Incident Analysis (EDC/VCM)

Half yearly Incident analysis From Jan-June 2011

Incidents

*Prepared by : AUH *Reviewed by :AR

Over All leakage Trend EDC/VCM (Jan-June)

Overall Half yearly Incident bar chart
70 60 51 50 42 40 30 20 25 10 0 Jan Feb 40 46 Jan Feb Mar Apr May Jun No of Incidents 80 70 60 50 40 30 20 10 0 Jan Feb Mar Apr

Months

No Of Leakages

Most vulnerable month

Reason (Continuous shutdown from Jan to may summary pasted below till may)

Jan Feb Mar Apr May Jun Total

51 42 40 46 69 25 273

69

Trend of Incidents over last 06 months

Mar

Apr

May

Shutdowns Summary 3 - 18 Jan (Fur / Oxy) (16 days) 1 - 30 Mar (Fur / Oxy) (30 days) 1 - 5 Apr (Fur / Oxy) (5 days) 6 - 10 Apr (Fur / Oxy) (5 days) 15 - 17 Apr (Fur / Oxy) (3 days) 28 - 30 Apr (Fur / Oxy) (3 days) 4 - 6 May (FurA) (3 days) 4 May - 19 Jun (Fur B) (15 days)

Jun

Incidents in months , 25

May

Jun

Total 65 days shutdown prior to the month of MAY which lead to fatigue and other factors leading to incidents and if may shut down also included it goes to more then 100 days of shutdown In next slide we will see the break down of theses incidents which will give a better insight of the problems

Incident Monthly break down To Types

70 60
64

No of Incidents

Incidents Trend
near misses

50 40 30 20

47

70 60 No of Incidents 50 40 30 20 10 0 Jan Feb Mar Apr May 25 51 42 40 46 69

38 37

41

FAC MTC Process release operational upset

10 1111 0 Jan
4 12

23

Process Incident Fire

1 112 Apr

Feb Mar

22 1

Envc release

No of month 1

Jun

Months

May Jun

EDC-VCM Incidents Monthly Trend

Jan Near misses FAC MTC Process release Operational upset Process Incident Fire Env release Total 51 47 1 1 1 1 4 Feb 38 Mar 37 Apr 41 1 1 1 2 2 2 69 1 1 24 May 64 1 Jun 23

High no of near misses are due to higher no of leakages in the plant May has highest no incidents then any other months due high leakages in this month also for reference see section of leakages latter There are 03 operational upset in last six months 01 cause shut down which was in April rest of the 02 were in startup phase

1 2

42

40

46

Incidents break down per month

51 1 50 1 49 1 48 1 47 47 FAC near misses operation al upset Process release MTC 39 38 37 36 45 Jan Feb 38 42

40
41 40 4 Process Incident near misses

46

1 1 2 1

FAC process release process incident operational upset near miss

39 38

2
process incident

45 44 43 42 41 40 39

1 37 36 35 Mar 37

operation al upset Nearmiss

46

41

38 Apr

69 68 67 66 65 64 63 62 61

25 FAC Fire 24.5 24 23.5 Pricess Incident 23 22.5 22 23 1 1 Env Process Incident Near miss

64

Near miss

May

Jun

Incidents distribution on basis of dept responsible

88 90 78 80 70

Incidents distribution w.r.t departments

Ops

6% 33%
52

Maint 13% Inspection 29%

60 No of Incidents 50 40 30 18 20 10 0 Ops Maint Inspection 37

19%

I&E

Others (multiple discpline)

I&E

Others shared responsibilites

06 % of the total incidents that were purely operation related (which has 03 operational upsets 01 process incident)

Most of the incidents are based on leakages at different points which led to a higher no of incidents in inspection department which has 78 no of incidents (29%) Rest others include shared responsibilities of misc group 2nd most vulnerable department in case of incidents is I&E which shares 19% of all incidents that took place at EDC/VCM plant Pure operational related incidents are fewer then any other department but are critical as well room of improvement is there

Incidents bar graph as per type

Distribution of incidents type
Distribution of Process w.r.t dept responsible 12 11 10 8 6 4 2 0 1

