Source: Industrial Safety Management: Hazard Identification and Risk Control, 1st Edition

ISBN: 9780070617681
Authors: L. M. Deshmukh

A. CASE STUDIES — A: Process and Chemical Handling

A-1. An Unexpected Chemical Reaction

At a certain plant carbon disulphide is manufactured by reacting sulphur with calcified charcoal at a very high temperature
which is attained from an electric arc, produced between two electrodes—anode and cathode—in an electric furnace. The
furnace is worked only for a scheduled period and then switched off for cooling and cleaning. When the temperature inside the
furnace comes down to room temperature, two trained operators, well protected by necessary safety equipment, go inside
through the manhole at the bottom to dig and shovel out the hardened residual mass from the furnace base. They work inside
for half an hour and come out for fresh air while another team of two operators replace them and continue the work.

The hard mass thus dug and thrown out of the furnace is removed and collected a distance away so that it can then be
gathered in bulk and be disposed of or dumped into the marked ditch yard. The mass of waste residuals from the furnace gets
hardened over a period of days, forms a huge heap and requires further digging and shovelling to collect and load it into a truck
to transfer it to the scrapyard.

On one of the monsoon days, a contractor's employee was found lying unconscious on the heap of furnace waste residues,
with his equipment strewn around. No one knew how long he had been lying there in that condition as the place was isolated
and remote. He was removed to the company's hospital, where he was declared dead. At that instance, it was assumed to be a
natural death, possibly due to a massive heart attack.

The post-mortem report confirmed death due to asphyxia, caused by an overdose of poisonous gas. The waste material had
always been dumped at that location. It was in the open and no other chemicals or chemical wastes were ever dumped there.
The immediate inspection and investigation did not disclose any valuable clue to ascertain the exact reason.

Hydrogen sulphide gas, which evolves in the process of forming of carbon disulphide in thefurnace, remains trapped in the
residual mass at the bottom of the furnace. When the solidified mass is broken into pieces, hammered or dug out, the
entrapped gas escapes. It is more likely to escape in wet conditions. On that day, it had rained heavily before the deceased had
been thereto work.

A-2. Expect the Unexpected

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A-2. Expect the Unexpected
In a plant manufacturing rayon textile yarn, a viscose solution comprising alkali cellulosedissolved in caustic soda lye is passed
through a spinning machine jet, immersed in the bath of clean dilute sulphuric acid.

After the separation of sodium sulphate salt and sulphuric acid in the slurry collected from the spinning machine, through the
filtration process in the Rotary Vacuum Filter, the recovered acid, spent acid, is stored in the spent acid tank and filtered through
Columbia filters, concentrated to the desired level, stored in a clean acid tank and, from there, reused on spinning machines.

Four large rectangular tanks were provided in the basement of the spinning room, two forstoring spent acid and two for clean
acid, in a row adjacent to each other. One of the spent acid tanks was taken out of circulation for maintenance. The tank was
thoroughly emptied, isolated from inlet lines, and was to be cleaned manually from the inside. A safe-entry-permit was procured
with the gas concentration, tested and certified, to be within threshold limits.

After an hour or so of working inside the tank, the workman on the job of cleaning was observed, by the supervisor, to be lying
flat. Realising the gravity of the situation, the supervisor rushed into the tank to rescue the workman. He also became
unconscious and fell down inside the tank. Others working nearby rescued both the affected persons in time, making use of
self-breathing apparatus during their rescue operation. Both victims survived on receiving immediate first aid followed by
medical treatment in the hospital without any loss of time.

The hold up in the adjacent spent acid tank had increased to a greater extent during the one-hour period while the workman was
cleaning the other tank. H 2 S gas liberated from the tank, being heavier than air, spread out and entered the empty tank.

A-3. Lack of Safety Procedure

A road tanker filled with strong caustic soda (47%) lye was parked in the tank yard on the premises of a hazardous chemical
factory at about 6:30 p.m. on a working day. The general shift was over and most of the responsible senior persons had gone
home. This delivery was expectedearlier or if delayed, the next day. However, for reasons not communicated, the tanker was
sent by the transport agent late in the evening. Not only was it allowed to enter by the security but it was also allowed to unload
by the production shift in-charge.

The driver parked the vehicle in its usual place and went away, asking the cleaner to unload the chemical into the tank of the
factory. The vehicle had a compressor on its chassis. However, a compressor from the maintenance department was used for
decanting the chemical from the tanker truck to the static tank. The cleaner, who was standing on the body of the tanker,
inserted the free end of the hosepipe, connected to the compressor, onto the protruding vent pipe of the tanker. The caustic
soda lye was to be decanted from the tanker to the tank under compressed airpressure.

