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, probably never 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 could give rise to, ill health or injury, damage to property, plant, products or the environment

Accident
An undesired event, which results in physical harm and /or property damage, usually resulting from contact with a source of energy above the ability of the body 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 harm to 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 FIRE EXPLOSION LEAK SLIP OR FALL

IMMEDIATE CAUSES

Substandard Conditions

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 or protective system

SUBSTANDARD ACTS
Operating equipment without authority Failure to warn others of known hazard Failure to operate equipment at the appropriate time Operating at improper speed Making safety devices inoperable Removing safety devices Using defective equipment Failing to use personal protective equipment properly or at all Under influence of alcohol or drugs

UNDERLYING CAUSE OF THE ACCIDENT

Individual Factors
Inadequate: Capability Knowledge Skill Motivation
Organisation Factors Job Factors

Lack of Procedures Inadequate Leadership Unsafe work conditions Unsafe systems of work

Inadequate: Inspection Engineering Maintenance Equipment Work Standards

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 identification during design No work permit system No modification procedure Inadequate compliance with loss prevention standards

Management System Defects Root or Underlying Causes Immediate Causes Contact Incident

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 fire or explosion

Piper Alpha 1988

Transco pipeline failure USA

Buncefield explosion and fire

Where do releases occur?

Which pipe do you mean?

Offshore Christmas Tree

Why do releases occur?

I Chem E study into releases in chemical plants and 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

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 was instrumentation, especially on turbines and compressors 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 management system failure. Inadequate design, fabrication, understanding of systems, planning or control of work, or training/competency. Non existent or inadequate procedures, poor equipment, 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 account for 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 under insulation, or internal corrosion/erosion of pipes/vessels Deliberate/misunderstood use of inferior materials

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