Env Incident Fire Operational upset

FAC MTC Process Incident

I&E
3 2 1 3 2

Ops

Nearmiss; 92%

4% 1% 1% 1% 1%

Percentage of Incidents excluding Nearmiss

Env Incident No of leakags 1 FAC 3 Fire 2 Operational Process MTC upset Incident 1 3 11 Process release 2

2, 9% 11, 48% 1, 4% 3, 13% 2, 9% 3, 13% 1, 4% Env Incident FAC Fire MTC Operational upset Process Incident Process release

Near misses accounts for almost 92 percent of all incidents which lead to other critical incidents needs to be control in future to a lesser extent If we exclude Near misses largest no of incidents that took place are Process incidents total 11 (48%) out of which 08 are related to I&E and 03 to operations

Procedure related Incidents

No of incidents comparison of ops vs other departments
18 16 14 No of Incidents 12 10 8 6 4 2 1 0 Inadequate Proceduer not followed Category Not available
17%

Procedure related incidents distribution

Proceduer not followed, 17 Total (alldept.) Ops related

2, 9%

4, 17%

Inadequate
Proceduer not followed, 74%

Proceduer not followed Not available

Inadequate , 4

4 Not available , 2 1

Procedure related incidents distribution (Operation )

inadequate
16%

25 20 15 4

Procedure not followed has a huge share both in ops and all other departments for incidents related
Ops related

Proceduer not followed, 67%

Proceduer not followed Not available

10 5 0 Inadequate 1 4

17 1 2 Proceduer Not available not followed

Total (alldept.)

On analysis its shown that training on procedures and its ease of availability is required to over come the not following part and already emphasis on internal grooming is being taken care at EDC/VCM Plant 74% are the incidents related to procedures which are not being followed similarly 67% is the share in ops distribution of these incidents

Incidents distribution on the basis of score allotted

11-20% 20-36% 50-65% 70-85% 90-100% 105-120% 125-135%

Pie chart showing percentage of most incidents as per rated score

161 18%

4% 3%

1% 11-20% 20-36% 4% 50-65% 70-85% 90-100%

10%

60% 48 27 11 10 7 3

105-120% 125-135%

11-20%

20-36%

50-65%

70-85%

90-100%

105-120% 125-135%

Almost of all the total score given to all incident lies in the category of 50-60% and 70-85% which contributes almost 78% of the all the incidents that occur during last 06 months

High percentage of incidents score lies in the middle to top score category which is alarming as 88 % of all the whole incidents lies in category in between 50-100%

Above charts indicate to have strong analysis of all those incidents lying in this score and formulating a way to minimize them and their reoccurrence should not occur at any stage Need to focus on major part of these incidents which is the middle portion also safety department to give feedback on these

Incidents distribution on personnel behavior

Chart Title
100 16 16 14 12 10 8 6 4 2 0 Careless act Judgement Lack of communication Ops 3 2 3 11 13 90 80 70 60 50 40 30 20 100

Events at which incidents occur most

31

13 7 6 1 normal Operation Plant start up Plant shutdown 1 1

10 0

Commissioning

All dept.

Misc dept

Ops

Judgment error Carless act

Lack of communication

Normal operation has high no of incidents due to leakages involved thats why score of other dept is high as compared to ops

Most of the incidents that are related to plant shutdown are indicative of physical and mental tirdness which includes slipping of blind, injuries etc

Personnel issue (requires training)

PSRM wise distribution of incidents

68 70 60 50 40 30 21 20 10 10 0 PSI PHA O&MP SWP 5 2 1 8 8 7 0 PSSR 0 MI QA 6 1 PT&P 1 1 E&RP 1 1 auditing 38 33 Total (all dept) Ops 55 Are high due to high number leakages on the plant and

Ops distribution of incidents indicating area of concern is procedures and safe work practices

Ops distribution of Incidents on PSRM violation

PT&P 3% E&RP QA 21% 4% auditing 4% PSI 7%

PSRM basis distribution of incidents (All dept)

PSSR 3%

Safe work practices are align with operation and maintenance procedure both PSRM violations are high and critical also operation related incidents major contributor s

