Case study – Incident at Yashashvi Rasayan Pvt Ltd.

, Dahej
Risk Assessment by the bowtie methodology www.sudakshaconsulting.com
Analysis models for risk management and incident analysis explained here is limited to the information available in public domain. The illustration is an example to demonstrate the

Ambient Environment
conditions

Continuous weather Provide shelter to Provide observation

monitoring in the sensitve booths/ towers for
location instrumentation monitoring
Sudaksha Management Solutions LLP or its personnel do not claim to have first hand information and are not liable for the accuracy of the incident information considered for the discussion.

Storage site
conditions

siting & construction - Implementation of Restrict storage of Colour coding of Implement additional
Used on 1 Incident Installation of flame Display signages for
MoEF, PESO & PCB storage license authorised materials pipelines for controls as and when
proof electrical fittings adherence
approvals conditions only identification - IS 2379 facility is expanded

Used on 1 Incident Used on 1 Incident Used on 1 Incident Used on 1 Incident Used on 1 Incident Used on 1 Incident Used on 1 Incident
Fail 100% Fail 100% Fail 100% Fail 100% Fail 0% Fail 100% Fail 100%
(1 of 1) (1 of 1) (1 of 1) (1 of 1) (0 of 1) (1 of 1) (1 of 1)

Storage of chemcals
for manufacturing
operations
comprehensiveness of bowtie methodology and is based on the EHS, technical and process expertise of our available with Sudaksha Management Solutions LLP.

Working conditions
in the site Used on 1 Incident

Unloading material Deployment of Adherence to SoP & Deployment of Use of approved &
from tankers Restrict entry only to Round the clock adequate stand-by to
qualified & trained checklist for operation certified tools and
complying with CMVR authorised persons supervision by experts man during rest
personnel steps - SDS extract tackles
rule 9, 129 - 134 intervals

Operations
monitoring Loss of control
Unloading material Installation of gas in chemical
seamless monitoring 24/7 manned Shut down systems for
Used on 1 Incident from tankers Implementation of detection systems to containment
from central control operations with stand- controlled shut down
complying with CMVR work permit system detect spillages /
room by support during abnormalities
rule 9, 129 - 134 leakages
Used on 1 Incident Used on 1 Incident Used on 1 Incident Used on 1 Incident
Used on 1 Incident Used on 1 Incident
Fail 100% Fail 100% Fail 100% Fail 100%
Fail 100% Fail 100%
(1 of 1) (1 of 1) (1 of 1) (1 of 1)
(1 of 1) (1 of 1)

Piping and
instrumentation
integrity
use materials for
pipelines compatible
transmission fluid (E.g,
glass lining for Nitric
acid)
This effort is in academic interest to enhance approach to safety for a stronger risk management in industrial operations.
Routing of pipelines to
prevent vehicle cross
over
Colour coding of
pipelines for
identification - IS 2379
Pressure testing of Pressure control Carry out periodical
Earthing and bonding devices (valves,
piplines & vessels for maintenance as per
to maintain continuity rupture discs) to
mechincal integrity established plans
monitor safe working
pressure

Tanker truck
operations

Limit entry to vehicles Deployment of wheel Routing of pipelines

Movement of vehicles facilitating vehicle
complying with CMVR chokes for TT before
in defined paths cross over and prevent
rule 9, 129 - 134 filling operations
damages

Seamless power
supply for operations

Install dedicated Operation of AMF DG

UPS backup for critical
power supply line from sets in case of load
operations
ESCOM shedding

Awareness in the
local community

Conduct periodical Knowledge sharing on Conduct periodical Involvement in

training and Do's donts through table top exercises periodical On-site and
awareness campaigns leaflets and local with stake holders & off-site mock drills
media MARG

Run away reactions /

gas release to
atmosphere
Stop operations and Neutralisation of the Stop all activities Activate reponse Make annoucements
Storage of chemcals Dyke wall to contain involving use of energy measures as per informing community
Shut down the plant in spill as per SDS B0 B0 C0 B1
for manufacturing the spill to prevent ignition in onsite / offsite in the vicinity and
a controlled sequence recommendations
operations the location emergency response evacuate them to safe
plans locations
Used on 1 Incident

Fire / explosions

Stop all activities Evacuation of Neutralisation of the Activation of automatic Fire mitigation using Cordon the site for
involving use of energy personnel from the spill as per SDS fire fighting systems to equipment, personnel investigation & related Used on 1 Incident
to prevent ignition affected area to safe recommendations contain the damage & MARG resources process
zones C2 C1 B2 C1
Used on 1 Incident Used on 1 Incident Used on 1 Incident Used on 1 Incident Used on 1 Incident
Loss of control Used on 1 Incident
in chemical Fail 100% Fail 100% Fail 100% Fail 100% Fail 0%
Fail 100%
containment (1 of 1) (1 of 1) (1 of 1) (1 of 1) (0 of 1)
(1 of 1)

Injuries / fatalities

Evacuation of Provide first aid Operate relief camps Shift personnel with Inform families of
personnel from the treatment for minor through doctors from major injuries to injured persons & take Used on 1 Incident
affected area to safe injuries in the site OHC nearby hospitals & hospital for treatment necessary measures to
zones MARG fufill legal formalities
Used on 1 Incident Used on 1 Incident
Used on 1 Incident Used on 1 Incident Used on 1 Incident
Fail 100% Fail 100%
Fail 100% Fail 100% Fail 0%
(1 of 1) (1 of 1)
(1 of 1) (1 of 1) (0 of 1)

Loss of reputation

Cordon the site for Issue public statement Provide relief Conduct and Comply with legal
investigation & related in local media to measures to all participate in requirements for
process inform the incident affected to ensure investigation by restoration of
their safety and well experts to identify normalcy
being failure causes

Incident Analysis by - Barrier failure Analysis Technique

Operations
Fire / explosions
monitoring
Unloading material seamless monitoring 24/7 manned Installation of gas Shut down systems for Stop all activities Evacuation of Neutralisation of the Activation of automatic Fire mitigation using Cordon the site for
from tankers Implementation of detection systems to personnel from the
from central control operations with stand- controlled shut down involving use of energy spill as per SDS fire fighting systems to equipment, personnel investigation & related
complying with CMVR work permit system detect spillages / affected area to safe
room by support during abnormalities to prevent ignition recommendations contain the damage & MARG resources process
rule 9, 129 - 134 leakages zones

Storage of chemcals
for manufacturing
operations / Loss of
control in chemical
containment

Storage site
Injuries / fatalities
conditions

siting & construction Implementation of Restrict storage of Colour coding of Implement additional Evacuation of Provide first aid Shift personnel with Operate relief camps Inform families of
Display signages for personnel from the through doctors from injured persons & take
of facility - MoEF & storage license authorised materials pipelines for controls as and when treatment for minor major injuries to
adherence affected area to safe nearby hospitals & necessary measures to
PCB approvals conditions only identification - IS 2379 facility is expanded injuries in the site OHC hospital for treatment
zones MARG fufill legal formalities

ST1 New chemicals PL1 Pipeline colour

Chemical storages Pipeline color had
were added without faded
approvals

Legends - Barrier failure modes

PL2 Exposure to
ST 2 Temporary extreme weather
storage Pipelines were exposed
Temporary storage due to extreme weathers
to urgent customer leading to erosion of
requirements colours

MOC Management of PL3 Paint selection

change Cheap paints selected
No management due to budget and cost
intervention to review constraints
chages in site
operation