Findings and Recommendation

Finding

This report concluded that the fire and explosion of this Petronas Petroleum Complex was
caused by the some of hazard assessment failures which is chemical hazard, physical
hazard, mechanical hazard, electrical hazard and also because of some environment factors
and human errors. The main hazard leads to this explosion is because of chemical hazard
which usually involving a rapid and violent oxidation reaction that produces large amounts of
hot gas and the force called as catalyst. One of the most applicable elements using in
PETRONAS petroleum processing plant is nitrogen which is categorized as chemical
compound. Because of the sensitivity of the compounds and elements being handled, such
as nitrate gases, one slight factor was quickly precipitate an unforeseen explosive
catastrophe at Petroleum Petronas Complex. Moreover, improperly stored chemicals include
acids, pesticides, carbon monoxide, flammable liquids, welding fumes, silica dust and
fiberglass fibres are also leading to this explosive incident. When comes to physical hazard,
it is the rapid liberation of heat that causes the gaseous products of most explosive reactions
to expand and generate high pressures. This rapid generation of high pressures of
the released gas constitutes the explosion. So, the gas started to release deliberately from
an accidentally a broken or leaking valve, its spin out of control with great force and become
a reason for happened explosion at this petroleum processing plant industry. Thus,
summarized that serious failures can happen in different layers starting from the workers’
decision about safety which is implied under hazard assessment failure.

Using welding tools near flammable substances at this processing plant created a spark and
ignite highly flammable chemicals at this industry complex. When the rig applies too much
pressure during the drilling it causes a sudden rush of pressure up and happened this
explosion. Overheating of transformer cooling fluids presents a serious hazard. This
processing plant exposed to uncontrolled electrical, mechanical, hydraulic, or other sources
of hazardous energy if equipment is not designed, installed, and maintained properly.
Lightning strike, which damage wires and or equipment and cause too much electricity to
flow into the transformer, leading to explosion at this PETRONAS petroleum industry
complex. The machines and equipment used for petroleum process production including
transformers, engines, motors, generators, pumps, drill rigs, and piping generate very high
levels of noise and vibrations that cause this explosion. Moreover, unsecured, uncapped
cylinders when knocked over causing the cylinder valve to break and high-pressure gas to
escape rapidly and its lead to explosion.
There are some environmental factors also become a reason for lead to this explosion. Oil
rig blowouts occur when the rig applies too much pressure during the drilling, causing the
pool of underground oil to erupt. It causes a sudden rush of pressure up the system there.
Once the pressurized natural gases are exposed to a less pressurized atmosphere, there
was be a kick and it became a reason for happened this explosion. Effects of the humidity,
temperature and slow oxidation reactions on the occurrence of explosions in gasoline-air
mixtures too. The occurrence of gasoline-air explosions is very sensitive to the gas mixture
temperature. Influenced by slow oxidation reactions, concentrations of reactants can
decrease below the explosion limit range, resulting sometimes in no observed occurrence of
gasoline-air explosions. In the case of Oil and Gas (O&G) industry, human error constitutes
as the largest contributor of over 70% of all accidents. As O&G industry deals with a variety
of risky chemicals and operations, the costs of these accidents are too high to the
employees, workplace, economy and society. The human error of gas bursting in Petronas
at Terengganu 2012 into six types which are action, checking, retrieval, `transmission,
diagnostic and decision errors and the most common human error in this gas bursting
incident is because of careless of smoking cigarette.

Recommendation

Explosion depends on an atmosphere of a mixture of flammable material with oxygen. In the

complex industry of petroleum processing plant, there’s a lot that could go wrong. One of the
more serious risks for this industry is the potential for fires and explosions. The combination
of powerful equipment, flammable chemicals and processes that are under high pressure
can lead to hazardous and even deadly incidents. There are ways or recommendations to
prevent fires or explosion from happening at this complex as follows:

