Incident investigation in Pakistan's fertilizer industry—Common safety management system failures and issues

Abstract

The learning from operational incidents plays a key role in improving the performance and safety of the chemical process plants. In this article, the incidents occurred during January 2011 to April 2012 in different sections, that is, Ammonia, Urea, and Utility Units of fertilizer sector in Pakistan have been analyzed using Why Tree analysis. The aim is to identify the failures in the safety management system to prevent the incidents. One thousand and fifteen, root and contributing causes identified in investigations strongly assert that improvement in safety management systems could have prevented or mitigated the intensity of many of the occurred incidents/accidents. The flaws in mechanical integrity, maintenance procedures and operating procedures, and job risk assessment are the most common recurrent as root cause failures of safety management system. © 2014 American Institute of Chemical Engineers Process Saf Prog 33: 399–404, 2014

Operational discipline in practice

“…Rashid et al has shown that its very important to construct why tree diagrams for occurred accidents to identify the safety management systems failure. 21 Improvement in these safety management systems will prevent future incidents and enhance operational discipline. First step to construct a why tree diagram is to complete a detailed incident report form.…”

“…It was observed that flaws in operating procedures were responsible as a root or contributing cause for 13% of the occurred accidents or incidents. 21 Existence of work instructions improve operational discipline as they enlist step wise procedure for routine jobs and chance of errors minimize. Pre start-up safety review must be performed before the start-up of the normal facility or before the start-up of a newly installed facility or part of the facility.…”

“…Existence of work instructions and or operating procedures and their correctness is very important for an organization or corporation. It was observed that flaws in operating procedures were responsible as a root or contributing cause for 13% of the occurred accidents or incidents 21 . Existence of work instructions improve operational discipline as they enlist step wise procedure for routine jobs and chance of errors minimize.…”

Process safety management and process hazard analysis implementation progress in Pakistan chemical process industries

“…11 Exactly 16% of the root or contributing causes for accidents in fertilizer complexes were due to deficiencies in PHA. 12 It is recommended that PHA can identify such causes and prevent accidents, 5 whereas the deficiencies in process safety of process plants can be highlighted via leading and lagging matrices. 13,14 PHA is one of the 14 elements of process safety management (PSM), 15 and metrics for PHA have been developed to monitor its performance.…”

Consequence assessment of anhydrous ammonia release using CFD‐probit analysis

“…In the year 1991, the ammonia was released from Urea Fertilizer Factory Limited (UFFL), Bangladesh and led to severe damage including control room and also led to economic crises in the industry . Also in the year 2011, the ammonia was leaked from mechanical seal of ammonia feed pump in an ammonia storage facility located in Pakistan and this ammonia dispersed to the atmosphere . An operator was narrowly escaped from being affected by ammonia.…”