cf lecture 8 incidents - loss of containment

7/27/2019 CF Lecture 8 Incidents - Loss of Containment

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Incidents

Loss of Containment



Learning from Accidents

A wise man learns from his own mistakes. A wiser

man learns from those of others. (Anon)

We learn wisdom from failure rather than from

success. He who never made a mistake, probablynever made a discovery. Samuel Smiles 1812-1904

Those who do not learn the lessons of history are

doomed to repeat them. George Santayana 1863-1952



Incident

• Any undesired circumstance or occurrence which gives rise to, or couldgive rise to, ill health or injury, damage

to property, plant, products or theenvironment



Accident

An undesired event, which results inphysical harm and /or property damage,usually resulting from contact with a

source of energy above the ability of thebody or structure to withstand it.



Near-miss

An unplanned / undesired event which

has the potential to result in personal

injury, or damage to property, or harmto the environment



ACCIDENT MODEL

THE LOSS

THE EVENT

THE IMMEDIATE CAUSE

THE UNDERLYING CAUSE

THE MANAGEMENT SYSTEM FAILURE



THE LOSS

FATALITY

INJURY

PROPERTY DAMAGE

ENVIRONMENTAL SPILL

FINANCIAL LOSS



THE EVENT

IMPACT

COLLISION

FIREEXPLOSION

LEAK

SLIP OR FALL



IMMEDIATE CAUSES

SubstandardConditions

Substandard

Acts



SUBSTANDARD CONDITIONS

• Inadequate guards or barriers• Inadequate or improper protective equipment

• Defective tools, equipment or materials

• Congestion or restricted action

• Inadequate warning systems

• Poor housekeeping

• Noise exposure• Radiation exposure

• Toxic material exposure

• Operation of equipment with isolated alarm orprotective system



SUBSTANDARD ACTS

• Operating equipment without authority• Failure to warn others of known hazard

• Failure to operate equipment at theappropriate time

• Operating at improper speed• Making safety devices inoperable

• Removing safety devices

• Using defective equipment

• Failing to use personal protective equipmentproperly or at all

• Under influence of alcohol or drugs



UNDERLYING CAUSE OF THE ACCIDENT

• Individual FactorsInadequate:

•Capability

•Knowledge

•Skill

•Motivation Inadequate:

•Inspection

•Engineering

•Maintenance

•Equipment

•Work Standards

Lack of Procedures

Inadequate LeadershipUnsafe work conditions

Unsafe systems of work

Job Factors

Organisation Factors



MANAGEMENT SYSTEM FAILURES

• INADEQUATE LOSS PREVENTION PROCEDURE

• INADEQUATE LOSS PREVENTION STANDARDS

• INADEQUATE COMPLIANCE WITH LOSS

PREVENTION STANDARDS



MANGEMENT SYSTEM FAILURE

• Inadequate loss prevention procedure• No operating procedure

• Inadequate loss prevention standards

• No system for reviewing operating

procedures• No system for checking standards are set

• No programme for hazard identificationduring design

• No work permit system

• No modification procedure• Inadequate compliance with loss prevention

standards



Management System Defects

Incident

Root or Underlying Causes

Immediate Causes

Contact



Loss of containment events

• Range from minute leaks to massive releases

• Can be liquid or gas

• Commonest defect in many industries, and

hence often ignored

• Majority occur during normal operations or

maintenance

• Often the trigger for larger events such as fireor explosion



Piper Alpha 1988



Transco pipeline failure USA



Buncefield explosion and fire



Where do releases occur?



Which pipe do you mean?



Offshore Christmas Tree



I Chem E study into releases in chemical plantsand refineries found:

•Work systems 26%

•Mechanical damage 19%

•Internal corrosion 12%, external corrosion 6%,stress corrosion 3%

•Material problems 9%

•Freezing, vibration, thermal fatigue, water

hammer accounted for 8% and

•17% other or unclassified

Why do releases occur?



HSE Hydrocarbon Database

• Set up to record release types and causes.

• 55% were gas releases, 17% oil, 15% condensate,and 13% were non- process.

•6% major, 55% significant and 39% minor.

• Equipment with highest leak rates wasinstrumentation, especially on turbines andcompressors which are subject to vibration.

• 6% of all releases ignited

• Mechanical was the highest failure mechanism.



Work system failures

• Often occur as underlying cause or managementsystem failure.

• Inadequate design, fabrication, understanding of systems, planning or control of work, or

training/competency.

• Non existent or inadequate procedures, poorequipment, weak leadership

• Overall the biggest cause of incidents and

accidents e.g. Piper Alpha, Texas City, Buncefield,Flixborough, Bhopal, HCC Pasadena



Mechanical damage

• Impact on piping or vessels during mechanical

handling

• Excavation without prior investigation

• Dropped objects

• Ship impact on pipeline risers

• Overstressing of components, overpressure



Digger ruptures pipe



Bombay High North platform



Fake extended stud bolt



Corrosion/material problems

• Corrosion and material failures together accountfor more leaks than any other cause

• Often due to inadequate understanding of process fluids composition, changes in

temperature/pressure/flow regime

• Often not observed e.g. corrosion underinsulation, or internal corrosion/erosion of pipes/vessels

• Deliberate/misunderstood use of inferiormaterials



Failure during hydro test. Inadequate materials



Other failure mechanisms

• Water or hydraulic hammer. Rapidly flowing

fluid hits elbow or valve. Very high pressures

generated.

• Pipe contents freezing and expanding.• External sources of heat.

• Vibration. Oscillation of pipes by wind or

flowing water. Inadequate pipe support.



Novel pipe support



Exploding aerosol can left in car on a sunny day



Fractured pipe on vibrating compressor outlet



Summary

• Loss of containment is probably the largest

cause of dangerous occurrences in the

chemical industry

• Often occurs on small or less significant lines• Can rapidly escalate to fire/ explosion or toxic

poisoning incidents

• The largest cause of fatalities in refineries and

offshore

cf lecture 8 incidents - loss of containment

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