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Process Safety Management
and Business Impact Analysis
eteX- june 2021
ete
X
eteX 1
Case : Explosion in a Manhole (MH) in an
Atmospheric Distillation Tower
eteX 2
In 2004, maintenance was carried out on an atmospheric
distillation unit of 100,000 barrels/day. The Atmospheric
Distillation Unit (ADU) is part of the refining complex with
this simplified configuration:
ADU VDU FCC
Crude oil
AR HVGO
Diesel
Naphtha
Atmospheric
Residuum
Fuel Oil
LPG
Gasoline
AR: Atmospheric
Residuum
VDU: Vacuum
Distillation Unit
FCC: Fluid Catalytic
Cracking
HVGO: Heavy
Vacuum Gasoil
MH Manhole
Distillation
Tower
MH
Stripping
ete
X
Tower opening release steps
eteX 3
 Emptying the Distillation Tower
 Start of Steam out
 End of Steam out
 Cooling
 Gas measurements inside the tower through openings
in the bottom drains, bottom level taps and top vent.
 With safety conditions, release of the tower for
opening the manholes (4).
Distillation
Tower
Steam
out
Steam
out Gas test
Gas test
Gas test
ete
X
Opening the Manhole at the bottom of
the tower
eteX 4
 Security Team releases the opening of the Tower for
maintenance and inspection.
 Maintenance Team starts opening the Manhole (MH) at the
bottom of the tower. – Does not use the proper torque
tools due to damage to them.
 Start with common tools.
 Difficulty for opening is very high.
 Maintenance team, very experienced (~30 years of activity),
starts heating the MH nuts with a torch in an attempt to
make the opening easier by loosening the nuts with heat.
 First attempt didn't work.
 Continued heating, using more time.
 MH increased the temperature.
 Success in removing the nuts for opening.
 MH still locked even without the nuts.
Torch
ete
X
The Explosion
eteX 5
ete
X
 An employee from the maintenance team hits
the MH with a sledgehammer to try to open
it.
 The MH opens, with a spark from the
sledgehammer hitting it.
 Explosion in MH when it opens.
 The two maintenance team employees are
injured, one with a 2nd degree burner and
the other with head trauma from being
thrown into a pipe in the explosion.
 The inside of the bottom of the tower is also
damaged.
Distillation
Tower
Probable cause
eteX 6
ete
X
The probable cause was the entry of oxygen
at the time of forced opening of the MH, plus
the spark caused by the hammer hitting the
MH plus the gas that was generated when the
MH was overheated.
Gas origin: Heavy material residues (bottom of the
column sticked to the inside of the MH that did not come
out with the Steam Out operation.When the MH was
overheated, there was an evaporation of the light part
associated with the residue creating a gaseous
atmosphere.
Spark
oxygen Gas
Failed PSM Elements - Barrier Failure
eteX 7
ete
X
1.Process Safety Information
2.Process Risk Analysis
3.Operational procedures
4.Employee Participation
5.Training - Initial / Reinforcement /
Documentation
6..Contracted Outsourcers - Application /
Responsibilities
7.Pre-Start Up Safety Review
8.Mechanical Integrity
9.Hot Work Permit
10.Change Management
11.Accident investigation
12.Emergency Response Plan
13.Compliance Audit
OHSA -PSM
Barriers Fail > Accidents Happen
*Unfulfilled
items
marked in
red
Grêmio X Real Madrid – Final World Championship
Business Impact Analysis - BIA
eteX 8
ete
X
Accidents have an impact on the physical
structure and on people who are studied and
investigated within the PSM , which also has
barriers to prevent them from occurring , but
we still have an analysis tool for the impacts
on business that is part of a business
continuity plan . Business, which is an
important part in a company beyond the PSM
implementation.
