ert 312 safety & loss prevention in bioprocess accident investigations prepared by: pn. hairul...
TRANSCRIPT
![Page 1: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/1.jpg)
ERT 312SAFETY & LOSS PREVENTION IN
BIOPROCESS
ACCIDENT INVESTIGATIONS
Prepared by:Pn. Hairul Nazirah Abdul Halim
![Page 2: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/2.jpg)
Objective
• To discuss the method to investigate the accidents in the plant
• To analyze & evaluate in a case studies
![Page 3: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/3.jpg)
Introduction
• The investigation of accidents and near misses provides opportunities to learn how to prevent similar events in the future.
• Accident investigation includes detailed descriptions and recommendations of the events.
![Page 4: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/4.jpg)
Sub-topic
• Learning from accidents• Layered investigations• The investigation process• Investigation Summary• Aids for diagnosis• Aids for recommendation
![Page 5: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/5.jpg)
Learning from accidents
• Build an investigation team• Every member learns about problems that
precipitate accidents• To avoid similar situations in the future• Learn how to prevent future accidents.
![Page 6: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/6.jpg)
Learning from accidents• Fundamental step in accident investigation:
1. Developing a detail description of the accident2. Accumulating relevant facts3. Analyzing the facts and developing potential
causes of the accident4. Studying the system & operating method
relevant to the potential causes of the accident5. Developing the most likely causes6. Developing recommendations to eliminate
recurrence of this type of accident7. fact-finding not fault-finding.
![Page 7: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/7.jpg)
Layered Investigations
• First layer: immediate technical recommendations, • Second layer: recommendations to avoid the
hazards, • Third layer: recommendations to improve the
management system.
![Page 8: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/8.jpg)
Example 12-1
Illustrate the layered investigation process to develop underlying causes of a municipal pool accident.
A drowning accident occurred during an open swim period. Approximately 100 children, ranging between 5 and 16 years old, were in and around a pool (3 ft to 9 ft deep). An older child unknowingly pushed a 5-year-old into the deep water. The pool was relatively crowded, and the 5-year-old slipped under the water without being noticed by others, including the lifeguard.
![Page 9: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/9.jpg)
Solution
The facts uncovered by an investigation team are
1. the pool did not have deep and shallow markings,
2. the older child was engaged in horseplay,
3. the younger child did not know how to swim,
4. the lifeguard had many blind fields of vision,
5. the pool was overly crowded,
6. the pool did not have an orientation program, and
7. the pool did not offer swimming lessons.
![Page 10: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/10.jpg)
First layer recommendations: Immediate technical recommendations
1. Paint pool depths at the pool edges.
2. Add more lifeguards.
3. Reduce the number of swimmers.
![Page 11: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/11.jpg)
Second layer recommendations: Avoiding the hazard
1. Prohibit horseplay.
2. Zone pool to keep smaller children at shallow end of pool.
3. Add swimming lessons for all age groups.
4. Give all new swimmers (especially young children) a pool orientation.
5. Add a roving lifeguard to monitor and control pool behavior.
![Page 12: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/12.jpg)
Third layer recommendations: Improving the management system
1. Train lifeguards to alert supervision of observed potential problems.
2. Assign the supervisor to make formal (documented) audits on a regular basis.
![Page 13: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/13.jpg)
![Page 14: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/14.jpg)
Investigation Process
Steps
(1) Investigation team – choose team
(2) Brief survey – make overview survey to understand the type and information needed to derive causes of the accident.
(3) Set objectives and delegate responsibilities – based on (1) and (2)
(4) Preincident facts
- gather & organize preincident facts. Use flowsheets, procedures, photograph
![Page 15: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/15.jpg)
Investigation ProcessSteps
(5) Accident facts
- make detailed examinations with photos, inspections.
- record extent of damage, hypothesize the sequences of event, cause of accident
(6) Research and analyses
– initiate research-type experiments & analyze facts
(7) Discussion, conclusions and recommendations
- study (2) to (6) to develop conclusion & layered recommendations.
