Chemical Engineering Progress Case Study Analysis Q1: This question involves reading a paper, watching a safety video, and answering open- ended questions:

Chemical Engineering Progress Case Study Analysis Q1: This question involves reading a paper, watching a safety video, and answering open-
ended questions:

Watch “Mixed Connection, Toxic Result” via the Chemical Safety Board.

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Chemical Engineering Progress Case Study Analysis Q1: This question involves reading a paper, watching a safety video, and answering open- ended questions:
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https://www.csb.gov/videos/ or

Read ‘Don’t Do This!’ by Glenn Young and Joel Olener.

What overlaps, if any, do you see between the video and the article? What does overlap
(or the lack of) imply/mean?

Q2: Read ‘Ethics- Examining Your Engineering Responsibility’ by Deborah L. Grubbe and
“Ethics Survey Results: Your Responses” from Chemical Engineering Online. In ~1 typed page,
summarize key points and reflect on anything that stands out to you. Q3: Read the ‘Crashing into Law’ case study attached here. Address the following:
a. List 3 to 5 relevant stakeholders in this case.
b. Pick three stakeholders, and describe the duties and rights these stakeholders have
toward each other. This is best done with a drawing of each stakeholder with arrows
indicating duties one owes to other and rights one has.
For c and d, use the three stakeholders identified in Part b to:
c. Determine to what degree each stakeholder’s duties were fulfilled or neglected.
d. Determine to what degree each stakeholder’s rights were violated or protected, and by
whom.
e. Construct an alternative scenario that would have avoided any problematic ethical issues
you identified in the case. An alternative does not have to be perfect or even optimal to
be better than what happened.
f. The AIChE code of professional ethics is a guide for chemical engineers. What professional
and ethical issues highlighted by this case are addressed in the AIChE code of Ethics? This is the AIChE code you might need it for question 3 (AIChE Code of Ethics (March 28, 2016) [http://www.aiche.org/about/code-ethics] is included at the end of the
case study). for part (b) in the question (1) I upload for you the file named ( don’t do this ). Safety
Don’t
Do This!
Glenn Young
Glenn Young & Associates, LLC
Joel Olener
Process Safety and Security
International, LLC
These are some of the worst process safety
management (PSM) practices we have seen.
Don’t make these mistakes.
O
ver our extensive careers in the chemical process
industries (CPI) and the field of process safety
management (PSM), we have observed many good
— and bad — practices.
For example, in the 1970s, one of us worked at a major
commodity chemical manufacturing complex with 10 individual plants onsite. Management’s attitude was “run it till
it breaks and then patch it,” and we averaged three to four
explosions, fires, or releases per year.
When the U.S. Occupational Safety and Health Administration (OSHA) published the PSM standard in 1992, an
internal company debate raged over whether or not we were
already in compliance with the regulation. Management
eventually brought in an outside auditor to answer the question. The resulting audit report was so damaging that it was
instantly sealed up under attorney-client privilege and was
never seen again.
This article summarizes some of the worst PSM practices that we have seen, both as employees at manufacturing
companies and as consultants at various clients’ facilities.
Maintenance
A company gave maintenance managers a quarterly
bonus based on how far under budget their expenditures
were. This gave the managers a financial incentive to not
provide maintenance. Almost all of the site maintenance
managers routinely qualified for their bonuses — with
This article is based on a paper presented at the 2016 AIChE Spring Meeting
and 12th Global Congress on Process Safety, April 2016.
46
www.aiche.org/cep January 2017 CEP
predictable results. The worn-out equipment consistently
leaked, failed, and was otherwise a hazard to operate.
Paying maintenance
managers to not do their
jobs is a worst practice.
Don’t do this!
A common reason for
safety system failure is
that nobody is assigned
direct responsibility
for their inspection and
maintenance. In one
plant, emergency isolation
valves had been installed
on pressurized equipment,
but the valves were tested only when it was convenient to
do so — which was on scheduled turnarounds that were
held every two or three years.
A safety control that is not tested is worse than one that
does not exist. If employees know that no safeguard exists,
they can implement administrative controls to accommodate
for the lack of the safeguard. However, if a safeguard is part of
the design, operators assume that the safety controls will work
on demand. But unless the controls are routinely tested, operators are relying on safeguards that may not function.
Failure to routinely test safety-critical equipment is a
worst practice. Don’t do this!
