Management of Change (MOC) ?

When plants run for sometime, engineers will find that something is not working as required or they may feel that something else can give better results or some problems will necessiate to modify flowsheet, etc. When shopfloor engineers and supervisors go for implementation of the proposed change, they think that they are doing the right thing to improve. However, the possibility of unexpected events because of the change are normally not studied or anticipated.
Further they think that involving safety department is a waste of time or their work will be delayed because of possible discussions. Therefore they carryout changes without following the established safety procedures. Sometimes, there works give the desired results and therefore makes them to think that they are in right direction ALWAYS. This will set in wrong notions, disregard for safety procedures and will set a bad example for the others to follow the same methods.
Ultimately, a day will come when something goes wrong and blame game starts. Safety department says they are not aware of the change and plant executives say that safety department is not doing its job of surveillance and monitoring. If people do unsafe jobs and then wait for others to point out, then nobody can help. Safety departments are for providing advise and also monitor to caution the mangements. However, if people do works by hiding the information, they are doing so at their own peril.
So, change management should first be applied to persons' attitudes and understanding of safety procedures and then established MOC in the system will be followed by these people with complete understanding and regard for system.

Whether safety procedures cause stress at workplace

Sometimes I hear shopfloor people grumbling at safety supervisors that by seeing them, B.P. increases in shopfloor workers. Others say that they are afraid that safety manager will come to them to enquire on some issue. Shopfloor supervisors advise safety persons not to approach their workers directly to avoid undue stress. All such talk or apprehensions appear to be unwarranted unless people do not follow safety procedures or the safety man talks in a dominating manner.
Some safety professionals too think that they get truth, if they pose like a  tough guy. But, with my own experience, I can say that this is not true. Whatever the shopfloor person is willing to tell will escape from the scene next time as soon as he sees the tough talking safety guy. The smooth talking safety supervisors also should be careful that they are not taken for granted. They have to develop friendly networks in all departments so that before entering the shopfloor to enquire about unsafe conditions or investigate accidents / incidents, full information is obtained through these friendly networks.
When someone gives information on phone, safety person should not insist to know the name of the person so that he will feel secured and will have peace of mind. If he is willing, then safety person can declare his sources and also recommend for some appreciation and reward.
Stress will be felt by safety guys also when all shopfloor people surround him questioning his failure to identify and communicate hazards. This, I think should be handled by being visible in the shopfloor through frequent inspections,giving pep talks as often as it warrants and making the people to know about their responsibilities under law. Then, safety department persons will be viewed as their friends and get their help to solve safety issues at the shopfloor.
Workers will be stressed for other reasons also as it was mentioned in a news paper article today that spouse causes more stress than the boss. Again, males cause more stress to their spouse than the female. Other reasons for stress can be ill health, unfulfilled ambitions,  family issues, etc

Safety violations are found, then why the plants are allowed to run?

In an article at http://www.safetyxchange.org/, I read that there were more than 700 violations of safety, operation and environment found by OSHA, EPA and other regulating agencies. It was questioned about the compulsions or need for allowing the unit to operate though so many violations were found before the spillage itself. Many times, regulators identify violations and give time to rectify or pay penalty later for continued violations. Only a few times, unit operations were suspended or stopped. This creates a lenient attitude by managements that outweigh profits over the loss of production suffered because of suspension of unit operations to carryout works for rectifying the violations. After some accident / incident occurs, we repent for not doing the right thing before the event. This like applying the balm after burning rather than avoiding the burns itself.

If plant operations are stopped after allowing some time to correct, then everybody will fall in line and though it looks difficult to achieve safety discipline and people are scared of immediate losses, long term benefits will outweigh these losses and every one will follow the directions of regulators. Or they will not give chance for regulators to find safety violations and a system of identification and rectification will be established by the organizations themselves.

Poisonous fumes from incinerator near Indore - six lost vision?

Y’day a scrolling news item in TV channels and news reports today mentioned about six labourers losing part of their vision because of toxic fumes from an incineration plant in Pithampur, while cleaning solid waste. It is stated that all labourers suffered symptoms of insecticide poisoning (organo phosphorous) like blurred vision, vomiting. Before taking up any chemical handling work, engineers and supervisors should refer to Material Safety Data Sheets (MSDS) of the chemicals to be handled. It will give information on nature of hazards, handling methods, personal protective equipment (PPE) to be used, etc. It is mentioned that workers did not use any PPE, though the company that engaged the persons is a reputed one.


If the companies do not follow safe procedures and do not ensure supervision, public will lose faith in the industry and whatever they do later will be of no use.

