March 12, 2015 Mary Kay O’Connor Process Safety Center Changwon Son Steering Committee Meeting [email protected]
I am …
From Ulsan, South Korea 3yr 4yr In early 30s
5mo A husband (good vs bad) Three children’s dad B.S. in industrial engineering Spent 6.5 years in HSE dep’t Will spend my life in HSE !
“You should never get a job in a safety department” - A senior year professor
2 What does SAFETY mean to you? 安 全
House People + + Woman King + Man
Process Safety! 3 Fuel Sulfur Fluorine Acid Outline
Background Incident Description Related Information Causes of Incident Lessons Learned Acknowledgement References
4 Background
South Korea is a big chemical producer and seller
900 Chemical sales in 2011, US $ billion[1] 800 832.8
700
600
500
400 463.2
300
200 198.7 177.3 100 134.1 99.6 94.1 70.4 64.5 62.7 0
5 Background
World’s 10 Largest Refineries[2]
Crude Capacity Rank Company Location (b/d) 1 Paraguana Refining Center Falcon, Venezuela 940,000 2 SK Innovation Ulsan, South Korea 840,000 3 GS Caltex Corp. Yeosu, South Korea 760,000 4 Reliance Petroleum Ltd. Jamnagar, India 660,000 5 ExxonMobil Refining & Supply Co. Jurong, Singapore 605,000 6 Reliance Petroleum Ltd. Jamnagar, India 580,000 7 S-Oil Corp. Ulsan, South Korea 565,000 8 ExxonMobil Refining & Supply Co. Baytown, Texas, USA 560,500 9 Saudi Arabian Oil Co. (Aramco) Ras Tanura, Saudi Arabia 550,000 10 Formosa Petroleum Co. LLC. Mailiao, Taiwan 540,000
6 Background
South Korea also known for increasing chemical accidents
120 Number of Chemical Accidents in Korea[3] 104 100 87
80
60
40
17 16 15 20 12 9
0 2008 2009 2010 2011 2012 2013 2014
7 Background
Chemical accidents in S. Korea after a huge HF release Date Chemical released Region Consequences 09/27/2012 Hydrogen fluoride Gumi 5 deaths, 18 injuries 01/15/2013 Hydrogen fluoride Chungju 1 injury 01/27/2013 Hydrogen fluoride Hwasung 1 death, 4 injuries 02/06/2013 Hydrogen chloride Chungju 2 injuries 03/14/2013 Gas Explosion Yeosu 6 deaths, 10 injuries 03/22/2013 Chlorine Chungju 4 injuries 04/15/2013 Chorine Ulsan 6 injuries 05/02/2013 Hydrogen fluoride Hwasung 3 injuries 05/10/2013 Argon Dangjin 5 deaths 05/18/2013 Hydrogen fluoride Siheung 70 evacuated 11/26/2013 Blast furnace gas Dangjin 1 death, 8 injuries 12/02/2013 Blast furnace gas Dangjin 1 death +22 deaths 01/31/2014 Naphtha, Crude oil Yeosu 1 injury, 340 sought medical treatment /31 months 02/11/2014 Ammonia Yeoungju 1 death, 2 injuries 03/27/2014 Carbon dioxide Suwon 1 death 07/31/2014 Ammonia Yeosu 1 death, 21 sought medical treatment 08/22/2014 Sodium chlorate Incheon 22 sought medical treatment 09/13/2014 Chloric acid Yeosu 1 death, 6 sought medical treatment 12/10/2014 Sodium hypochlorite Daegu 38 sought medical treatment 01/12/2015 Nitrogen LG display 3 deaths, 3 injuries 01/30/2015 Phosgene Yeosu 5 injuries 02/14/2015 Carbon dioxide Gyeongju 1 death, 6 injuries 8 Incident Description
Date :March 14, 08:51pm, 2013 Location : HDPE storage silo at Daelim Co. in Yeosu, South Korea Possible scenario : During the hot cutting of a manhole into the silo, decomposed gas from HDPE fluff had been accumulated inside and the gas was ignited by welding spark. Consequences : Six(6) deaths*, ten(10) injuries and damages to facilities (Silo B&D). * All deaths were of scaffolding workers 9 Location of the Incident
36.4% % Amount of chemicals treated
34.1%
10 Polyethylene (HDPE, LDPE)
Properties[4] Melting Flash Auto-Ignition Formula CAS # Point Point Temperature 115~135°C 341°C 330~410°C (C2H4)n 9002-88-4 (239~279°F) (646°F) (626~770°F) Products : plastic bottle, plastic pipe, plastic lumber, etc.