When control systems are tested, it is critical that the
tests be “fully functional,” which means that all parts of the
system are tested. This includes the sensor(s), the logic, the
Copyright © 2017 American Institute of Chemical Engineers (AIChE)
actuated element(s), and the communications between all
elements. Some mechanical integrity programs omit some or
all of these elements from testing. Testing part of the system,
or parts in isolation (e.g., omitting the communications), is
insufficient to ensure function on demand.
Omission of ANY part of a safety-critical control system
from routine testing is a worst practice. Don’t do this!
Operations authority
One day, the lead operator of a plant announced over the
radio, in an alarmed voice, “TRIP THE FURNACE!” The
board operator immediately complied, but before the trip
sequence was complete, the plant manager skidded around
the corner, yelling, “Don’t trip it! Don’t trip it!” As it turned
out, during the previous turnaround, the furnace outlet piping was decoked by bead-blasting, which caused significant
thinning. The piping was so thin that the 16-in. furnace
outlet bend was becoming translucent. Had it failed, the hot
and flammable gaseous contents, at 250 psig, would have
been released in a massive explosion.
After the furnace was secured and cooled, the plant
manager assembled the operations staff and demanded that
no process interruption would be made in the future without
his personal approval. Some of the operators refused for
safety reasons and were threatened with termination. Process
operators must have independent authority to use their best
professional judgment to apply whatever emergency safety
measures are necessary.
Waiting for management approval before implementing
emergency measures is an almost sure way to create disasters and is an absolute worst practice. Don’t do this!
Operational knowledge
A plant being audited had a cyanogen bromide process
with runaway potential. The board operator being interviewed by the auditor did not know the warning signs of a
runaway reaction, the rate at which such a reaction would
propagate, or the maximum safe operating temperatures or
pressures of the reactor. When asked why this was not of
concern, the operator explained that the entire process was
in a sealed room that was vented to a scrubber. When asked
if the sealed room was robust enough to withstand a reactor
failure, the reply was “I never thought of that!”
Operations staff must be given enough information to
safely operate the process. This includes the maximum safe
limits for temperature, pressure, flow, or any other critical aspects of the equipment being operated. Management
Copyright © 2017 American Institute of Chemical Engineers (AIChE)
concern about trade secrets of a proprietary process is an
insufficient reason to not educate the operations staff about
safe operating limits.
Keeping operators in the dark about the safety limits of
their equipment is a worst
practice. Don’t do this!
In several plants, the
operations staffs of multiple
packaged waste-heat boilers
were unaware of the mechanics of boiler steam explosions. When the water levels
drop in a boiler, exposing the
fired tubes to heat without
the thermosiphon cooling provided by circulation
through the boiler, the tubes become red hot and then soften.
If boiler feedwater flow is then resumed, the cold water hits
the overheated, softened tubes, and a steam (phase-change)
explosion occurs. The head of the boiler is typically blown
off, and fatalities can occur. The relief valves on the steam
drum are insufficient to vent this localized overpressure.
Boilers are just as deadly as highly hazardous chemicals
in terms of explosion potential. Although most boiler operators are aware of the hazards of unburned fuel in the boiler
firebox, many are not trained on the mechanics of steam
explosions. The mechanics of boiler steam explosions must
be included in every boiler operator’s training.
Allowing operators to run boilers without an understanding of steam explosions is a worst practice. Don’t
do this!
Operating procedures
In a recent incident (www.csb.gov/williams-olefinsplant-explosion-and-fire-), an experienced supervisor was
preparing a heat exchanger for service. The exchanger had
been isolated from the process by block valves, but apparently flammable process liquids had leaked through the
closed valves into the exchanger’s cold process side. The
supervisor opened the valves on the exchanger’s hot process
side to warm up the exchanger, but without first opening
the cold side to the process. The cold process side liquids
expanded in the isolated shell of the exchanger and the leaking manual block valves could not release the cold liquids
quickly enough to avoid a pressure rise. Since the cold side
of the exchanger had no mechanical overpressure protection,
it eventually exceeded the maximum allowable working
pressure (MAWP) and failed catastrophically.
The engineering solution that would have prevented
this incident is to provide overpressure protection (a pressure safety valve or rupture disc) on the cold side of the
exchanger. But the incident could also have been prevented
CEP
January 2017
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47
Safety
if the operating procedures had specifically instructed first
opening the cold side of the exchanger to the process before
applying energy (heat) to the exchanger. Engineering safeguards are the most reliable, but ensuring that operators are
trained in the safe way to put equipment into service is also
mandatory.
Failure to have operating procedures that document the
safe way to put equipment into service is a worst practice.
Don’t do this!