(8) Report
- develop accident investigation report.
![Page 16: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/16.jpg)
Accident Investigation Report• format should be flexible and designed specifically to
best explain the accident. • The format may include the following sections:
(1) introduction,
(2) process description (equipment and chemistry),
(3) incident description,
(4) investigation results,
(5) discussion,
(6) conclusions,
(7) layered recommendations.
![Page 17: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/17.jpg)
Investigation Summary
• Summarizes the events and recommendations in a diagram
![Page 18: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/18.jpg)
![Page 19: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/19.jpg)
Aids for Diagnosis
• The data collected during accident are studied and analyzed:
- to find the cause of accident
- to develop recommendations to prevent a recurrence
• Sometimes, the evidence needs added analysis to uncover explanations.
• Require special techniques or aid to diagnosis to relate the evidence to specific cause.
![Page 20: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/20.jpg)
Aids for Diagnosis
a) Fire
b) Explosions
c) Sources of ignition in vessel
d) Pressure Effects
e) Medical Evidence
![Page 21: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/21.jpg)
Aids for Diagnosis
a) Fire
- identification of the primary source of ignition is one of the major objectives of investigation.
- For example;
- the depth of wood charring is proportional to the duration of burning
- most woods burn at a rate of 1.5 in/hr.
- If the time of extinguishment is known;
- If the depth of char at various locations is known;
- the region of the origin can be approximated.
![Page 22: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/22.jpg)
Aids for Diagnosis
b) Explosions
- The classification of the explosion as either deflagation or a detonation & magnitude of the explosion may be useful to develop causes and recommendations.
![Page 23: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/23.jpg)
Aids for Diagnosis
b) ExplosionsDeflagration-The pressure increases during deflagration:
for hydrocarbon-air mixtures
for hydrocarbon-oxygen mixtures
P1 and P2 = upstream & downstream pressure, respectively
81
2 p
p
161
2 p
p
![Page 24: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/24.jpg)
Aids for Diagnosis
b) Explosions
Detonations
-In a single vessel detonations increase pressures significantly:
201
2 p
p
![Page 25: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/25.jpg)
Aids for Diagnosis
c) Pressure Effect
- Investigation on ruptured pipe and vessel
- important to know the pressures required to create the damage
- Pressure necessary to produce a specific stress in a vessel depends on:
1. thickness of the vessel
2. vessel diameter
3. mechanical properties of the vessel wall
![Page 26: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/26.jpg)
• For cylindrical vessel (pressure p < 0.385SM)
• For cylindrical vessel (pressure p > 0.385SM)
Where: p is the internal gauge pressure,SM is the strength of the material,tV is the wall thickness of the vessel, r is the inside radius of the vessel.
![Page 27: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/27.jpg)
• For spherical vessel (pressure p < 0.665SM)
• For spherical vessel (pressure p > 0.665SM)
![Page 28: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/28.jpg)
![Page 29: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/29.jpg)
Example 12-3
Determine the pressure required to rupture a cylindrical vessel if the vessel is stainless 316, has a radius of 3 ft, and has a wall thickness of 0.5 in.
![Page 30: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/30.jpg)
Solution• Because the pressure is unknown, Equation 12-4 or
12-5 is used by trial and error until the correct equation is identified.
• Equation 12-4 is applicable for pressures below 0.385SM.
• SM for Stainless Steel 316 (from Table 12-3) = 85,000 psi, 0.385SM = 32,700 psir = 3 ft = 36 in tv = 0.5 in.
Therefore Equation 12-4 is applicable, and a pressure of 1170 psi is required to rupture this vessel.
![Page 31: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/31.jpg)
Example 12-4
Determine the pressure required to rupture a spherical vessel if the vessel is stainless 304, has a radius of 5 ft, and has a wall thickness of 0.75 in.
![Page 32: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/32.jpg)
Solution• Equation 12-6 is applicable if the pressure is less
than 0.665SM
• SM for Stainless 304 = 80,000 psi
• 0.665 SM = 0.665(80,000) = 53,200 psi.
