2017 PSM Moment

Process Safety Awareness

Imperial Sugar, Georgia
9th Anniversary,
7th February 2008
 Incident Summary
• Combustible Dust Explosive incidents occurred at the
Imperial Sugar plant in Port Wentworth, Georgia :
1. 14 killed, 38 injured, extensive damage to the plant
destroying 2 silos and 1 building.
2. Resulted from inadequately designed and maintained
dust collection equipment.
3. Inadequate emergency response plan.
• Key Issues:
 Leadership  Operating Manual and
 Standards and Practices Procedures
 Hazard Identification  Emergency Response
 MOC

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 Background and Incident
This refinery converted raw sugarcane into granulated sugar. A system of screw and belt
conveyors and bucket elevators transported granulated sugar from the refinery to storage
silos, and to specialty sugar processing areas.

On February 7, 2008, a series of sugar dust explosions at the manufacturing facility in Port
Wentworth resulted in 14 worker fatalities. The explosions and subsequent fires destroyed
the packing buildings, and silos and parts of the sugar refining process areas.

The first explosion initiated in the

enclosed steel belt conveyor located
below the sugar silos. The enclosure were
recently installed which allowed explosive
concentrations of sugar dust to
accumulate inside. After that, the second
explosions occurred throughout the
packing buildings, parts of the refinery,
and the loading buildings. The pressure
waves from the explosions heaved thick
concrete floors and collapsed brick walls,
blocking stairwell and other exit routes.

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 Root Causes
Three major causes:
(1) The conveying equipment was not designed to minimize the release of sugar dust
and eliminate all ignition sources in the work areas;
(2) Housekeeping practices were poor; and
(3) The company failed to correct the ongoing and known hazardous conditions.

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 What went wrong?
1 2
Sugar dust in the work area with Screw & Belt conveyor under the
inadequate housekeeping practices silos and packing area. Airborne dust
throughout the packing building. were released.
4 5
But the Cover allowed accumulation 1st Explosion in the conveyor belt
of the sugar dust above the MEC under the silos, pressure wave and
inside the enclosure, with overheated fireballs pass into the work area
bearing on belt support ignited above silo.
airborne dust.
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MEC : Minimum Explosible Concentration
3
Avoided contamination by installing
steel cover panels on the belt
conveyor without dust collection
and explosion vents.
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Explosion blow apart the packing
building lead to catastrophic dust
2nd explosive that sugar dust had
accumulated on the work area
floors.
 Consequence damage

Photo from www.csb.gov

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 Elements of Process Safety Management
PTTEP 21 Process Safety Elements
Process risk
Process Safety Risk Management Review and
identification/
Leadership Improvement
assessment

Leadership Operating manuals Process start-up

and procedures
Incident Reporting
Hazard and Investigation
Identification Process and Emergency
Legal/standard operational status preparedness
compliance monitoring /
handovers
Inspection and
maintenance
Employee Management of
competency/assur operational Audit, Assurance,
ance interfaces Management of Management Review
Safety Critical and Intervention
Elements
Workforce Standards and
involvement practices
Documentation, Work control, PTW
Records & KM
Communication Process Safety Event
MOC Contractor Indicators
with stakeholders management

The 21 Process Safety Elements as specified in SSHE-106-STD-440;

Red: Ineffective barriers – details provided in the next slide.

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 Elements of Process Safety Management
1. Leadership: Management accepted a riskier condition and failed to correct the hazards conditions even there were
similar incidents before.
2. Legal/Standards compliance:
3. Employee Selection, Placement, Competency and Health Assurance: No dedicated officer responsible for workplace
safety.
4. Workforce Involvement:
5. Communication with Stakeholders:
6. Hazard Identification: No evaluate the hazards and no process hazard analysis to identify MAE.
7. Documentation, Records & KM:
8. Operating Manuals and Procedures: Maintenance procedure were not followed regularly.
9. Process and Operational Status Monitoring and Handovers:
10. Management of Operational Interfaces:
11. Standards and Practices: Equipment in hazardous area were not designed in accordance with standard.
12. Management of Change: No MOC to manage the hazard of the modified equipment.
13. Operational Readiness + Process Start-Up:
14. Emergency Preparedness: Emergency evacuation plans were inadequate. Company did not conduct the emergency
evacuation drills.
15. Inspection and Maintenance:
16. Management of Safety Critical Elements:
17. Work Control, Permit to Work and Task Risk Management:
18. Contractor Selection and Management:
19. Incident Reporting and Investigation:
20. Audit:
21. Process Safety Event Indicators:

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 Lesson Learned
Even this MAE was not in E&P industry, the lesson learned are worth
to be shared;
• Hazard identification awareness shall be promoted and controlled
with strongly support from management.
• Apply the Standard to the equipment in hazardous area is critical
issue in design and operation.
• MOC shall be implemented in modification projects to ensure all
hazards are identified and controlled.
• Effective Emergency Management Plan shall be prepared and
executed. Drill shall be performed routinely.

Process Safety: Keep oil and gas in the pipe !

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