Further, such accidents will show that more inspectors are required to inspect more frequently the premises of the organizations, audit their systems and the findings have to be put in public domain. It may be remembered that though the auditors from head quarters of UCC reported serious nature of hazards in the Bhopal unit, as the report was not known to many, the inaction could not be questioned in time and only after the worst chemical disaster, all concerned started questioning.

Therefore, it should be made mandatory about making availability of audit findings (by regulators as well as certifying agencies) also public like the provisions of Factories Act 1948 under Chapter IV-A and should attract penal provisions like those for violations of Sec 41-B,C,H

Increase of fuel prices - what is its impact on safety?

From y'day, the increased prices of fuels came into effect. Many are opposing the increase. I thought, okay, it will make a hole in my pocket, but what is its impact in my field, i.e., safety and environment. I think that the increased prices may reduce consumption of fuel to some extent thus contribute to the reduction in environment damage. When something is available cheap, it will loose its value / importance.

Many people use vehicles, particularly 4-wheelers for joy rides. Two advertisements which I am seeing in TV channels for last few months depict the same. In one advertisement, a child is sad because he did not get good marks or so, so his father takes him on a ride and the child asks for one more ride. In another advertisement, I think a couple or would-be couple will be on a ride to come out of their moodiness. Actually, it appears many persons don't have any work and therefore wander aimlessly in bikes, cars, etc. Subsidising fuel for such people is a crime. Similarly, supplying subisidised fuel for cars and sports cars whose mileage is very less is also waste of public money which could have been sent on providing education to poor children. In fact, subsidies are becoming a headache for the governments in the long run and they are finding it difficult to come out of this expenditure.

My suggestion is to eliminate fuel subsidies totally. Government should subsidise only public transport to such an extent that people of all categories should feel it economical to travel in public transport than using their own transport. All students can be allowed to travel without paying during their college hours. A pass should be issued to each student and should be punched for one trip to college per day so that wandering by students for timepass can be avoided.

Like issuing licence for driving, governments can issue permits for private transport at a price. This will reduce traffic congestion, reduce pollution, leading to better environment and good health of people. Then, to take care of emergency requirements, government should strengthen ambulance services for medical care and run public transport throughout 24x7 so that people will not be at disadvantage.

Similarly, government should increase excise duty / sales tax on vehicles equivalent to the cost of the vehicle or more. Today, I read in the newspaper that in Nepal, 300% tax is levied on imported cars and thus the cost of Nano car at Nepal works out to INR 4.5 lac. We should tax at these hight rates for all vehicles that are made within the country also.

The decrease in vehicles on the road will also reduce road accidents also and will save many elders and dependents caused by deaths.

The money spent on fuel subsidies can be better used for providing education and public health care which are becoming costly. Though the oil companies claim huge losses on account of subsidies, I am unable to understand why their shares value somuch. The share value of any loss making company will not even quote at its face value but all oil shares trade at multiples of their face value. I have to understand why it is so. After freeing the fuel prices from control, by how much their shares will go up will tell the extent of losses suffered due to subsidies.

Nothing lasts forever. It is obvious that if not now, in another 25-50 years fossil fuels will not be available. As the reserves comedown, oil producing countries will increase their prices and atleast next generation has to pay higher prices because no government can subsidise forever. Instead of using recklessly the valuable resources, let us use them judiciously and increasing the prices is a forceful method for conserving the fuel resources.

Accident liability of independent directors

An article published in Deccan Chronicle today (24.06.2010 Thursday) states that CII asked government to insert a clause in the Companies Bill 2009 to exclude independent directors from any criminal liability for offences commited by the company, saying that they are not involved in day-to-day running.

Though they are not in operation, but any influence of these independent directors in the decision making process of business towards profits, cost cutting measures, etc will have a direct bearing on the safety measures followed by plant operators and thus they are involved indirectly in day-to-day running of the plant. Therefore, it is not correct to exclude them from liability. If they are like ordinary public shareholders and not consulted or involved in any decision making process (in finance, technical,...), then they can be excluded.

All those who are involved in decision making of financial aspects should be made liable for accidents. The deactivation of safety systems at Bhopal was done to cut business losses with the assumption that a plant not in operation does not require maintenance of safety systems. The decision was made because of lack of technical knowledge on what can go wrong.

Any financial decision on plant operations should be supported by a report from operations in-charge (who should be a technical man) that was discussed by all directors and approved.

Compensation for victims of industrial accidents

There is discussion on deciding the quantum of compensation for victims of industrial accidents. The compensation amount should be fixed for every person injured / died in an accident instead of fixing the liability to the company for an accident.