-5% IN PROFITS
-10% ON SALES
DELAY IN DELIVERY OF FUEL TO CUSTOMERS
MORE THAN U$ 1MM in costs
eteX 9
Business Impact Analysis - BIA
ete
X
Accident
40 days
Operational Return Service Level Return
20 days

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Process safety management and business impact analysis

  • 1. Process Safety Management and Business Impact Analysis eteX- june 2021 ete X eteX 1
  • 2. Case : Explosion in a Manhole (MH) in an Atmospheric Distillation Tower eteX 2 In 2004, maintenance was carried out on an atmospheric distillation unit of 100,000 barrels/day. The Atmospheric Distillation Unit (ADU) is part of the refining complex with this simplified configuration: ADU VDU FCC Crude oil AR HVGO Diesel Naphtha Atmospheric Residuum Fuel Oil LPG Gasoline AR: Atmospheric Residuum VDU: Vacuum Distillation Unit FCC: Fluid Catalytic Cracking HVGO: Heavy Vacuum Gasoil MH Manhole Distillation Tower MH Stripping ete X
  • 3. Tower opening release steps eteX 3  Emptying the Distillation Tower  Start of Steam out  End of Steam out  Cooling  Gas measurements inside the tower through openings in the bottom drains, bottom level taps and top vent.  With safety conditions, release of the tower for opening the manholes (4). Distillation Tower Steam out Steam out Gas test Gas test Gas test ete X
  • 4. Opening the Manhole at the bottom of the tower eteX 4  Security Team releases the opening of the Tower for maintenance and inspection.  Maintenance Team starts opening the Manhole (MH) at the bottom of the tower. – Does not use the proper torque tools due to damage to them.  Start with common tools.  Difficulty for opening is very high.  Maintenance team, very experienced (~30 years of activity), starts heating the MH nuts with a torch in an attempt to make the opening easier by loosening the nuts with heat.  First attempt didn't work.  Continued heating, using more time.  MH increased the temperature.  Success in removing the nuts for opening.  MH still locked even without the nuts. Torch ete X
  • 5. The Explosion eteX 5 ete X  An employee from the maintenance team hits the MH with a sledgehammer to try to open it.  The MH opens, with a spark from the sledgehammer hitting it.  Explosion in MH when it opens.  The two maintenance team employees are injured, one with a 2nd degree burner and the other with head trauma from being thrown into a pipe in the explosion.  The inside of the bottom of the tower is also damaged. Distillation Tower
  • 6. Probable cause eteX 6 ete X The probable cause was the entry of oxygen at the time of forced opening of the MH, plus the spark caused by the hammer hitting the MH plus the gas that was generated when the MH was overheated. Gas origin: Heavy material residues (bottom of the column sticked to the inside of the MH that did not come out with the Steam Out operation.When the MH was overheated, there was an evaporation of the light part associated with the residue creating a gaseous atmosphere. Spark oxygen Gas
  • 7. Failed PSM Elements - Barrier Failure eteX 7 ete X 1.Process Safety Information 2.Process Risk Analysis 3.Operational procedures 4.Employee Participation 5.Training - Initial / Reinforcement / Documentation 6..Contracted Outsourcers - Application / Responsibilities 7.Pre-Start Up Safety Review 8.Mechanical Integrity 9.Hot Work Permit 10.Change Management 11.Accident investigation 12.Emergency Response Plan 13.Compliance Audit OHSA -PSM Barriers Fail > Accidents Happen *Unfulfilled items marked in red Grêmio X Real Madrid – Final World Championship
  • 8. Business Impact Analysis - BIA eteX 8 ete X Accidents have an impact on the physical structure and on people who are studied and investigated within the PSM , which also has barriers to prevent them from occurring , but we still have an analysis tool for the impacts on business that is part of a business continuity plan . Business, which is an important part in a company beyond the PSM implementation. -5% IN PROFITS -10% ON SALES DELAY IN DELIVERY OF FUEL TO CUSTOMERS MORE THAN U$ 1MM in costs
  • 9. eteX 9 Business Impact Analysis - BIA ete X Accident 40 days Operational Return Service Level Return 20 days