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Committee report on Styrene gas leak at LG Polymers, Vizag, India

  • 1.  Committee report on Styrene gas leak at LG Polymers, Vizag, India

    Posted 07-08-2020 22:57
      |   view attached

    Hi all,

    I have attached the report on Styrene gas leak (May 2020) at Vizag India. Ignoring the penal recommendations of the committee, can you please provide your comments on:

    • The appropriateness of the fishbone diagram in arriving at the causal factors
    • The veracity and accuracy of the fault tree
    • Chapter 8 recommendations of the committee in establishing a central factory safety board
    Thanks in anticipation of your comments and repsonses.




    ------------------------------
    Raj Sreenevasan
    Principal Control Systems Engineer
    Wave International
    Willetton ACT
    ------------------------------


  • 2.  RE: Committee report on Styrene gas leak at LG Polymers, Vizag, India

    Posted 07-10-2020 17:36
    First and most importantly, as a process safety investigator, my heart is heavy for those that died, and those that were injured. It is difficult to balance the focus that comes to an investigation team with the emotions of the impact to those affected. I hope there comes a time when their memories will bring warmth and inspiration to their friends and family that are hurting so badly today.

    I'm retired, so I certainly do not speak for my former employer. Speaking for myself, this is a very impressive investigation report.

    I really took note when I read in section 2.2.1.7 about the modified cooling system circulation piping inside the tank and realized the importance of the resulting stratification. It seemed to me the polymerization initiated because of stratification, and stratification resulted from the modified cooling system internals. I was looking forward to a description of the company's MOC systems and how this significance could have slipped by. I was interested to compare the MOC system at this plant to what I was used to seeing as part of the U.S.-based OSHA Process Safety Management requirements.

    I was amazed to find that the company had no PSM systems; there was no MOC process! (Section 2.4.1, item iv) Wow.

    My hope is the same as that of every investigator; that the lessons from this tragedy will be used to actually make systemic change to prevent similar incidents.  Recommendations from an incident like this need to be implemented throughout the country. Changes must have broad, significant impact. For example, no one should operate a chemical or refining facility without a robust and functioning process safety management system. And just having a regulation that declares they have to have it is not good enough.

    Those that read this report, regardless of their country or company processes, need to avoid off-handed judgement. Do not apply pride and hindsight bias, saying, "Well, something like that could never happen here. Those people were just...." fill in the blank. The majority of investigations the CSB conducted while I was there had to do with situations where there were no procedures, or perhaps could not be procedures. You do not have it all figured out.

    Thanks for sharing the report on Discussion Central.


    ------------------------------
    Steve Cutchen
    Investigator, retired
    US Chemical Safety Board
    Houston TX
    ------------------------------



  • 3.  RE: Committee report on Styrene gas leak at LG Polymers, Vizag, India

    Posted 07-13-2020 23:37

    Steve,

    Thanks for your comments. I have followed CSB investigations closely for over 7 years now. The latest MRR investigation report did include a causal analysis chart (which is the first time I have seen in a CSB report). Were you involved in that investigation?
    Regards,
    Raj



    ------------------------------
    Raj Sreenevasan
    Principal Control Systems Engineer
    Wave International
    Willetton ACT
    ------------------------------



  • 4.  RE: Committee report on Styrene gas leak at LG Polymers, Vizag, India

    Posted 07-14-2020 02:18
    No, I was not part of MRR.

    The CSB has been including hierarchical cause and effect charts called AcciMaps (developed by Jens Rasmussen in 1997) in most reports for quite a while.

    Also, as part of our internal working documents, we typically used cause and effect charts to help structure and track our investigation. For cause and effect diagrams, I used a mind mapping program called SimpleMind, which I found gave me great structure, a lot of room for documentation, and a lot of freedom in application. 

    The charts would all start with a box that contained the What, Where and When of the incident, followed by a box with all of the primary effects of the incident. From there, each box would be followed by all of the things that fit with the statement "caused by..." We worked hard to incorporate not just active causes (momentary, often people driven; noun, verb.. "button pressed") and condition causes (exist over time, a thing that exists or is.) We would have text and links to evidence documents. And when a cause/effect was still a hypothesis, we would color it yellow so that we knew it needed investigation and was subject to change. It was not unusual for there to come a point where the original working cause and effect chart got so confounded by all kinds of arrows and "gotos," that the team would start from scratch and develop a new cause and effect chart, restructured to properly and simply incorporate all of the information gleened up to that point.

