharge effluents / offgases / solid wastes into environment. Large quantities of dangerous materials are transported through public domain, probably, without the knowledge of local government agencies. All these can affect the health of the people if not immediately, but over a long period of time.

The most common finding of CSB during their investigations is lack of training. Training and retraining programmes should be established and examinations should be conducted for the employees to put them in to service. It is not sufficient to cut the incentive which is paid for acquiring and renewing operators' licence after passing out the examinations. Such failed employees should not be engaged for plant operations till they pass out. And while evaluating the performance, it should be ensured that they answer all questions and not that because they answered 50% or so, they can be passed. Because, any mistake can lead to accidents greatly affecting the people and environment.

Plants should have policy of not operating the plant in case of failure of any of the safety systems. And ensure monitoring of the plant even when it is under shutdown.

Plants should realise that safety department alone can't guaranty safety as they are not operating the plant and they do not have the knowledge as good as actual plant operators. Further, how many organisations give serious thought to the advice of safety department. Many times, they are projected as hindrance for production and any production loss is attributed to as obstacles from safety department.

Government and regulators should make start a website with different categories and or key words for publishing all accidents, investigation reports from both the concerned company as well as regulators/government agencies. Governments should encourage all companies to upload about accidents and incidents in government website as per the category and should assure that those who reveal accidents immediately after occurrence in the website and also upload investigation reports say within 3-6 months will not be prosecuted for criminal proceedings. But penalties and compensation as applicable have to be borne by the company.
We can't expect organisations to run for charity, but they should ensure safety of their employees, public and environment and in this process they should not bypass safety procedures. 

A case for adopting inherently safer technologies - Message from Chairman, US Chemical Safety Board

CSB Chairman urged the industry to adopt inherently safer technologies in their processes, by substitution, reduction in inventory, operating at lesser temperatures and pressures and finally going for simpler instead of complex processes.
The main reason why industry is reluctant to change from existing conditions is that it costs money. Further, it requires lot of research and development and again it requires money. Governments too can do their bit in this regard to help the industry financially also by offering tax benefits to those who change their processes for achieving more safety.
The processes which are dangerous now, are approved by the government, when they were setup. These manufacturing facilities paid their taxes over the years to the government. Once, we are aware of the dangers, it is the responsibility of all stake holders, mainly, the industry and government, to contribute for a common cause i.e going for inherently safer technologies. As governments dole out subsidies and tax benefits to newly set up facilities, they can do the same to help the ailing industry (w.r.t safety).
Rafael Moure-Eraso: It's time for government and industry to adopt inherently safer technology  - Op-Ed Commentaries - The Charleston Gazette - West Virginia News and Sports -

LINK

Lab safety - CSB advice

Safety is talked much in industries and followed to some extent. But, the research facilities and academic institutions, where experiments are carried out, this important activity is normally left to the wisdom of the individuals. No study is carried out about hazards in the experiments.

Chemical Safety Board of US recommends the following for improving lab safety.

1. Laboratory safety management plans must include physical as well as chemical exposure hazards.
2. Institutions should ensure that research-specific hazards are evaluated and mitigated.
3. Laboratory researchers need guidance documents to help manage hazardous chemicals that are unique to their research environments.
4. Research-specific written protocols and training are necessary to manage laboratory research risk.
5. Academic institutions must ensure that safety inspectors report directly to those with authority to implement improvements.
6. Incidents and near-misses should be documented, tracked, and communicated.

The full article can be read here. http://pubs.acs.org/cen/government/89/8943gov1.html

CSB video - W.Va. chemical leak

As per Chemical Safety Board (csb.gov.in) investigation, the three chemical leaks in 33 hr, causing death of a person are due to ineffective alarm, poor maintenance, failure to carryout proper investigation of near misses and emergency response system. CSB said that the person taking readings near the tanks, could have been saved if tanks had enclosures.The hose for phosgene transfer which leaked and sprayed on the person causing death, as per company policy, is to be changed once in a month, but was not done for the last 7 months. The report says, each of the three leaks were preceded by an incident (near miss- a warning sign). The suggestion of an employee for replacing with better material hose was not listened as it was costly. The incident made it more costly to the company. This proves again and again that safety is never costly and in the words of Mr Om P.Kharbanda, SAFETY IS FREE! - IN FACT IT PAYS!!