With this arrangement, the cleaner shouted and signalled to the operator to start the compressor. The operator, without
checking the procedures that were required to be followed, started the compressor. Within a minute or so, the hose end on the
vent of the tanker body snapped off and the caustic solution splashed out, spurting all over the face and upper body of the
cleaner who, at that time, happened to be leaning over the vent. Because of the sudden spray he panicked and jumped down to
the ground.

A few workmen who were working in the vicinity rushed to help the injured. They washed him with water through a hose,
connected to a water tap nearby. They did spray water on his face but neither he nor the rescuers tried to open his eyes during
the wash.

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The chemical burns he sustained on his face, neck, shoulders, arms and chest were minor compared to his eye injuries. He
sustained minor scratches and cuts on his legs and buttocks because of jumping down onto the rough ground.

Proper first aid had not been administered to him in the absence of a medical officer, nurse or a qualified first-aide. Most
importantly, his eyes did not receive the adequate and timely first aid they required. Quick arrangements to take him to a
hospital to get him prompt medical treatment were not made. They first took him to a nearby clinic, where the doctor advised
them to take him to a good hospital to ensure immediate treatment by an ophthalmic surgeon.

In spite of that, it was almost six hours later that the injured was admitted and examined by a competent ophthalmic surgeon,
who after a thorough examination and adequate tests, arrived at the conclusion that his left eye was completely damaged and
offered no guarantee of any recovery of vision, even after performing surgery on that eye. However, the surgeon opened that
recovery of partial vision of the right eye was possible and immediately operated on it. As predicted, the injured lost the use of
his left eye completely and regained about 50% of the vision in his right eye.

A-3-1. Investigative Report and Findings

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 A-3-1. Investigative Report and Findings
1. The compressor was started without opening the bottom transfer valve.

2. The hosepipe end was only inserted on the vent-line and not clamped firmly onto the vent pipe.

3. The cleaner did not protect himself with helmet-cum-face visor, goggles, rubber apron, hand-gloves and gumboots as
required.

4. There was no supervision by competent persons from both sides, the company as well as the supplier and/or the transport
agent.

5. The security guards permitted the tanker to enter without written permission or any procedural authority.

6. The risk of unloading the tanker after the general shift was taken by the production chemist against the standing safe
operating procedures without seeking permission from the department head.

7. No entry was ever registered as regards the tanker, driver, cleaner, supplier or transport agency. It was a task in itself to get
the necessary details the next day in order to complete the notification formalities.

8. Pressurising the chemical by means of compressed air pressure started before opening thebottom transfer valve, which in
effect pressurised the chemical and resulted in the snapping off of the loose hosepipe, leading to eruption of the chemical
out of the vent which was the only available passage.

9. The tank of the truck was filled to capacity as against the standard practice laid down to leave minimum empty margin of
about 20% for evaporation.

10. The standard safe procedure adopted and recommended is to transfer such a chemical by gravity, never under pressure.

11. The tanker was not well equipped with personal protective equipment and safety garments required by the operatives nor
was the 'Hazchem' card carried in it. Security guards did not check for the same.

12. The 'Permit-to-work' system was not in force for 'Unloading Hazardous Chemicals'.

13. Neither the staff of the company responsible nor the driver and the cleaner were ever trained in carrying out such hazardous
jobs.

Had there been someone who would have forcibly opened the eyes of the injured and washed them thoroughly with water by
taking him to an eye-fountain or by pressurised water-jets, continuously for not less than 20 minutes, his eyes would not
have been damaged to the extent that they were.

Secondly, the injured should have been taken to the eye-surgeon immediately after washing his eyes in opened condition.
His eyes would have been saved to a greater extent, possibly by 90-100%.

A-4. Potential Hazard Not Considered

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A-4. Potential Hazard Not Considered
A horizontal concentrated sulphuric acid storage tank, measuring 9 ft in length and in diameter, was located on the
sulphuric acid tower at a height of 60 ft outside a chemical plant. It was to be replaced as it was old and corroded. Hence, it
was emptied by draining off the acid completely, washing it over thoroughly and dismantling it from its structural members.

The sludge that remained at the bottom could not be flushed out nor could it be neutralised at that height. Hence, a metal tray
was welded onto the lugs below the tank as a precautionary measure to collect the sludge, if it leaked down during transit while
the tank was being lowered. All the pipelines connected to all the tanks on the tower were blocked and blanketed.

