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Exercise on recent accidents - Case 3 and 4: M/S.Superfine Aromatics company Ltd & Urea Plant at M/s. Mangalore Chemicals and Fertilizers Ltd.

Case 4: M/S.Superfine Aromatics company Ltd

Incident:

M/S.Superfine Aromatics company limited is a chemical factory located at Nanjangud, in Mysore District of Karnatak state of India. This factory is engaged in manufacturing of perfumery chemicals using hazardous chemicals viz.,toluene, Alpha pinene, acetic acid, hydrogen peroxide, ethane di-sulphonic acid, soda ash etc.,

On 17.8.2001 at around 9.45 am there was an explosion in Alpha Campholenine Aldehyde plant. The HDPE drum containing an intermediate of alpha penine which was decanted from a reactor exploded instantaneously. As a result, two employees got injured by the splinters due to the blast, the injuries were of minor in nature. However the severity of the blast was of high intensity which caused flash fire and damaged the complete structure of ACA plant including the adjacent buildings.

Investigations

Investigations conducted by the department revealed that the main causes for the said blast in subject is presumably due to the presence of foreign oxidising material in the HDPE barrel into which highly explosive peracetic acid was decanted.

Recommendations
Recommendations made to prevent such accident includes strict compliance of safety rules in handling, storing, and usage of hazardous and explosive chemicals as envisaged in the respective Material Safety Data Sheets and establishment of proper work procedures in handling such chemicals.

Exercise:

  • First discuss the accident
  • Apply the domino and Swiss Cheese model

Case 4: Urea Plant at M/s. Mangalore Chemicals and Fertilizers Ltd.

Incident:

There was a chemical accident in the Urea Plant at M/s. Mangalore Chemicals and Fertilizers Limited, Panambur, Mangalore on 9.2.2000. An 8" dia high pressure pipe line housing a weldolet was connected between autoclave (urea reactor) of 108MT capacity and the stripper to carry ammonium carbamate (Urea Solution). The pressure of pipe line was of the order of 141kg/cm2 and the temperature of 180 C. The Solution had contained 29% of ammonia, 18% carbon dioxide and 32% of urea. The parameters such as temperature and pressure are required to be maintained at the same level throughout the pipe line for effective transfer urea solution. For this purpose pressure gauges and thermocouples were introduced at regular intervals and the readings were recorded.

Investigations:

Investigation conducted by the department under the guidance of an expert committee revealed that the weldolet used in the high pressure pipe line had high carbon content which is not suggested for that kind of a process, maintenance/repair works was undertaken on line even after noticing the hazardous solution which amounts of non implementation of shutting down procedures envisaged in the on-site emergency plan. Further the high-pressure pipeline was not subjected to hydrostatic test, ultrasonic tests and examinations as required under relevant provisions of law for its soundness. The personnel who were on the job were not wearing any personal protective equipment in addition to non-adherence to work to permit system.

On 9 February 2000, a substantial quantity of ammonium carbamate solution leakage was noticed at the weldolet joint of the pipeline. A maintenance manager along with two operators, an engineer and two contract workmen were trying to plug the leakage by providing a proper clamping. In the process, the weldolet joint gave way resulting in sudden release of pressurized hot ammonium carbamate solution. As a result, the personnel on the job were exposed to hot solution and toxic gas. Consequent to which, 8 persons were affected amongst them 2 died on the spot and the other two at the hospital amounting to death of 4 persons including the maintenance manager and an engineer.

Recommendations

The expert committee constituted to investigate the incident went into the details of the causes and had made the following recommendations to avert any incident in future.

  1. The pipe line, connected equipment and the accessories must be subjected to Hydrostatic test as required under the relevant provision of law;
  2. Weldolet must be subjected to 100% examination to detect corrosion and the soundness;
  3. Maintenance/repair works shall not be undertaken on line, it shall be done only as per standard maintenance procedure drawn up before hand;
  4. Permit to work system shall be strictly adhered to along with suitable personal protective equipment;
  5. The on site emergency plan rehearsals shall be put to rigorous tests and practiced by updating the weaknesses noticed from time to time;
  6. The personnel including the contract workmen shall be put to rigorous training in handling chemical emergencies particularly to bring a change in their attitudinal behaviour of over confidence;

Exercise:

  • First discuss the accident
  • Apply the domino and Swiss Cheese model

 

 
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