Before 1984 accident in Bhopal also, a person died because of phosgene spray.

http://www.csb.gov/newsroom/detail.aspx?nid=383
CSB releases video of deadly W.Va. chemical leak - BusinessWeek
http://blogs.wvgazette.com/watchdog/2011/09/23/csb-was-alarmed-by-series-of-dupont-incidents/
http://ehstoday.com/safety/management/dupont-prioritize-cost-safety-0713/

Dust explosion

There is one more dust explosion at Hoeganaes facility, Tennessee on May 27th in which two persons died and another is seriously injured. Earlier in the explosion on 31st January, two persons died and a person was injured during the flash fire on 29th March. My post on 14th May gives some details of iron dust explosion provided at CSB website. The latest incident appears to be initiated by hydrogen gas leak from 3x7 inch hole on a hydrogen pipe in a trench. The trench also contains nitrogen and water lines. After hearing hissing sound from the trench, nearby annealing furnace operators informed maintenance who unsuccessfully tried to remove the trench cover. Later tried to open with the metal chain hooked to a forklift and during cover opening, a flash and explosion occurred. The statement for news conference on June 3, 2011 by CSB gives status of their investigations and a short video (1:16 min) on iron dust flash fire experiment.
The shortfalls at the plant identified are poor containment of dust, improper dust collection, thick layers of dust, unsuitable electrical fittings and availability of various ignition sources nearby.These types of causes are well reported and NFPA Standard 484 and we fail to take measures to eliminate these types of causes.
Providing dust containment and collection, elimination of ignition sources, flameproof electrical fittings, providing and maintaining obstruction-free aisles, regular wet mopping and incineration of mops at safe distance, testing of electrical continuity between equipment and earth pits, maintaining 50-60% humidity, use of antistatic uniform and PPE are some of the measures that will surely help in avoiding such incidents.

Fatality at a Zirconium-Titanium Facility

It is reported that two persons died in a facility that handles zirconium-Titanium. Read the information from the link here. The incident occurred during packing of titanium powder into bricks. Federal Investigators Seek Cause Of Fatal Hancock Co. Blast - News Story - WTOV Steubenville. CSB in a statement stated that it is deploying 4-member investigating team. Internet search shows some accidents/injuries during the handling of pyrophoric materials, in which some useful information can be found in these links. LINK1, LINK2. 

1. Zirconium, titanium, thorium and other metal fires have great potential to cause injuries and fatalities as the thermal radiation can initiate fires in the surrounding areas. They can easily ignite and explode when subjected to friction/impact. It is well known that explosions be devastating in confined spaces. 
2. In combination with insufficient water, the metal fires can grow bigger due to release of hydrogen and can also cause sputtering leading to flying of burning splinters all around (some times to a few hundred meters distance - source: internet search) and cause secondary fires.
3. The zirconium fires are intense and bright and can cause retinal damage when viewed with naked eye. The fire once initiated can reach great heights in no time depending upon the quantity of material involved and size, when turnings are involved. It is reported extensively in literature and NFPA that metal powder/dust can cause dust explosion and friction is sufficient to initiate this.
4. TEC powder in portable extinguishers is effective only for small fires and big fires can be extinguished only by application of large quantities of water from all directions by experienced fire fighters. Further, continuous watch for at least a day is required after extinguishing as it is likely that the material under the heap can keep burning for a long time.
5. As per the safety advice mentioned in MSDS/NFPA, and as it is with any chemical, lesser the inventory, the more safer it is. We can't sit assuming that everything is safe when we are only storing and not handling / processing, which proved very costly during the famous Bhopal accident.
6. Pyrophoric materials need very little energy to catch fire / explode and it is stated that the static charge accumulated on a person is sufficient to initiate fire of this dust/powder. For a safe work place, it is recommended to use antistatic apparel, provide earthing to discharge static charge on the equipment/containers, flameproof/explosion proof electrical fittings, maintain at least 60% humidity, etc in the work area.
7. The powder generated should be incinerated every shift / day (depending upon the quantity) under controlled conditions so that the material can be rendered safe and can be disposed off as landfill.