 applying job safety analysis

Fire is a process in which substances combine chemically with oxygen from the air &
typically give out bright light, heat and smoke. Explosion is a sudden release of mechanical,
chemical, or nuclear energy is a sudden often violent manner with the generation of high
temperature and usually with the release of gases. Explosion is a hazard if it occurs once
then it cannot stop easily as it spread within a short period of time with the help of medium,
so for the prevention of these hazard this complex should applying job safety analysis by
which can easily identify the risk and once risk is identify then it easy to prevent the hazard.
According to OSHA, job safety analysis is an accident prevention technique that is used to
find the potential hazard associated to the job and give the control measures to minimize the
hazards. A job safety analysis can do much toward reducing accidents and incidents in the
workplace but it is only effective if it is reviewed and updated periodically, even if no changes
have been made in a job hazard that were missed in an earlier analysis could be detected.
According to the job safety analysis method have some important facts and recording and
selection of the job then identifying the potential hazard process and so on. JSA
methodology using for the improve productivity and JSA have 4 basic step wise work which
are

 Selection of jobs to be analysing

 Breaking the job down into steps

 Identification of potential hazards in process

 Determine preventive measure and control to overcome this problem

The basic purpose of JSA is to identify workplace hazards with a “likelihood” of possible or
greater, identifying problems and break the job, and then also control the main issues. So
definitely this JSA will help this petroleum processing plant industry to identify the factors of
happen explosion and will prevent from this accident happening again.

 training for workers

All employees should have an excellent understanding of the machinery they work with, the
chemicals they are handling, the dangers for combustion, and the risks associated with
certain actions. All employees should be taught how to prevent combustion and make sure
they know how to avoid any potentially hazardous situations involving mixing chemicals or
using an open flame near flammable materials. Many incidents have occurred in the
petroleum process industries because operators or supervisors or even managers did not
understand the hazards of chemicals or technology. While training in hazard communication
will help employees to be more knowledgeable about chemicals they work with, additional
training should be conducted on operating procedures and safety work practices, emergency
evacuation and response, safety procedures, and other areas pertinent to process safety
and health.

OSHA's general standards for employers include, but are not limited to:

 Safe work habits

 Safety guidelines to reduce the risk of working with hazardous substances

  Chemical safety hazards

 Control measures for chemical safety

 Basic emergency response training

 What hazardous materials and their containers are prepared for transportation

 What types of documentation are required to transport hazardous material

 Various aspects of working safely with electrical equipment at a plant

 Structural checks and power system check that should be completed before using a
forklift

 Preventing the release of chemical hazards

Petroleum is made up of a complex mixture of hydrocarbons of various molecular weights

and other liquid organic compounds, meaning the improper release of these chemicals may
create a negative impact on the chemical’s surroundings such like bursting or explosion.
Chemicals such as those in petroleum have the ability to react when exposed to other
chemicals, or certain physical conditions. According to Occupational Safety and Health
Administration (OSHA) chemicals that are not properly managed can have harmful or even
catastrophic consequences, such as toxic fumes, fires, and explosions that may result in
injury and or death, damage to physical property, and severe effects on the environment. In
order to ensure the safe release of chemicals, it is imperative that facilities are well
designed, safely operated, and properly inspected and maintained.

 Environmental pollution prevention

The exploration and exploitation activities of the petroleum processing industry often cause
environmental degradation that has significant impact on quality of air, water, soil,
vegetation, and on health unless adequate preventive measures are planned. Petroleum
activities encompass several sources of pollution including the exhaust of engines,
generators or compressors, the discharge of natural gas directly into the atmosphere, and
the increase in surrounding temperatures and glare effects due to flare. The cause of fugitive
emissions at some facilities may be associated with vents, leaking pipes and turbines,
valves, connections, pump seals, pressure relief valves, tanks, or open pits, and loading and
unloading operations. To prevent the pollution of the environment from petroleum-related
procedures and products, environmental awareness must be integrated as a part of every
job function a worker performs. There are very specific rules and regulations regarding the
amount and types of emissions, discharges, and disposals a facility is permitted. Make sure
workers know and understand the physical and chemical properties of the materials they
handle or are exposed to.