Another common problem is that many operating
procedures do not capture
institutional knowledge. One
of the largest demographic
shifts in the U.S. workforce
ever is taking place now. As
the baby boom generation
retires, they take with them
decades of process knowledge. They are being replaced
with younger workers, who,
regardless of how technically competent they are, lack the
experience and training of the retiring workers.
To avoid losing this valuable experience, companies
should assign older workers to review and supplement operating procedures. Adding “caution” and “danger” statements to
existing procedures gives new trainees not only information
on how to safely perform a task but also why the task must be
performed that way and the hazards created by failure to follow the procedure. This information increases the likelihood
that the training will be remembered and followed.
Another best practice is to pay retiring employees a
small annual retainer and keep them as consultants. In turn­
around situations, for example, having extra experienced
employees on staff is a good way to reduce injuries and to
ensure smooth and timely restarts. If situations arise that are
baffling (e.g., product quality issues, unexpected pressure
drops across distillation columns or scrubbers, etc.), these
retired, experienced operators can be called to shed light on
problems that they have dealt with in the past. Retirees can
also assist in updating operating procedures.
Don’t let decades of valuable institutional knowledge
walk away upon retirement. Find ways to utilize the experience of retirees.
Failure to capture institutional knowledge of retiring
employees is a worst practice. Don’t do this!
Emergency response
Operators at a vinyl chloride monomer (VCM) plant
opened a drain valve on a reactor full of liquefied flammable gas (www.csb.gov/formosa-plastics-vinyl-chlorideexplosion). As the reactor contents escaped, a vapor cloud
48
www.aiche.org/cep January 2017 CEP
began to form. The operators issued a shelter-in-place order
and tried for a full 15 minutes to stop the source of the leak
rather than calling for an evacuation. Eventually, the vapor
cloud found an ignition source and a massive explosion
occurred, with multiple fatalities.
The company had failed to provide clear instructions
on when to evacuate. Unless the operations staff has clear
evacuation guidelines, it is the nature of operators to keep
trying to fix the problem. But there comes a point in incident
management where further efforts to fix the problem are
likely to be futile and/or create imminent danger for proximate personnel. At that point, the focus must change from
equipment protection to protection of life and health. Unless
the company has clear guidelines for the specific circumstances requiring evacuation, and unless the operating staff
is stringently and routinely trained on those guidelines, lives
will continue to be lost.
Failure to provide operations staff with clear guidelines
on when to evacuate is a worst practice. Don’t do this!
A chemical plant’s firewater reservoir and header system
had been designed when ground was broken for construction
at the site. Since that time, the number of production units
onsite had more than doubled. No survey of the fire system
had been conducted to determine whether the firewater
capacity was sufficient for the additions.
When new processes or debottlenecking of existing processes are contemplated, utility systems must be reanalyzed
via a management of change (MOC) procedure.
Failure to review firewater demands during debottlenecking or new construction
is a worst practice. Don’t
do this!
Flare header systems are
often designed during the initial plant design. Over time,
the plant adds streams to the
flare header without recalculating the header capabilities.
Because there could be a total
release of flammable and
toxic materials from multiple
sources to the flare header system, the site must be designed
for multiple simultaneous worst-case flows.
Assuming that the original flare header design will work
as designed is a worst practice. Don’t do this.
Many plants omit the scenarios used in the development
of their risk management plan (RMP) from the emergency
brigade’s drills. Since the RMP worst-case scenario events
are the worst events identified for the site and the alternatecase scenarios are the most likely failure events, the emergency brigade must consider all of them in drills. To skip
these events not only creates regulatory liability, but it also
Copyright © 2017 American Institute of Chemical Engineers (AIChE)
leaves the emergency team unprepared for the worst-case
scenarios.
Failure to use ALL RMP scenarios as emergency drill
scenarios is a worst practice. Don’t do this!
A plant stored all of its emergency gear (bunker gear,
hazmat suits, air monitoring equipment, etc.) in a single
building. If a release or fire occurred that blanketed the
building in smoke or toxic chemical clouds, all of the emergency gear would be unavailable. Emergency gear should
always be stored in multiple, physically separated locations
to ensure that at least some of the gear will be available
on demand.
Storage of all emergency
gear in a single location is a
worst practice. Don’t do this!
During a PSM inspection
of one facility by the U.S.
Environmental Protection
Agency (EPA), personnel
were asked whether they had
drilled for the scenarios of an
airliner coming down on the
plant, a ship detonation in the
adjacent shipping channel,
and a railcar derailment and
boiling liquid expanding
vapor explosion (BLEVE) on adjacent tracks. The site’s
PSM manager responded that since those were beyond the
plant’s control, they had not been reviewed. The plant was
cited for failing to prepare for external events. Since the
plant was in the takeoff and landing path of a major inter­
national airport, and was adjacent to navigable waterways
and rail lines, the events were credible even though the plant
had no direct control over them.