A team of 14 khalasies, one mukadam, one fitter and an assistant fitter was assigned the job of dismantling and lowering the
tank from the top of the tower down to the ground under the direct supervision of the Deputy Chief Engineer and his Assistant
Engineer.

An adjacent overhead projection structure was provided for the purpose of lowering the tank after dismantling it. Taking the
tank down from the structure was organised with the help of a chain-pulley-block and the multiple-chain-pulley-block
arrangement, tied firmly onto the projection structure. The tank was to be guided by means of guy wires (steel wire rope of
an inch in diameter) taken through a crab. Plank pieces were provided, which were tied onto the cross members of the structure
at a height of about 20 ft, for two khalasies to stand on and guide the lowered tank with the help of probe-rods.

As per the planning, organisation and various arrangements mentioned above, the tank was dismantled and was being lowered.
When the tank was brought down successfully to about 20 ft above ground level, one of the corners of the welded metal tray
dashed against the tee joint of a1 inch diameter vertical acid inlet line that was running vertically parallel to the main tower
structure. A horizontal branch inlet to one of the acid tanks installed on the same tower was alsoconnected to this vertical line
by means of the same tee joint. When the tray dashed against it, the tee joint gave way and the residual hold of strong sulphuric
acid in that line splashed out onto everyone working there.

The two khalasies, standing on the plank platforms, received severe burn injuries on their face, arms, chest and legs. Their eyes
were badly affected. Eight others sustained comparatively minor acid burns.

A-4-1. Comment
Adequate precautions were taken to dismantle and bring down the tank from such a height, after thorough thinking, planning
and organising. Adequate spacing was also planned to keep the tank away from the main tower structure while lowering it.
However, the possibility of the heavy tank swinging in transit was not considered.

A-5. Possibility of a Toxic Gas Leak Not Considered

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A-5. Possibility of a Toxic Gas Leak Not Considered
A 40,000 gallon tank was located and joined to other process chemical tanks with all the necessary equipment and gadgets in a
chemical complex. This tank was used to collect acids in measured quantities from other tanks for the purpose of mixing them.
A power driven agitator was installed in the tank. The chemical operation involved evolution of hydrogen sulphide gas.

The mixing equipment projecting into the tank had to be repaired. A contractor was brought in to perform the necessary repairs.
Prior to the entry of the contractor's men into the tank, it had been completely emptied of any residual chemicals, cleaned
thoroughly, flushed and checked for the presence of hydrogen sulphide gas. A safe-entry-permit was issued with the
certification that the gas concentration of H2 S was below the Threshold Limit Value and it was therefore safe to enter and
work.

After being assured that the tank was clean and clear, the contractor's men, along with the plant's maintenance service people,
entered the tank and worked on the equipment. At lunch time all the people, with the exception of one of the contractor's men,
left to eat. During this time the production supervisor instructed his operator to fill in a head tank with H2 S. His intention was to
be ready to start operations shortly after lunch.

Soon after the head tank had been filled, the supervisor happened to look into the tank only to find the contractor's man lying
flat at the tank bottom. The operator stood by as the supervisor entered the tank to rescue the victim. The supervisor also
collapsed at the bottom.

The operator shouted for help. Immediately people rushed to the site and managed to procure suitable gas masks and safety
belts. With the use of gas masks and lifelines both the victims were removed from the tank into fresh air.

The contractor's man was pronounced dead on arrival at the hospital and the supervisor was in a very serious condition.

A-5-1. Investigative Findings

1. It was determined that hydrogen sulphide had leaked through a pump from a head tank and into the mix tank. Both men had
been overcome by H2 S in almost a fatal dose.

2. The contractor's man died before reaching the hospital, possibly because of his prolongedexposure to the noxious gas in
such a high concentration, whereas the supervisor survived as he was immediately attended to.

3. The Work-Permit-System was not up-to-date and systematic. The following were the shortcomings in administering and
monitoring the desired norms and conditions of the Safe-Entry-Permit:

a. Failure to disconnect and blank off all inlet lines to a vessel when required to be entered for cleaning or repairs.

b. Failure to suggest and provide normal protective equipment to the men entering and working inside.

c. Failure to supply fresh air inside the tank, by a forced ventilation draft, while the men are inside.

4. No observer was posted outside to watch and hold the free end of the lifeline for the person inside, to pull him out in case of
emergency.

5. Proper controls and check procedures to be put into effect before allowing persons to enter the confined space were not set
and implemented.

6. Lack of adequate education and training to the supervisors and employees, both of thecompany and the contractor,
regarding the Work-Permit-System and the Emergency Control Measures.

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