Empowering safety department - How long?

Recently, I read an article that the new boss of BP is reshuffling the safety division and is making it as the most powerful voice and that they can intervene in any of the technical functions of the BP. This is what is required by law also. Only that we do not follow.
I do not doubt about the capabilities of earlier safety staff of BP. I doubt only about the production staff. It is normal to see in any production facility that production staff and their bosses pay little attention to what safety department says. As the safety department is part of the facility, it can only advise. Implementation depends on the whims and fancies of the production department. Safety department becomes powerful only when the top man gives unconditional support to it. In the present case also, though the new boss ALLOWED safety division to be powerful, the time upto which it can be allowed to function this way will be limited, as Mr Trevor Kletz said, "corporate memory is short". As the memory fades gradually, well meant safety advises become additional work and time consuming for the production staff and slowly they start ignoring the safety advises. By that time, the BP boss who is making safety division powerful may also leave the organization and the STORY WILL REPEAT. Again as observed by Mr Kletz in his books.
It is my observation which evolved with my interaction with many of my friends in various industries and also from my knowledge of reading various books, safety blogs and investigation reports of CSB, HSE, etc that it is a worldwide phenomenon of giving importance to safety only after an accident and then slowly forgetting about it.
A KNEE JERK REACTION INDEED.

How to make safety training effective?

Today, I read to articles on makeing safety training effective. One is on presentation skills by the trainer to grab the attention of participants (Safety Daily Advisor). The other is use of safety videos. The original link is published separately in this blog.

Attention: It says that attention of the participants is short and therefore the trainer has to be careful in planning his presentations by giving introduction, a video, narration, quiz for evaluation, etc with interaction in between. This is like a typical James Bond movie which I am attracted to because of an action stunt in the beginning, titles with music, then movie.

Videos: Videos are quite effective in understanding any subject. There is a proverb that a picture speaks 100 words. We remember scenes of a movie for a long rather than the dialogues in it unless otherwise it is a punch dialogue. In the article I read, the author mentions that it is difficult to gather employees at one place to train them. Further, what I feel that general training to meet different trades of employees present in a training session will not be effective and we can't be specific to a particular trade of employees when other trades are present. To overcome this, the author rightly said that making availability of safety videos on-demand will be quite effective. If the videos are made available through intranet with monitors provided at workers' change rooms/cabins (rest places) where they take rest for sometime after lunch / tea break, those interested can see the videos of their interest. This viewing can also be done where there is no work and workers got a free time.

I got benfited a lot and my understanding of chemical safety improved when I watched CSB videos. For more details, whenever required, I went through the investigation reports of CSB. In my training sessions for fresh batches, I start with a brief introduction, followed by some principles and then show a video. There is a huge demand from participants for more videos. I give them the website addresses instead of videos as I feel that if we provide videos as such, then the CD/DVD will be lying in the cupboard without using it ever. If they themselves go to the website and watch / download videos, then, I am sure they will go through in length and make them to surf the net for more and more such videos and information.

Recently, in a training session for experienced employees, when I showed a video on impact of a gas cylinder when it valve is broken, many employees, some them on the verge of superannuation told me that for first time they understood why gas cylinder valves should be protected and why gas cylinders should be chained. Even in feedback forms, they mentioned the same. Mind you, I went for the training session to fill a gap of 15 minutes as the lunch was not ready.