Motto of the semester ___________________
John F. Kennedy: The time to repair the roof is when the sun is shining
MAHBulletin
Number 7, June 2015
JRC96479
ContACt
For more information on related to this bulletin on lessons learned from major industrial accidents, please contact
zsuzsanna.gyenes@jrc.ec.europa.eu or emars@jrc.ec.europa.eu
Security Technology Assessment Unit European Commission Joint Research Centre Institute for the Protection and Security of the Citizen Via E. Fermi, 2749 21027 Ispra (VA) Italy http://mahb.jrc.ec.europa.eu/
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(Continued from accident 4) Wrong equipment
Important findings • The gasket of the flange was leaking but not the leakage was only noticed after it had been occurring for some time. This gasket had been installed about 18 years before when the tank was built. • According to the supplier data, the gasket in question, a “Viton” gasket was phenol-resistant, yet it had suffered serious degradation due to a reaction with phenol. • Since the day the phenol tank was taken into service, the spindle of the manual valve had never been closed or inspected. • The level indicator in the phenol tank no longer functioned. This malfunction was probably recent because the indicator was routinely consulted during operations. A few days prior to the incident the indicator was still working properly.
Lessons learned • The accident indicates that phenol resistance can degrade over time such that it loses its ability to resist phenol altogether. Even equipment that are manufactured to be resistant to certain reactive phenomena must be regularly inspected (following appropriate standards) and at some point in time, it may have to be replaced. • Safe working procedures should be followed. It is good practice to close the manual valve after each run of phenol-based production batches or at the end of the working week. • During earlier visits Seveso inspectors diagnosed an insufficient inspection system. Although some work had already been done to develop a better system, the new inspection system was not completely in place by the time of the phenol leak. In such circumstances, a follow-up inspection might be necessary in order to ensure that the site safety management system is up to date.
[EMARS Accident # 41]
Self-assessment questions
• Does your company use indicators of ageing? If not, why? If yes, what indicators do you use? • Does the establishment have up-to-date documentation of all the safety-critical mechanical equipment (tanks, pipelines, pumps) present on the site, including all component parts (replacements, additions, etc.)? • Are all safety-critical equipment fit-for-purpose? Is it documented? • Does the company plan a life cycle for their plant/equipment, and have a date for retirement/replacement of the plant/equipment ? • What policies are in place for determining the end of equipment life (economic analysis, considering the costs of inspection, maintenance and repair and lost production failure versus the costs of decommissioning and replacement is a good basis for determining end of life)1? • Have plant and equipment signs of ageing, such as corrosion, erosion, fatigue, creep, obsolescence been identified and monitored2? • Does the site have clear, up to date procedures and instructions available to cover normal operating, emergencies and management of change? • Do you have complete documentation on the history of all safety-critical equipment, including use parameters, changes and additions since installation? If not, how do you deal with incomplete knowledge to make relevant maintenance and change decisions? • Do staff and contractors engaged in maintenance and change operations have access to all relevant documentation? • How do you ensure that key skills, knowledge and experience relevant to asset integrity management and ageing is transferred and maintained with people leave, retire, move to a new position in the company1? • Do you have a systematic inspection program in place that addresses ageing phenomenon in order to monitor condition of plant and equipment or handle inadequate design? • How do you ensure that deficiencies in project management addressed in the site’s safety management system as well as the overall site management system? _____________________________________________________________________________________ 1TWI Ltd, ABB Engineering Services, SCS (INTL) Ltd and Allianz Cornhill Engineering for the Health and Safety Executive 2006: Plant ageing Management of equipment containing hazardous fluids or pressure http://www.hse.gov.uk/research/rrpdf/rr509.pdf 2HSE: COMAH Competent Authority Ageing Plant Operational Delivery Guide Appendix 2 - Site Operator Self-Assessment Question Set (HSE, http://www.hse.gov.uk/comah/guidance/ageing-plant-app2.pdf
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