Failure to consider and drill for credible external events
is a widespread worst practice. Don’t do this!
Most older plants lack a master shutdown switch. There
are many credible situations that might require immediate
evacuation of a facility, such as a tornado, earthquake, failure of levees, and toxic releases from adjacent facilities. In
such circumstances, the immediate evacuation of personnel
will preclude any orderly
shutdown of the equipment.
A master shutdown switch
should be available that:
• closes all chemical
and energy feeds to the
process
• closes all chemical
and energy feeds from the
process
• closes all energy
Copyright © 2017 American Institute of Chemical Engineers (AIChE)
sources in the process (electricity, steam, etc.)
• isolates as many parts of the process as possible.
Such a shutdown will certainly cause rupture discs and
safety relief valves to lift, adding to the hazards, but will
prevent catastrophic vessel failures, runaway reactions, and
domino effects that would be orders of magnitude worse.
Not having a master shutdown switch is a definite worst
practice. Don’t do this!
Operator fatigue
At a plant’s pre-op
cleaning and startup,
it was typical for the
operations staff to work
16 hours per day, seven
days a week. During
a four-month startup,
it was not unusual for
operators to go home,
sleep, and dream about
operating the plant — and wake up more tired than when
they went to bed. Numerous errors occurred during the
startup process, most attributable to fatigue.
In another instance, an operator had been on a trip that
required him to be awake for almost a full 24 hours. Upon
returning home, he was called by the plant to immediately
report for overtime duty. He refused on safety grounds, and
was subsequently threatened with dismissal if any such
refusal happened again.
Fatigue has been proven, again and again, to cause
significant operational errors. A company fatigue rule that is
understood and enforced is essential to preventing operator
errors. Operators who have legitimate reasons for being unfit
for duty must be similarly accommodated. A tired operations
staff is an accident waiting to happen.
Failure to have a worker fatigue policy that is rigorously
enforced is a worst practice. Don’t do this!
Quality control
A refinery had been buying pump seals from a particular
authorized vendor for decades. Without notification, the
seal manufacturer moved its production facility to another
country. The seal brand did not change and the seal part
number did not change, but poorer seal tolerances caused
the failure rate to go from less than 5% to nearly 50%, and
several fires resulted. The refinery’s quality control program
for warehouse spares was limited to checking the vendor and
part number of arriving parts. This is inadequate.
The process owner and the vendor should enter into a
written legal agreement that requires all changes related to
parts — manufacturer, manufacturing location, materials of
construction, tolerances, etc. — to be communicated to the
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49
Safety
process owner in writing prior to
any change. However, this alone
is still insufficient. In order
to become an authorized
vendor, the supplier must
also have such agreements
with all manufacturers of the
parts it purchases. The vendormanufacturer agreements should
be periodically audited and corrections made as needed.
Verifying the quality control of warehouse spares by putting
them into the PSM-covered process to see if they fail is not
acceptable.
Failure to have an audited, manufacturer-to-warehouseshelf quality-control program for spare parts is a worst
practice. Don’t do this!
Disabling safeguards
The entire operating area of a large refinery is electrically classified as Class 1, Division 2. This classification is
intended to prevent electrical gear from creating an ignition source in a hazardous atmosphere. In the center of the
electrically classified area of the refinery are several large
fired furnaces and crackers. As supplied by the vendor, the
fired equipment was fitted with an automatic steam purge
that actuated on loss of flame or on manual trip of the burners. However, this safety feature had been disabled — the
operating staff had manually closed the steam valves to the
furnaces, ostensibly to prevent spurious activation and to
improve the onstream factor of the equipment.
What the operators did not realize was that the steam
purge served several critical safety functions. In the event
of a vapor cloud in the operating area, the furnace burners and the red-hot refractory can serve as ignition sources.
The steam purge is intended to reduce this risk by instantly
quenching the burner flames and simultaneously cooling the
refractory. In addition, if the vapor cloud itself puts out the
burners (because the mixture is too rich to burn), the steam
purge creates enough flow through the furnace to reduce the
likelihood of a back-flash ignition.
When informed of the purposes of the automatic steam
purge, the operators still refused to recommend reinstating
it. When asked what would happen if a flammable vapor
cloud formed, the operators stated that they would enter the
cloud and manually unblock the steam purge valve. In fact,
one such vapor cloud had already occurred, and the operator
was able to run into the flammable vapor …
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