General Process Ethylene Unreacted (monomer) monomer Fluff Pellet Intermediate Final Reaction Treatment Storage Extrusion Storage (Polymerizing) (Silo) (Blender)
Packing 11 Four Main Manufacturing Processes [5]
*
HDPE *
* Continuous Stirred Tank Reactor Process Slurry Gas Solution Reaction Type Loop CSTR Fluidized Bed CSTR Licensor Phillips Mitsui/Hoechst/Chisso Basell Du-Pont Catalyst Cr Z-N(Ziegler-Natta) Cr, Z-N Z-N Comonomer C6(Hexane) C3, C4 C4, C6 C4, C8 12 Slurry Loop Process[5]
BAG FILTER CYCLONE OFF GAS COOLANT R-I C4 STORAGE TANK PIPE LOOP REACTOR R-I C4 FLASH COLUMN CHAMBER
FLASH GAS CONVEYOR DRYER COMPRESSOR
PURGE CATALYST COLUMN ACTIVATION ADDITIVES BLOWER CATALYST(Cr) NITROGEN PRODUCT BLENDER FLUFF RIBBON STORAGE SILO BLENDER PACKING ETHYLENE BLOWER HYDROGEN ISO-BUTANE HEXANE-1 EXTRUDER
BLOWER BLOWER
13 Fluff The Facilities at the Incident
Plan Storage Silo Elevation EL. 30.3m – 9 workers : worker
EL.30.3m V-59A V-59B V-59C
Inspection V-59D V-59E V-59F Manhole D=0.9m V-59D V-59E V-59F EL. 7.9m – 7 workers 5m V-59A V-59B V-59C 1.5m EL. 7.9m
V-59D V-59E V-59F EL. 3.0m
EL. 0m
14 Newly built(with manhole) The Overview
Top Level Scaffold
V-59F V-59C V-59B (behind 59C) V-59A
V-59E V-59D (behind 59B) (behind 59A) “you will regret Lower Level your unsafe behavior Scaffold for the rest of your life”
15 Manholes
2nd explosion
Manhole D was facing manhole B Cutting & Welding were performed (1st explosion)
16 Preceding events & conditions[6]
06/28/2012 Two blenders exploded presumably due to static electricity.
Two out of six silos were damaged. Company decided to rebuild two broken silos (E&F) and make a manhole for other four silos (A~D). 08/XX/2012 Change request above was approved by a plant manager.
01/18/2013 A contract was made for manhole installation with Yuhan Eng.
03/08/2013 Company-wide maintenance plan was established. (03/12~04/05)
03/12/2013 ~03/14/2013 Overall facilities were shut down and purging was performed.
03/14/2013 Morning Two new silos were installed around noon.
17 Sequence of the Incident[7] Video March 14, 2013 6 died, 3 injured Manhole installation began V-59C V-59F 1:00pm V-59B ~ Cut Weld Change Trim V-59E a hole a Seat location a hole V-59A V-59D Scaffold started to be erected 6:00pm (for walkway installation at top)
Welding for manhole re-started 08:35pm at V-59D
Explosion occurred in V-59D 08:51pm 7 injured followed by V-59B
Local fire department received 08:59pm emergency call
18 The Aftermath Silo top
Charred fluff
Manhole seat Welding machine
Fallen fluff
Damaged silo bottom
19 Causes of the Incident
Direct Causes
The Conclusion of Korean National Forensic Services( NFS) While fluff remained in the silo, hot metal pieces cut off from a manhole fell into the fluff creating flammable gas such as propene, butene. When welding began for the manhole pipe, spark ignited the flammable gas inside silo leading to the explosion.[8]
20 KOSHA PSM Elements
Manage Process -ment of Hazard Contractor Incident Change Analysis Manage Investigation -ment
Permit-to- Audit work
Emergency Mechanical Response Integrity Process Pre-Startup Safety Safe Review Information Training Operating Procedure
21 Causal Factors
Management of Change
Explosion in 2012 damaged two silos
Existing silos without New silos with Make a manhole a manhole a manhole at existing silos
Company failed to identify and mitigate the risk that arises from the change (installing manholes)
22 Causal Factors
Poor Hot Work Management
HDPE Fluff was not fully cleaned out of the silo by water spraying[7] Fuel To save the maintenance cost To shorten the time that would have been used for silo drying The foreman closed the outlet at the bottom of the silo to keep the fluff from falling on the ground (after about 10 kg had fallen)
Purging (inerting) & gas monitoring were not sufficient during the hot work[7]
Company said the silo was purged but it was not maintained during hot work Continuous gas monitoring was not present (once before entry)
23 HDPE Thermal Decomposition
Yield of volatile compounds in thermal pyrolysis of HDPE[9] Pyrolysis products(in wt%) of HDPE[10]
Pyrolysis Products(wt%) Temp. tc (°C) (s) Waxes Gases Liquids Aromatics Char (>C11) (C1-C4) (C5-C10)
500 510 65.8 20.2 13.2 0.7 0.1
550 91.7 58.2 32.8 8 0.85 0.15
600 66.3 44.1 43.7 11 1.03 0.17
Gases from HDPE thermal decomposition is flammable with low ignition energy and is likely to be ignited.