In cases like Chernobyl, Bhopal and Seveso, the impact was immediate and is still continuing. In such cases, we can't decide compensation and cleanup costs immediately. The company has to pay for all victims. If the total compensation is limited to some amount, then in the cases like above, the amount received by the individual victims may become peanuts, whereas companies whose sole aim is to make profits will simply escape. When a company is in the business to make profits, then we can't allow them to make those profits at the cost of human lives, environment and property damages by following unsafe practices and procedures.
In fact, the certifying auditing agencies for quality, environment and safety practices of companies should be made accountable like financial auditors so that certificate can't issued / renewed without compliance with norms.

Now-a-days, the victims of road / rail accidents get Rs 2-10 lakhs from various agencies of the government. Sometimes, jobs are also offered for the next kin of the victims. Similar amount should be paid to the victims of industrial accidents apart from health treatment costs.

When the compensation will be decided for each victim instead of lumpsum per accident, then I am sure, companies will follow international safety practices everywhere and ensure safety of employees and public.

There are NO instant solutions for achieving safety - You can't see results immediately

If there is an accident in the workplace, immediately investigation committee is constituted, some report is produced with recommendations and people will forget about implementation or followup. They tell that they investigated and found the root cause.
Similarly, people will appoint safety professionals or somebody as safety officer and expect accidentfree workplace from the next moment.
Someothers reduce their alertness on safety and say that they contributed to profits (by reducing the expenditure on safety), as there were no accidents in the last few months.

In all above situations, expectations are to see immediate results. People forget that for any good or bad to happen, it will take some time for the system to develop in the direction of increase or deterioration levels. Normally, the time will be about five years, though this time can vary depending upon the commitment levels of the management and employees.

That's why when some company gets a safety reward or recognition, the CEO at that time thinks that its all because of his efforts after assuming the charge, though this is due to the efforts by the earlier CEO(s) for last few years. One may get certicate of ISO/OHSAS or something after one year effort, but the certification for the first time is mainly because of documentation (normally by consultants and therefore employees do not know anything) and management programmes listed in the manuals and resources allocated. By the time, the certificate comes for revalidation, if the CEO puts his heart into it and looks back, the improvements achieved would have been negligible and he chides his MR or safety manager for not followingup properly with the departments.

If at all there are any instant results, they will fall under corrective actions and not preventive actions. Therefore, similar incidents / accidents occur again and again and companies will get NC from auditors for not seeing any efforts for preventing the incidents.

Therefore, there are no immediate solutions and results for achieving safety, but efforts are required for permanent solutions and to be sustained.


LINK

Why people continue to do mistakes even after accidents take place

Many times people repeat same mistakes and similar accidents take place. Even if root cause analysis is done, still they fail to take preventive measures. This shows that they do not understand the value of life and are bothered only about their output minus safety. Driving the importance of safety into their heads is very difficult for safety officers. It is better to remove such people from the job if they do not listen.

Sometimes, the top man gives importance to safety but the leadership one step below do not have such importance and drive field engineers for output at shortest time and this leads to accidents. Instead of penalising the department, if penalties are collected from the salaries of such leaders and field engineers as well as from payments made to the contractors, then people may listen. Otherwise, they do not bother about safety measures at site and contractors will continue to do the work that maximizes their profits. Possibly the money spent on accident victims treatment / compensation must have been less over a period of time for these contractors.


LINK

Learning from others-blogs or accidents whatever it is!

I used to write a lot in my earlier posts. However, it's my feeling that these are lengthy. I also saw posts of some bloggers which are brief. So I decided to write only to the point. If I want to explain, I can do it in different posts. This is what I learned from others. Similar thing we can do in learning mistakes done by others when they had accidents or near misses and avoid the same.

Accident prevention is cheaper than the accident

Yesterday evening, a 2-year old boy fell in an unused open borewell in a village in Andhra Pradesh. Today evening he died, though efforts were made to save the child.

It is not uncommon to hear such news now and then. There are many unreported incidents as well. Some lucky ones were rescued safely and many unlucky children could not. It is outrageous that when a borewell is dug, till other piping work is completed, the well is to be capped and all it costs for a perfect capping is only about Rs 500. People spend thousands of rupees for sinking a borewell but think that it costs them to securely close. Now, see the cost of resources put into saving the child fell in the borewell.
- EMRI service 108 personnel spent more than 24 hrs in rescue efforts
- District collector and SP also spent considerable time
- Earth removers were engaged on the job (it costs about Rs 500-1000 per hour when you rent it and for 24 hrs, more than Rs 20000/- is spent and this amount alone can be used for capping 40 wells. If you add cost of personnel and medical emergency care engaged in the work, the rescue efforts amount to another Rs 20,000/-)

It is good that TV9 channel started a campaign to inform them about all open wells so that message can be driven into concerned officials for capping the wells and save other children.

