Training Outline to Explain the Incident:
1. Introduction to the Incident:
1.1. Sample Collection Error: A casual contract worker at IOCL was tasked with collecting a sample from a benzene tank. During this process, an error occurred; the worker left the valve open after taking the sample. This caused benzene, a highly flammable substance, to flow out of the tank along with vapors, creating a dangerous situation.
1.2 Nearby Welding Work: Approximately 10-15 meters from the benzene tank, a large welding operation was taking place as part of the tank farm expansion. This welding activity, conducted by a contractor from EIL, posed a significant ignition scurce in proximity to the benzene vapor release.
1.3. Spark Ignition and Vapor Explosion: The energy from a spark during the welding process ignited the benzene vapors that had been released, causing a vapor cloud explosion. This explosion set off a fire within the partially open valve area of the tank, further intensifying the hazard.
1.4. Tank Rupture and Pressure Increase: The initial fire caused an increase in vapor pressure, leading to a drastic rise within the benzene tank. This pressure increase resulted in the tank rupturing from both the top and side at around 3:30 p.m., which led to benzene spilling widely in the area.
1.5. Spread of Fire to Nearby LAB Tank: The hol, burning benzene liquid that spilled over came in contact with a nearby LAB (Linear Alkyl Benzene) tank. This secondary ignition resulted in another explosion and further exacerbated the fire, causing it to spread over a larger area.
1.6. Firefighting Efforts: Around 30 firefighting foam tenders, along with water tenders and continuous monitoring spray equipment, were deployed to control and contain the fire. The collective efforts of the firefighting teams played a crucial role in managing the spread and intensity of the flames.
1.7. Fire Extinguished and Area Cleared: After an extensive firefighting operation, the fire was finally extinguished at approximately 2:30 a.m. Following the containment, an "all-clear" was given, and the area was declared safe after inspection and clearance. Summary The incident resulted from a combination of manual error (leaving the valve open during sampling) and system faults, specifically related to the hot work permit system and insufficient training for contract workers. This allowed high-risk hot work to take place near a hazardous area, ultimately leading to a catastrophic event.
2. Key Factors Contributing to the Incident:
• Human Error in Sampling: Emphasize the mistake in handling the benzene valve, remained open after sampling.
• Proximity of Hot Work Activities: Explain how the welding work created sparks the benzene vapors, leading to an explosion.
• Vapor Cloud Explosion and Tank Failure: Describe how the partially open valve ar build-up led to further ruptures and fire spread to adjacent tanks.
3. Lessons on Safe Work Practices:
Correct Sampling Procedures: Stress the importance of properly closing valves an safety protocols during sampling.
• Hot Work Permit System: Review the steps for obtaining permits and ensuring safe distances for hot work near flammable materials.
• Monitoring and Detecting Vapor Releases: Explain the role of gas detectors and the need for vigilance in high-risk areas.
4. Emergency Response Protocols:
Immediate Response Actions: Train on recognizing hazardous releases and initiating alarms or shutdowns.
• Coordination with Fire Services: Explain the process of contacting fire tenders and using foam to control chemical fires.
• Evacuation and First Aid: Outline evacuation routes and basic first aid for bums or inhalation exposure.
5. Preventative Measures and Continuous Improvement:
Reviewing Safety Systems and Procedures: Emphasize the importance of regularly reviewing and updating safety protocols.
• Ongoing Training for Contract Workers: Highlight the need for regular safety training, especially for contract workers handling hazardous substances. By the end of this training, employees should understand the critical nature of handling benzene safely, adhering to hot work regulations, and knowing the emergency protocols to prevent similar incidents.