24 Causal Factors
Contractor Management Failure
Production schedule Daelim Industries Pressure - SIMOPs Contracting - Night work Yuhan Engineering Risk contracted away Contract awarded Subcontracting - Safety cost not paid to lowest bidder - Safety supervisor not Daewon Plant certified - Lack of training to contractors (MSDS) - Emergency response Piping team Scaffold team made by contractors
- Installing manholes(lower) - Installation of scaffolds - Installing walkways(top) (lower and top) 25 Causal Factors
Permit-to-work System Not Worked
Hot work permit did not actually control the risk
Too many permits administered by a few people (20~30 permits/person) Lack of supervision during the work
SIMOPs (Simultaneous Operations) were not avoided
All of the deaths occurred on the top due to hot work below Scaffold team did not know about hot work (no communication) Objects such as plank may drop
26 Causal Factors
Late and Ineffective Emergency Response
Company (Daelim) and Fire Department responded too late
08:51pm 08:59pm 09:08pm 09:30pm FD received Fire engine Fire engine Explosion emergency entered arrived at 40 mins call the plant the scene
Responses were not effective in rescue
Company’s safety supervisor was not certified with any first aid skill
Rescue equipment was not readily available (Ladder truck not sent) No helicopter service was provided for long-distance transportation (for severe burn injuries) 27 ‘Crying over spilt milk’
Citations & Fines imposed by KOSHA[11] - Period : 03/19/2013 ~ 04/01/2013 (14 days)
# of Citations Fines
Dealim ₩ 837,403,000 1,002 Industries (US$ 769,000)
₩2,1950,000 Contractors 266 (US$ 200,000)
28 Lessons Learned [12]
1. Use alternatives Hot work should be avoided or at least it should be minimized.
2. Analyze the hazards Change introduces other risks at times. Those risks should be identified and controlled.
3. Monitor the area Gases always change. Keep checking the gas concentration before and during hot work.
4. Manage by permits Permits are of paper but it must not be a paperwork.
5. Train & Communicate Train on material used, job specific hazards, and emergency response.
29 Acknowledgement
Dr. Sam Mannan Dr. Chad Mashuga Dr. Ray Mentzer Dr. Sonny Sachdeva Dr. Maria Ramirez Marengo Mr. John Bresland All members of MKOPSC - Special thanks to Younggil Park
30 References
[1] Cefic Chemdata International, The European chemical industry in worldwide perspective Facts and Figures 2012, http://www.cefic.org/Documents/FactsAndFigures/2012/Chemicals-Industry-Profile/Facts- and-Figures-2012-Chapter-Chemicals-Industry-Profile.pdf [2] Warren R. True, Leena Koottungal, Oil & Gas Journal, Global capacity growth reverses; Asian, Mideast refineries progress, 2011, http://www.ogj.com/1/vol-109/issue-49/special-report-worldwide/global- capacity-growth-full.html [3] Korean Ministry of Environment, chemical accidents statistics by year [4] Batra, Kamal (2014). ROLE OF ADDITIVES IN LINEAR LOW DENSITY POLYETHYLENE (LLDPE) FILMS. p. 9. Retrieved 16 September 2014. [5] KOSHA (Korean Occupational Safety and Health Agency), Petrochemical Process Assessment Manual, LDPE/HDPE Process [6] H.B.Jeon, Judgment Case Analysis, KOSHA Code 23-1 and The responsibilities of contract awarder, 2014. [7] Dealim Accident Prevention Committee Activities Report, 2013 [8] Korean National Forensic Services(NFS), Investigation report of Daelim explosion, Yeosu, May 8, 2013. [9] Maria del Remedio Herna´ndez et al., Study of the gases obtained in thermal and catalytic flash pyrolysis of HDPE in a fluidized bed reactor, 2005. [10] S.M. Al-Salem∗, P. Lettieri, Kinetic study of high density polyethylene (HDPE) pyrolysis, 2010. [11] Korean Ministry of Employment and Labor, Accident Information and Occupational Safety and Health Audit Result of Daelim Industry, Yeosu, 2013 [12] U.S. Chemical Safety and Hazard Investigation Board(CSB), Seven Key Lessons to Prevent Worker Deaths During Hot Work In and Around Tanks, February 2010.
31 Q & A
32