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Incidents
Months
No Of Leakages
51 42 40 46 69 25 273
69
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
No of Incidents
Incidents Trend
near misses
50 40 30 20
47
38 37
41
10 1111 0 Jan
4 12
23
1 112 Apr
Feb Mar
22 1
Envc release
No of month 1
Jun
Months
May Jun
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
40
41 40 4 Process Incident near misses
46
1 1 2 1
39 38
2
process incident
45 44 43 42 41 40 39
1 37 36 35 Mar 37
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
6% 33%
52
19%
I&E
I&E
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
I&E
3 2 1 3 2
Ops
Nearmiss; 92%
4% 1% 1% 1% 1%
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
2, 9%
4, 17%
Inadequate
Proceduer not followed, 74%
Inadequate , 4
4 Not available , 2 1
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
10 5 0 Inadequate 1 4
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
161 18%
4% 3%
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
31
10 0
Commissioning
All dept.
Misc dept
Ops
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
Ops distribution of incidents indicating area of concern is procedures and safe work practices
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%
140
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
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
PG vessel Purge point FT mainifold Burner assembly GLG Switches GASKIT BELLOW Head cover (Exchanger) CONNECTOR tubing FLANGES VALVES Piping
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
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
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
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
10
APRIL
MAY
JUNE
Months 2011
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
50 22 382 13 0 8 14
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
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
20
15
13
22 10
13 5 8 8
14
3 0 Area 100 Area 200 Area 300 Area 400 Area 600
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
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
Description Of Leakage
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