MI PSSR 0% 0%

MI 29% QA 14%

SWP 16%

SWP 29% O&MP 29%

PT&P 9% PHA 3% O&MP 23% PHA 4% E&RP 0% PSI auditing 2% 0%

Top 10 Incidents at EDC/VCM Plant on basis of Score

Oxy inlet leakage causing shutdown of plant

140

120 135 100 125 125 120 120 110 105 80

Area 300 Cause Area 300 Electrical Issue Resp I&E Resp I&E Area 300 Electrical Issue Area 300 Sub Station Electrical Issue Resp I&E Area 200 Process release MI issue Resp ME /INSP Area 300 Electric al Issue Resp I&E Area 400 Ops Upset At start up of Area 200 Resp Ops Ops Upset TT-306B MI issue tube failure Resp Ops Area 400 Ops Upset LT issue Resp Ops/ I&E Sub station Electrical Issue Resp I&E

Incident score

105

105 105

60
MI Resp ALL

40

20

0
Fire in furnace B Gr-301 Tripping Gr-301 Tripping Partial power faliuer Oxy leakage inlet line Gr-301 Tripping Steam gasket rupture Lp header 105 High Acetylene in MS-304 105 High moisture in MS-403 Partial power faliuer (Transformer 1 Tripping) 105

Incident

135

125

125

120

120

110

105

Distribution Of Leakages As Per Identity

1, 2% 15, 21% MECHNICAL 54, 77% INSTRUMENT MACHINERY

1. 2. 3. 4.

Total no of leakages 70 in last 04 months till 2nd June Average leak per months 18 77% (54) of leakages occur on mechanical part of the plant that is 54 out of 70 21% are leakages are due instrumentation of plant that is 15 leakages out of 70

Distribution of leak points

seal RD holder
1% 1% 1% 1% Piping, 30% 1% 3% 3% 3% 3% 4% VALVES, 15% 4% 4% CONNECTOR , 6% FLANGES, 11% tubing , 7%

PG vessel Purge point FT mainifold Burner assembly GLG Switches GASKIT BELLOW Head cover (Exchanger) CONNECTOR tubing FLANGES VALVES Piping

Parts prone to leakages

Vulnerable parts prone to leakages:The most prone part where leakages occur is process piping including fitting T-joints elbows etc which accounts for 30% of the total leakages Second most vulnerable area are Valves where leakages report goes to 15% and subsequently flanges has 11% and instrument tubing connector 7% of the total leakages that occur during past four months

No of leakages due to service

Most leaking services

22 25 No of leakages 20 15 10 5 0 1 1 1 2 3 3 4 4 6 10 13

Chemical Released

Service where most of the leakages occur during last 04 month are 1. EDC 2. HCL & 3. Mix of EDC/HCL/VCM

Distribution of leakages as per service leak

Break of leakages as per Service released

2% 1% 1% EDC , 31%

CL2
3% 4% 4% 6% 6%

waste water EDC carbon material VCM Heavies VCM HCL Cautic NaOH 10% HCL Low Ph water Mix of EDC HCL VCM HCL EDC

1. EDC accounts for more then 30% of the leakages that occurred during last 04 months out of total 70 leakages 22 leakages occurred at EDC service then most highly leaking service is pure HCL which has a share of 19% of the total leakages that is 13 leakages out of 70

HCL, 19% 9% Mix of EDC HCL VCM , 14%

2. In addition both HCL and EDC accounts for 50% leakages that occurred in EDC/VCM plant and if mix of EDC/HCL AND VCM is taken in account it goes to 60%

Area of concern

Monthly Leakages Trend

25 25 20 20 16 15 16 10 5 9 0 FEB 5 0 JAN FEB MARCH Shutdowns Summary 3 - 18 Jan (Fur / Oxy) 1 - 30 Mar (Fur / Oxy) 1 - 5 Apr (Fur / Oxy) 6 - 10 Apr (Fur / Oxy) 15 - 17 Apr (Fur / Oxy) 28 - 30 Apr (Fur / Oxy) 4 - 6 May (FurA) 4 May - 19 Jun (Furnace B) MARCH APRIL MAY JUNE 21 21 20 15

10

Shut down Period Furnace A/B &oxy both

APRIL

MAY

JUNE

Months 2011

(Thats why ratio of leakages are minimum)