In the field of industrial safety, it is known that cost of accident prevention is only 1/4 of direct cost of the accident. Infact, the savings accrued from accident prevention, over a period of time, will far exceed the money spent on accident prevention and thus experts say that SAFETY IS CHEAP AND COSTS NOTHING compared to the expenditure one has to incur once an accident occurs.

The persons responsible for leaving the borewells in open condition should be held responsible and should be made to pay for their lapse so that all others will realize and try to be vigilant in their actions.

Publicity and awareness campaigns like the one started by TV9 should be on continuous basis and voluntary and should not be like knee-jerk reaction.

Deaths in confined spaces

Offlate, I started reading persons overcome by the atmosphere while working inside the septic tanks, underground water storage reservoirs / tanks, chemical storage tanks, etc. In some cases, persons while working in trenches, were buried alive by the soil heaps next to the trench. In one case a person was working only about at a meter depth, but he was buried when the soil was disturbed.

Some of the deaths were like this;

1. A Person want to see what is inside a tank from the top, to plan for the work. While looking down, he lost consciousness, fell down and died. Sometimes, to rescue the unconscious persons, others who tried for him also became victims.
2. A person went inside a rice brawn mill discharge storage tank. After some time, he became unconscious and was found dead.
3. A person went inside a water storage tank in the underground for cleaning and was found dead.
4. A person went inside a concrete mixing plant for cleaning. Not knowing this, soon after, the operator operated and the person inside died. Though in this case, it is not the hazardous atmosphere, but it is a confined space and a different type of hazard (Maintenance person's presence inside is not known to the operator).
5. Two persons were working in a trench and were buried alive by the loose soil heap that slid due to some disturbance.

There are many more such cases, mostly involving cleaning jobs inside waste storage tanks of rice brawn mills or septic tanks.

Earlier, while reading such news items, I used to think that my work place is safe and that I need not bother about confined space works. However, as I learn more and more deaths of people like above, whenever I get a work permit for work in a basement or tank, though it is fairly open to atmosphere, I get wild thoughts and sometimes I think whether I am thinking too much in visualizing the hazards. However, I stick to my wild thoughts and accordingly prepare precautions to be taken for the work.

Normally, the oxygen level in the work place will be checked before entry into such places. People say that it is fine if oxygen levels are between 19.5 % and 23.0%.

But in an article, the author advised to verify and find out the reasons for change in oxygen level from the normal levels. Though the general guideline says above 19.5% O2 levels are acceptable, but what are the other pollutant that brought down the O2 level from 21% to 19.5%? For example, if the pollutant is say CO, then we all know that CO is fatal at 0.5% (5,000 ppm) and it is not acceptable. Similarly, it may by H2S which is also a toxic gas.

Sometimes, our instrument may be wrong. In that case we can't depend on the values measured by it, because we do not know the error %. Sometimes, persons check O2 level at the entrance and then give clearance for the work. But, we should check O2 levels at the actual place of work and the measurement time should be reasonable. Instantaneous values may give us wrong picture. Again for checking O2 levels at work place, we should not enter and endanger our lives. Portable hand held instruments with suction pumps and connected hoses (even upto 100 ft) are availalbe at about Rs 30,000/- in the market.

We have to flush the work area continuously till we get O2 levels are as good as open atmposhere and should continue air supply till the work is over and all persons come out. If the work is to be carried for a long time with tea / lunch breaks, then the flushing and air supply should be continued during the breaks and before every entry, the O2 levels should be checked and ascertained that the work atmosphere is safe for work.

Sometimes, there may not be much head room available for free movement of the persons inside. In case of work inside chimneys or furnaces, the lining material may be loose and it may fall on the persons. There may be toxic gases (generated by the process) that are trapped in these lining material and if persons are working on these, they will be exposed to these toxic gases and may be overcome.

When persons work in open trenches, we know that the adjacent heaps of soil can be disturbed by heavy winds or from vibrations due to vehicular movement nearby. It is normally suggested to dispose the soil immediately to an earmarked place. Atleast, the soil should be kept atleast 1.5 m away from the trench and angle of repose should be considered for the soil. Again, as we go deep in the trenches, they should be supported on the sides to avoid collapse due to loads on the adjectent area by proper shoring. If long trenches are made, then for every 30 m, emergency escape ladders should be provided. Care should be taken that these trenches are not flooded by water / sewage lines and workers in it are taken by surprise. Earth moving equipment should be properly supported by outer rigs with proper base supports so that they do not topple due to loose soil and in the process endanger persons nearby.

With the availability of radio sets, workers inside should be in constant touch by the supervisor outside and buddy system should be followed on one-to-one basis i.e for every one person inside, there should be another person outside to monitor the condition and to provide immediate help. People may think it is waste of money, but in the event of some eventuality, the compensation claims and payments will put a big hole in the finances of the executors of the work and then they will regret for not taking protective measures.