    These working document charts typically become the basis for an Accimap.


    https://simplemind.eu

    https://www.researchgate.net/publication/278966716_SPE-174020-MS_Applying_the_AcciMap_Methodology_to_Investigate_a_Major_Accident_in_Offshore_Drilling_A_Systematic_Risk_Management_Framework_for_Oil_and_Gas_Industry

    Rasmussen, J., 1997, Risk Management in a Dynamic Society: A modeling Problem, Safety Science, 27 (2): 183–213



    ------------------------------
    Steve Cutchen
    Investigator, retired
    US Chemical Safety Board
    Houston TX
    ------------------------------



  • 5.  RE: Committee report on Styrene gas leak at LG Polymers, Vizag, India

    Posted 07-12-2020 10:01
    As desired by you, please find my detailed observations in attached document.
    It has taken reasonable time to go through the details.
    A model fishbone diagram also attached for reference.
    I will be happy to know how this information will be used.
    Your feedback on my observations will be highly appreciated.

    Regards,

    ------------------------------
    KOTTI KUMAR
    Ex. Leader - Plant Operations
    INDO GERMAN PETROCHEMICALS LIMITED
    ------------------------------



  • 6.  RE: Committee report on Styrene gas leak at LG Polymers, Vizag, India

    Posted 07-13-2020 23:40

    Kotti,

    I have downloaded your attachments, but have not had the opportunity to review them yet. Give me a couple of days and I will get back to you with answers to the questions you have posed.
    Regards,
    Raj



    ------------------------------
    Raj Sreenevasan
    Principal Control Systems Engineer
    Wave International
    Willetton ACT
    ------------------------------



  • 7.  RE: Committee report on Styrene gas leak at LG Polymers, Vizag, India

    Posted 30 days ago
    O.K.

    Regards,

    Rama

    ------------------------------
    KOTTI KUMAR
    Ex. Leader - Plant Operations
    INDO GERMAN PETROCHEMICALS LIMITED
    ------------------------------



  • 8.  RE: Committee report on Styrene gas leak at LG Polymers, Vizag, India

    Posted 29 days ago
    Koti,
    Apologies for the delay in responding to your questions. At the outset I would like to state that I did not participate in the investigations. My view is that every major accident (whilst loss of life is very much regretted) is an opportunity to test the validity of existing rules, whether it serves the purpose in the current environment, do the regulations aid in improving the safety culture in operating plants etc.

    Having said that, I will absorb and apply all lessons learned (I have provided a couple of examples in my response), including nuggets and gems of wisdom imparted by other peers like you and Steve Cutchen. If you disagree with what I have stated, then please state so. I will consider them as part of my lifelong learning.
    Thanks and regards,
    Raj

    ------------------------------
    Raj Sreenevasan
    Principal Control Systems Engineer
    Wave International
    Willetton ACT
    ------------------------------



  • 9.  RE: Committee report on Styrene gas leak at LG Polymers, Vizag, India

    Posted 29 days ago
    Mr.Raj Srinivasan,

    Thank you for the detailed reply. 
    Appreciate your approach towards this incident  (or earlier incidents) and analysis. 
    Good to note your rich experience in this field.
    I have downloaded attachments (useful) and will go through.

    Thank you & Best wishes,







  • 10.  RE: Committee report on Styrene gas leak at LG Polymers, Vizag, India

    Posted 29 days ago
    You are correct. I thought I replied to the other one and was surprised when it showed up in your discussion. I'll look closer next time to make sure I'm responding to the right comments. 

    Sent from my iPhone





  • 11.  RE: Committee report on Styrene gas leak at LG Polymers, Vizag, India

    Posted 07-13-2020 23:58
    This problem requires a feed forward control not a feed back control. It's possible with the concentration in one stream. Monitor the stream with a variable concentration and adjust the flow rate of the other as needed to give the desired mixed stream.

    ------------------------------
    Robert Clay, PhD, MBA, PE
    Sr. Associate Engineer
    ECI, Inc.
    Lenexa, Kansas
    ------------------------------



  • 12.  RE: Committee report on Styrene gas leak at LG Polymers, Vizag, India

    Posted 29 days ago

    Robert,

    I believe that this message was intended for the other discussion about controlling static mixers.
    Regards,
    Raj



    ------------------------------
    Raj Sreenevasan
    Principal Control Systems Engineer
    Wave International
    Willetton ACT
    ------------------------------