 Valve and pipeline safety

A typical petroleum pipeline runs from the gathering area, into transmission lines, through
compressor or pumping stations, to distribution lines, and finally to the end user. Since the
majority of pipeline contents and their vapours are highly flammable, pipeline safety policies
and procedures are focused on minimising worker exposure to these substances, and
controlling or eliminating sources of ignition in the work environment. To do this, the key
issues to look at may include pipeline agency staff resources, automatic pipeline shutoff
valves, penalties for safety violations, safety regulations for oil sands crudes, and the
possible need for pipeline security regulations, as well as other concerns. Recommended
practises have been developed to improve and maintain the mechanical integrity of
upstream pipelines. They are intended to assist upstream oil and gas producers in
recognising the conditions that contribute to pipeline corrosion incidents, and identifying
effective measures that can be taken to reduce the likelihood of corrosion incidents.

 Corrosion problems and prevention

It is almost impossible to prevent corrosion. The next best possible solution is to attempt to
control the corrosion rate through monitoring. By recognising and understanding the
mechanisms involved in corrosion, engineers may begin to eliminate corrosion by design.
Offshore structures are especially at risk of corrosion from the massive amounts of rain,
condensation, and spray. To provide long term resistance to corrosion, Corrosion Resistant
Alloys (CRAs) are essential for many components exposed to oil and gas production
environments, including offshore rigs. Components may include down-hole tubing and safety
critical elements, wellhead (structural and pressure-containing interface) components and
valves, pipelines, piping, valves, vessels, heat exchangers and many other pieces of
equipment in facilities that can be characterised by their resistance to specific environments.

 Process safety management

Petroleum processing facilities and extraction locations must have a comprehensive
management programme that integrates technologies, procedures, and management
practises in a careful review of what could go wrong and what safeguards must be
implemented to prevent releases of hazardous chemicals. Unexpected releases of toxic,
reactive, or flammable liquids and gases in processes involving highly hazardous chemicals
have been reported for many years in the oil and gas industry, which uses chemicals with
such properties. Regardless of the industry that uses these highly hazardous chemicals,
there is the potential for an accidental release any time they are not properly controlled,
creating the possibility for disaster.

 Heavy machinery safety

The use of heavy machinery is not only prevalent in the petroleum processing industry, but it
is also an essential tool needed to get a diverse number of jobs done. The type of equipment
used in this industry varies from earthmoving machines in lease preparation for explorative
drilling to site preparation for large refineries and plant sites. It also includes hoisting
equipment, including forklifts and cranes, as well as trenching equipment. While it is true that
machines can greatly increase the efficiency and ease of many work-related tasks, they can
also pose a significant threat of injury or even death when poorly maintained or used
improperly. Operations with heavy equipment should always be done by highly skilled
operators who have demonstrated the ability and necessary skills to operate safely.
Employees should be trained in how to work safely around the equipment and how to stay
clear. Unsafe practises by either the operator or those around the equipment can create very
dangerous situations where serious injuries can occur if the equipment strikes a worker, or if
the equipment rolls over.

 Emergency preparedness

Petroleum processing complex workers are subject to some of the most hazardous industrial
conditions in the world. Given the number of people employed by the gas and oil industry
and the dangerous nature of oil and gas drilling, it is almost inevitable that accidents will
occur. Oil and gas accidents can involve explosions, incidents while raising a pipeline, oil rig
and derrick safety violations, and other incidents, including:

 Drilling accidents

 Improper construction and maintenance

 Pipeline transportation accidents

  Storage problems, including contamination

 Salt dome accidents

Because of such accidents, it is essential to have an emergency plan or management

system that will allow for a timely response to an accident. This includes establishing a
decision framework and action plan that enables a quick and effective response to any
accident or incident, as well as working with the relevant local and national authorities,
ensuring workers have the appropriate training, and practising exercise drills with other
organisations. Fires on oil and gas sites can get out of hand before workers even realize it.
It’s important for everyone working on the site to know what precautions to take to prevent
fires, and what to do to keep themselves safe if a fire does break out. Preventing accidents,
protecting health, and protecting the environment depend on recognising potential hazards
in workplace, especially when hazardous chemicals like petroleum processing industries are
involved. Hazards can exist due to the nature of the task being performed, where it is being
performed, and the equipment or material involved. Follow best safety practises to lower the
potential hazards to the industrial plant and its employees.