However, the story repeats in the next job. BECAUSE, OUR MEMORY IS SHORT AND WE THINK THAT THOSE INCIDENTS ARE OF ONCE IN LIFE TIME AND THEY WILL BE CAREFUL THIS TIME.

Such persons should be put behind bars, with all their propery seized and utilized for helping the families of the victims.

Risk = Probability (???) x SEVERITY

Yesterday I read a news item that a US satellite Iridium-33 in use collided with a Russian satellite Cosmos 2251 that is no longer in use on Tuesday (10.02.2009) at 0455 GMT at 790 km height above Siberia. It seems that this type of accident happened for the first time. There are more than 17000 man-made objects at present in the space. I went through internet and found that the probability of such collision is once in tens of years and the debris now generated can reduce this probability to once in a year or so as there are some more satellites in the same altitude and the total debris may hinder space craft movement in the future.

Now, the question is not about space but on the events on the earth.

In any factory, accidents keep occurring. When somebody (normally safety officer / advisor) points out about unsafe acts / unsafe conditions in the shop floor / factory premises and asks for correction, the usual reaction is, a staring look and then the reply comes, "oh, we have been doing this for the last few years / we are doing like this from the beginning / who is expert -you are me - you safety people does not know any thing other than talking / I can't do - you come and do / so on...

How true are the words of the famous safety professional Trevor Kletz -

Corporates do not have memory.

We have done this way 100 times is not acceptable unless an accident on 101st time is acceptable.

We never imagined that satellite collision is possible. But, it happened. Where the chances are remote, still it happened and where the chances are high in our activities in the shop floor, we do not want to correct our selves.

If we see the accident history in any factory, after the accident, the usual sheepish answer from the injured or his colleagues or manager is that it happened for the first time, the person is experience, skilled, safety conscious, near retirement, he doesn't want to take official leave and will take personal leave for the period away from duty due to accident, so on.

In spite of all the above qualities, still accidents occurred, then imagine what can happen to others. It is the attitude that requires correction rather than any thing else.

When somebody narrates their own experience, people listen attentively, appreciate him that he came clean and after coming out from the room the listeners do the same old things. This is why accidents keep occurring again and again, if not to the same person / or same shop floor, they will be occurring somewhere else to some body else.

We love short cuts and feel that we are above all others, accident does not occur when we are working.

One of my colleague, who retired 4 years ago, used to tell in all his training classes, that we should leave the organization with same organs as we had when we joined.

Yes, it is true that no body wants to lose their organs and suffer. But, momentary decision without thought for consequences will lead to accidents.

Rarely, does the type of accident will be new in any factory that is few years old. May be after the accident, corrective actions are taken. But after few years, the corrected systems will be replaced because people forget the reasons for safe guards in place and meddle with the systems. They want to prove to their bosses that they are inventors and soon after their will be accidents and shop floor persons will be suffered. But, the so called inventor would have got his promotion or pay rise and even would have left the organization.

So, every body should work seriously on the hazards at the shop floor, let the probability is however less. Nobody says there is no (zero) probability of occuring for an accident. In fact the word probability it self gives meaning of some uncertainty. Hence, if the severity / consequence from even from remote probable event is not acceptable, without looking for chance of occurrence, we should eliminate all those hazards and make our work place safer.

Risk assessment and actions should concentrate more on consequence rather than on probability and make life safer for persons.

Location of industrial plants - safe distances

Two days ago, there was a fire and explosion incident at about 2100 hrs in a chemical factory that makes some product and supplies to well known pharmaceutical companies. As per the news item, two reactors out of fifteen exploded and the blast could be heard even 5-6 km away (my colleague who stays at this distance heard the sound, another one said he felt like someone above his apartment dragged cots). Two persons were injured and the fire was brought under control by state fire department in about 6 hours. The factory also housed about 50 gas cylinders and the adjacent factory has about 50 reactors. If the fire / blast fragments entered this adjacent factory, the consequence would have been severe, as reported. The plant though located in industrial area, is surrounded by residential buildings.

There were questions immediately about the wisdom of granting licence for setting up of factories in residential areas. Similar questions were raised even after the Bhopal incident in 1984.

This and such similar incidents always bring out few questions, like, which is first ?
The factory was set up first or residential buildings came up first?
In philosophy, a similar question is, seed first or (biological) plant first? OR egg first or chick first?

It is difficult to answer the philosophical questions as above. However, not so difficult for our question of factory or residential buildings, which is first? Even in the case of Union Carbide factory at Bhopal, as per the information available in various books, web sites, factory came up first. Shanties, hutments came up adjacent to the factory fence later. These habitats were not removed when they came up. The reason as mentioned in a famous book is that the management was also happy as cheap labour is available nearby. Apart from these, it is quite natural for development to take place near industrial set ups and this will lead to better realization of land and other properties.