Reasons for High no Of leakages in MAY:MAY has the most no of leakages and June has also potential for high no of leakages month, May apart from furnace incident has been running normal there are 3 major reason for high no of leakages in MAY 1. Plant was running no major shutdown apart from furnace fire 2. April has seen no of shutdown startups which resultantly effect the operation of MAY and increase leakages 3. 11th may high CL2 after which 05 Leakages occur at wash train before that only 01 leakage was reported 4. June also saw an equal amount of leakages including area 100/200 and area 900 as bulk of it

Leakages distribution area wise

Area -100 31%

Area -800 3% Area -400 4%

50 22 382 13 0 8 14

Area -900 20%

Area -200 12% Area -600 11%

Area -300 19%

Area 100 leakages break up

LTC A/B periphery

AREAS HAVING HIGH RATE OF LEAKGES :1. A-100 is the most gray area where leakages has occurred time to time and particularly wash train circuit which accounts for 63% of area100 leakages 2. Second most vulnerable areas include A-900 and A-300 which accounts for 20% and 19% of the total leakages combining these areas70% of the leakages occur in A-100/300/900
14

wash train circuit which contains highest no of leakages

Areas Most Prone to leakages and their break down

25

Top 03 most leakage vulnerable areas 1. 2. 3. Area 100 Area 900 Area 300

2nd and 3rd most vulnerable areas are A-900 and A-300 respectively

Break up of Area-300 leakages

Total no of leakages
Leakages at AS-302 and its circuit

20

Leakage on overhead circuit

15

13
22 10

7 (out of 07 04 on Reflux circuit of PP-302)

4 are on over head circuit

13 5 8 8

14

(remaining 02 leakages at furnace side)

3 0 Area 100 Area 200 Area 300 Area 400 Area 600

2 Area 800 Area 900

Break up of Area-900 leakages

Total 14 At Ko pots 06 at ko-pots At backend 06 backend area

Remaining 02 leakages at burner assembly

Top Seven heavy leakages in EDC/VCM Plant (last 04 months on the basis of extent of leakage)
10m
10 9 8 7 Heavy leakages but control without any abnormality

8m

6.25m
A-200

Extent of leakage Meter (m)

6 5 4 3 2 1 0 HCL feed line to Oxy Reactor tie in leakage from PP 101 B suction and PP 101 A/B common discharge lines and valve body Heavy caustic leakage gaskit rupture
A-100 A-800

5m 4m
A-300

4m 3m

A-600

A-300 A-100

PP-302 A seal oil pot level grass breaks

Bullet C SV up stream spool clamped leakage

Priming valve PP302A (gland leakage)

Description Of Leakage

02 pin holes at PP 101 A/B circulation line isolation valve to MS 103

Recommendation of Analysis
Incidents that occur repeatedly should have high score then previously allotted for example GR-301 Tripping on the same cause (control power issue) was scored 125 on all the three occasion it occurred 1. 3-Feb -11 2. 7-Mar -11 3. 14-Jun -11 For such incidents Quality of B-report should also be check by Safety Department (Resp Safety)

On the basis of these Incidents analysis Training on procedures and their availability to be ensured (Resp All interfaces)
Refresher of SWP , OMP, MI and other high violated PSRM to be conducted (Resp Safety, relevant dept) PM plans and Inspection plan of all equipment to be shared and should address chronic and problematic areas like A-100/800-900/300 (Resp Inspection)

Physical tiredness long shutdowns and continuous duties in these runs should be dealt with care in order to minimize the fatigue and mental tiredness of a employee esp. Maintenance person who works on 6 duty 1 rest Rota On normal plant run leakages have been most choronic issue which led to high no of incidents where as shutdowns and start up seems to have process related issue as well as injuries issue Most 21 TR done out of 70 leakages that is 30% of the total it is recommended to keep a close look at each TR done as in bullet C case a temporary repair was done on 11th April and after 8days a heavy leakage occur on bullet C same point from clamp, it is highly recommended to check integrity of such clamps and TR

Bullet C inlet manifold has 03 leakages during last 04 months which has a high probability of exposure to corrosive material as quench filters are deacon here all such circuits to be marked and highlighted and Inspection to be done 30% of leaks has occurred in process piping along with that other major 02 leak points are VALVES AND FLANGES there PM plan to be revised and its effectiveness to be checked thoroughly as its is causing 26% of the total leaky points

THE END