• Using Equation 12-6 for spherical vessels,
• The pressure criteria is met for this equation. • The pressure required to rupture this vessel is
1990 psi.
![Page 33: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/33.jpg)
(d) Medical Evidence• Medical examinations of the accidents victims may
be useful for identifying the source of accidents• Type of medical data:
1. type & level of toxic in the blood2. location & magnitude of injuries3. type of poisoning (CO, toluene, etc.)4. sign of heat exposure5. sign of eye irritation
Aids for Diagnosis
![Page 34: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/34.jpg)
Aids for Recommendations
• To develop recommendations to prevent a recurrence
• To prevent similar accident within the company / industry
![Page 35: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/35.jpg)
Aids for RecommendationsControl Plant Modifications• Often not given the same attention/concern as a new
plant design• Many accidents are result of plant modifications• Recommendations to prevent this problem:
a) All modification must be authorized.b) The modification design should have same quality of pipes/equipments as the original designc) Safety review – HAZOP must be conducted while the modification project is in the design phase.d) Training – operators & engineers: to understand the modified operatione) Audit – to ensure the modifications are made &
maintain as designed.
![Page 36: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/36.jpg)
User Friendly Design• Not create hazardous conditions• For example:
1. using nontoxic and nonflammable solvent
2. keep temperatures below the flash point & boiling point at atmospheric conditions
3. keep inventories low
4. design for safe shutdown during emergency situations
![Page 37: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/37.jpg)
Block Valves• Install throughout plants to return a process to a
safe condition under unusual circumstances• Block valves are often controlled on the basis of
analyzer results for:
1. detecting solvent leaks
2. reactor analyzer – detect runaway reactions
(block valve can be opened to add a reaction inhibitor)
3. sewer analyzer – detect high concentration of contaminants
![Page 38: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/38.jpg)
• Preventive Maintenance
- failure of emergency protection equipment such as cooling water pumps, instruments and deluge system can cause major accident.
- Protective equipments failed due to no preventive maintenance
- Preventive maintenance programs must be organized, managed & fully supported by management.
- Must have maintenance schedule
![Page 39: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/39.jpg)
ERT 312/4 – SAFETY & LOSS PREVENTION
PBL PROJECT- INDUSTRIAL ACCIDENTS
![Page 40: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/40.jpg)
Industrial Accidents
Group A1 & B1: Flixborough Works Accident, June 1974
Group A2 & B2: Bhopal, India Accident, December 1984
Group A3 & B3: Seveso, Italy Accident, July 1976
![Page 41: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/41.jpg)
Group A4 & B4: Thailand Toy Factory Fire, May 1993
Group A5 : Three Mile Island Nuclear Disaster, 1979
Group A6 & B6: Tokaimura Nuclear Disaster, September 1999
Group A7 & B7: Piper Alpha Incidents, July 1988
![Page 42: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/42.jpg)
Prepare an Accident Investigation Report. The format may include the following sections:
(1) Introduction(2) Process description (equipment and chemistry)(3) Incident description: chronology of event,
cause of accident, extent of damage(4) Lesson learned(5) Layered recommendations(6) Conclusions
![Page 43: ERT 312 SAFETY & LOSS PREVENTION IN BIOPROCESS ACCIDENT INVESTIGATIONS Prepared by: Pn. Hairul Nazirah Abdul Halim](https://reader035.vdocuments.us/reader035/viewer/2022062321/56649f175503460f94c2d2ca/html5/thumbnails/43.jpg)
PBL Presentation* 20 minutes presentation + 10 minutes Q&A Session
19 Oct 2009 (Mon)(12 – 2.00 pm)(Bilik Seminar) – Group A1, B1, A2, B2
20 Oct 2009 (Tue)(9.00 – 11.00 am)(DKD4) – Group A3, B3, A4, B4
20 Oct 2009 (Tue)(11.00 am – 12.00 pm)(BKD3) – Group A5
21 Oct 2009 (Wed)(2.00 – 4.00 pm) (Bilik Seminar) – Group A6, B6, A7, B7