In the case of accident mentioned at the beginning also, as is seen, the factory was set up in an industrial area about 7 years ago. However, by that time already the entire area is surrounded with thousands of residential buildings. Apart from this factory, there were other factories that were set up much before. I do not know whether at those times, the residential buildings existed or not. However, I am sure from hearsay that 35-40 years ago, this area was totally isolated from the city and is like a jungle and persons were afraid to reach other factories in the area after the sun set. Few less courageous persons used stay in side those factories in the night after their second shift (ends around 2200-2300 hrs) and go home only in the morning.

Now, these areas are so developed that it is difficult to get land and the price is as good as in the heart of the city, though these are located at about 10-15 km away from the railway station.

Then, the questions about why permission was granted look silly though the question about how safe is a safe distance for a factory remains. For this, the Environment Protection Act 1986 and the rules made under it will help. One has to prepare safety report and has to revise it atleast once in three years or if any additional information is available, it has to be revised even earlier also. Once, the distance of impact is known from toxic releases / fire / explosion, then a safe zone has to be maintained considering the future expansion of the factory as well as population growth in the area. However, preparation of safety reports are mandatory only when the chemical inventory / handled exceeds a threshold quantity. I feel, these limitations should be removed and should be made compulsory for chemicals of any quantity. If a factory is proposed to be set up, then impact distances and safe distances have to be determined and maintained for the chemicals, whatever be the quantity to be handled. Due consideration should be given to the domino effect that is effect of incidents in the proposed factory on the factories that are already in existence and if an incident occurs in the neighbouring factory due to the incident in the proposed factory, then what is the impact.

I also blame the greediness of people in the neighbourhood of the industrial areas. It is not correct to say that they do not know about factories. People spend so much time about genuiness of a property before purchase but care little about other factors. People buy vacant lands when they sense that some development activity is going to occur in the area, the activity can be any thing - setting up of factory / colleges / highway / railway station / etc. Then definitely, the greed is to also to be blamed when persons in residential areas are affected due to industrial activity in the neighbourhood, though the main blame goes to the factory management. When factories have to be set up, land should be enough for plant building area and this should be surrounded by forest cover upto the safe distance. The fence of the factory should be at the safe distance outer boundary. No expansion of factory should take place unless these two aspects are covered. If any violation occurs, the concerned persons should be tried by special courts, whether such expansion caused injury or not or plant operations are carried out without valid permissions.

When the profits are more compared to penalties, then people always prefer penalty. Here, I mean penalty in terms of money. If the penalty includes imprisonment or seizing of the total property of owners and their spouses (apart from the factory), then persons will not dare to do such acts.

Similarly, somebody puts up residential buildings within the impact distance, they should be demolished and persons responsible for granting permission should be taken to task.

Now, what to do with establishments already came up and later residential buildings came up.

Talk to concerned establishments for shifting to safe area in a reasonable time or if it is not feasible, then remove encroachments / take possession of residential and other buildings up to the safe distance as is done for expansion of roads / railway tracks. OR live with it and repeat the blame game as and when accidents occur.

Why Gas cylinders should be kept in sun shade?

I read in Rules for gas cylinders that gas cylinders should be kept under sun shade, should not be exposed to direct sun light, the storage area should have good ventilation, etc. Though the reasons are known, i.e to avoid over pressurization due to the exposure to sun, I saw practically how over pressurization takes place in the cylinder when exposed to sun light directly.

Recently, I was on a visit to one of our sites under construction. After my visit to the construction site, at about 1230 hrs in the noon, I was going back to the office where I normally sit. I don't have permanent table and chair as I visit the site occasionally and there are permanent safety officers already appointed at site. On the way, I saw some argon cylinders stored on the road side under direct sun light, without valve caps. I enquired with the contractor nearby about the cylinders and I was told that they are empty and are to be sent to the supplier. On close observation, I found that the valve discharge nozzle is having some water (there was rain on previous night) and small bubbles were being formed continuously.

From this I understood that though the cylinder is empty, it is not 100% empty and some leftover gas in the cylinder is getting expanded due to rise in ambient temperature. As the valve is not totally closed, the expanded gas is leaking out as bubbles through the water in the discharge nozzle.

This clearly demonstrates that though we assume empty cylinders are safe, they are not actually 100% empty and if the gas is toxic, then the little amount of gas leaking out due to sunlight exposure can harm the persons nearby. If the cylinders are full then they are hazardous and can endanger the persons around.

Similarly, being found on the roadside, any damage to the valve (breakage) can rocket the cylinder like missile and can hurt persons / damage equipment or property nearby or can have a domino effect. For this reason, the rules are specific that the unused cylinder valves should be protected with valve caps so that valves can't be exposed directly.

People talk about safety culture so much, but these small issues like valve caps, cylinder storage under sunshade, chaining the cylinders to prevent their fall, etc are not given due attention. Lip service alone will not improve safety culture. May be, talking about safety will bring admiration from listeners and even some appreciation by way of reward, but this will not help in improving the safety at ground level and all this admiration / appreciation / rewards will be washed off by any single accident and the same persons will admonish the in-charges of the area for not visualizing the hazards and not taking corrective measures for the safety of the people.

Gas cylinder Explosion

Yesterday (16.01.2009 Friday), I read a news items in a local news paper with the title, which is the title of this post. It states that four persons were seriously injured due to burns in this accident. It is reported in the news paper that when gas cylinder in use has become empty,  the house owner (a gold smith, may be with both shop and house together) informed and got refil cylinder from the LPG supplier at about 1430 hours. When the family members  of the house opened the gas (stove knob ? / cylinder cap ? / regulator knob ?), the gas leaked. Seeing this, the workers in the shop put the cylinder in a water tub. Still the leaked gas (obvious, as LPG does not dissolve in water) spread around and caught fire (there can always be an ignition source for a combustible material). The fire caused burn injuries to four persons who were working in the shop. After extinguishing the fire, the other workers admitted the injured in a private hospital and informed the police. The police went to the spot and shifted the injured to a government hospital for further treatment of the persons whose condition is serious.

The above news items and similar such news items earlier always raised so many questions in me.  A few of them are,

Whether the cylinder exploded (as per the title of the news item)

However, as per the news item mentioned below the title, it is understood that the cylinder did not explode but it is the leaked gas that exploded.

- Similarly, sometimes reports appear as gas stove explosion. This also gives impression that the stove (burners) exploded. But mostly it is the leaked gas explosion.

The reaction of the persons for arresting the leak is another question in my mind.

We can't blame the persons who have put the cylinder in a water tub in this case because of their knowledge / awareness. However, it is better if the gas cylinder suppliers put stickers on the cylinder containing information like, what to do in case of gas leak / leak and fire; whom to contact; the emergency contact numbers, what checks are to be done by the receiver i) when the cylinder is received (this is normally done by the supplier / delivery boy in some occasions) and also ii) during regular use; the cylinder test date and due date for next testing by the company; instructions for the user to inform with contact numbers  if receives a cylinder after expiry date / damaged condition of the cylinder,etc. Normally, this type of information is provided on the industrial gas cylinders and similar information with more details should be made available to the domestic users.

Eariler a few years ago, when I was in my office, I received a call that outside our organization a lorry (truck) with gas cylinders was stopped because of gas leak. My self with a colleague visited the spot and found that all gas cylinders were unloaded onto the road side and also observed some white powder on a few cylinders. On enquiry with the driver of the lorry, we found that as a precautionary measure, he used the portable fire extinguisher in the lorry.  This also shows the poor knowledge of the drivers of hazardous chemicals. Though he will get licence for hazardous chemical transportation and will be renewed every year, the employers should ensure that all their staff get required training and retrained again and again. Without training, they should not be engaged in transportation at all.  Sometimes, the material brought by the driver will be different from what is mentioned on HAZCHEM information on the containers. The trained driver will ensure that correct HAZCHEM stickers are displayed on the container and this will help the others on the road also, if the driver is not in a position to take proper measures. In the drivers cabin also, the tools and personal protective equipment list and location should be displayed prominently for the same reason.

Normally, the procedure in case of gas leak is take the lorry to a less inhabitated / less crowded place atleast and cordon the area by atleast 300 m around, simulatneously inform the police and their employer and wait for instructions. In case of gas leak of a domestic cylinder in a house, inform the supplier, take the cylinder outside in to a open area (not through lift), remove ignition sources in the nearby area to the extent possible and wait for the supplier to do the needful. In the news item reported above, it appears the cylinder was put in the water tub inside the house and may the confinement of the house lead to accumulation of gas and it is not able to disperse. The ignition source is obvious as it happened in the house that belongs to a goldsmith with shop in it. Goldsmith will have fire kiln  or of such arranagement for making the ornaments. Moreover, the refill was delivered at about 1430 hours and the cylinder was handled soon for replacement as per the news item. This shows that it happened during the working hours of the gold smith shop.

Had the cylinder was put in a water tub or covered with wet blanket / cloth outside, the leaked gas could have dispersed easily and cylinder will have cooling to prevent overpressurization in case of fire nearby.

The incident of gas leak happened in my house also once a few months ago. When I replaced the empty cylinder with a full cylinder and opened the regulator knob, I found gas leaking from the cylinder nozzle. I removed the knob and placed cylinder cap and it arrested the gas leak. I opened all windows ( I stay in an apartment) informed the supplier immediately about the leak. I could not get connection to the supplier as the phone line was busy (obvious as he will be getting calls for refill bookings). My wife went to the supplier's office located at about 3 - 4 km from my house. It took about 15 - 20 minutes to reach the office as the traffic was more on the roads and by the time we tried by phone and then informed personally, more than 45 minutes time elapsed. Then, the person came about 2 hours later, checked the cylinder nozzle and replaced the rubber gasket in it. 

It may be routine call for the gas suppliers but the users will be under tremendous tension. In my case gas leaked only when connected and regulator knob is opened. If it is leaking even when the cylinder cap is not removed then imagine the plight of the people. Similarly if the leak occurs on a weekend or non-working hours of the gas supplier, then getting help is also very difficult.

Though emergency numbers are listed in the telephone directory, in emergency people will be panicky and may not remember what to do. Also, the the numbers in the directory may be old. Further, telephone directories are not published by all telephone companies. If the users are having only mobile phones, then they don't have any directory. Fortunately, now phone number 108 is available to contact in case help required when there is an emergency (fire/police/ambulance). But, how many people know this information is questionable. Only learned people with an eye on what is happening in their surroundings will know. Otherwise, there are many people who don't read news papers or look around billboards / stickers pasted at important places.

If this information and other important details as mentioned in the beginning of this article are displayed on the cylinder itself, it will be help for all the users. The information should be available in English, Hindi and the local language. Pasting of the sticker by the gas cylinder delivery agency should be made mandatory. If the agency is made responsible, then the sticker with instructions in local language along with English and Hindi can be ensured. The sticker may cost 2-3  rupees. But, this will definitely help the users. If stickers are not used and only pamphlets are distributed, users may lose them and utility can'g be guaranteed.

I will put some more information on this subject in my future posts.

Importance of Learning

Accidents and near misses are the result of mistakes committed by some one.

On human errors, there is a quotation by the great safety professional, Mr Trevor A. Kletz (retired from ICI, UK and now is about 90 years old),

“Mistakes occur because someone does not know what to do. To prevent them we need better training or instruction or changes to the plant design or work method so that the task is easier”.

It can be due to shop floor person, supervisor, officer during operation, issue of instructions or during design. A mistake can be a part of the system right from the beginning or it could have been committed subsequently.

We all make mistakes. However we can become wise and knowledgeable only when we learn from these mistakes.

Experience makes a man wise. However, experience is not desirable in all aspects.

Again in the words of Mr Kletz in his book, “Still Going Wrong”,

“A high price was paid for safety information mentioned in various sources (like books, films and internet). People were killed or injured and billions of dollars worth of equipment was damaged. Someone has paid the TUTION FEES. There is no need for you to pay them again”.

It only takes one apple to spoil the whole barrel as the old saying goes, and this is time when a group of humans gather together. If one friend or family member is not happy, then their unhappiness can spread to infect the others in the group.

Same can be applied to safety. If a person is unaware / not bothered about safety, he will endanger others also.

If we see the accidents that occurred in any particular industry from its inception or even for that matter for the last few years, can we say that all those accidents that occurred were of first time in nature? It is unlikely and I am sure nobody agrees with this statement. Most of the accidents are of repetitive nature, if not exactly, slightly in a different manner. If we go through the accident and near miss records, we can find similarity in the type of accidents. May be it is not in the same plant but in some other plant under the management of same organization.

Dissemination of information is vital so that all of us can study the accidents and near misses and can see whether IS IT POSSIBLE IN MY PLANT FOR OCCURRENCE OF SUCH AN ACCIDENT. It is important in safety committee meetings held every month that the discussions should be on accidents and near misses occurred in the plant or other plants. Instead, the observation is that mostly discussion goes on pending safety related deficiencies (SRDs) which were already brought to the notice of the plant management by the safety officer and by allocating necessary resources (responsible person, man power, finance, etc), these SRDs can be corrected. Information on accidents, near misses, unusual occurrences etc is normally compiled at corporate level and are sent to all units under the organization after review. This is one valuable source of information on accidents. Similarly, we read such incidents in the newspapers that there is some fire, explosion, electrocution, fall of person, etc with some details. Therefore media is another source. Similarly those who had access for other sources like books (library) or internet can get valuable information.

Seminars can be conducted for employees in which those who were actually involved in accidents directly or witnessed can explain their experience in accidents with the noble cause of saving their colleagues from such accidents. Discussion of these in such seminars, plant meetings, etc creates an awareness about safety and can ignite our minds to take necessary corrective measures so that we can maintain a safe work place.