Over the past several months we have been working with a confidential client who has afforded me with permission to post this “learning opportunity” for others. This incident, although minor this time, was recognized as having the potential to end the business so this organization is pulling out all the stops to identify failures. Once such failure that we have come across deals with Emergency Shutdown Procedures and the In-House Emergency Response Team and here’s something for all of us to consider…
The incident involved a fire in a processing unit in which the in-house fire brigade responded to. This was, as some would call it, a “routine pipe flange fire”; although this facility did not have many of these fires, it supposedly is one type of fire that is “expected in the industry”. We can debate that mindset another time! But this fire was a bit different, a tad larger, and thus it came to impact one of the “connected PSM processes” within the facility. Where we ran into a significant issue was not the actual fire, but in the covered process. You see three of the fire brigade members came out of the PSM-covered process, leaving the covered process with only two (2) operators; normally their are four (4) operators and one (1) maintenance on this shift. This process has a somewhat “complex” shutdown and emergency shutdown procedures. In fact the emergency shutdown requires some unique timing between the four (4) operators due to the age and layout of this process.
So on the night of the fire, the Fire Brigade members did what they had done for years – they responded to the emergency and in doing so they switched their radios over to the emergency frequency. As the fire was larger this time, for reasons not yet known, the covered process nearby was impacted in a bad way with a powered blimp-related to the fire reaching some key electrical equipment and the covered process began to deviate from several of its safer upper/lower limits. The two remaining operators were overcome with alarms and were not able to carry out the “steps to correct” these deviations in a timely manner and decided that the unit needed to go into “emergency shutdown” ASAP. Problem was, there were only two of them and four operators were needed. The control room radio did not have the emergency frequency (another debate for a rainy day) and thus the operators who left for the fire (and ultimately were not needed at the fire scene and could have easily been released had they know their presence was needed back in their process) were left unaware of what was happening. The control room called the control room of the process that was experiencing the fire and word filtered down (unaware of the importance – after all, we were fighting a fire!). However, before the operators could return to their unit the process relief valves began popping, flaring began, and soon to follow were the community noise and odor complaints along with the trips to the ER with breathing difficulties, the news media requests, etc.
So the moral of this story is:
Evaluate your emergency systems as a whole. Understand the process impacts that may arise with removing in-house ERT personnel from covered processes; keeping in mind that PSM Emergency Shutdown Procedures require “the assignment of shutdown responsibility to qualified operators to ensure that emergency shutdown is executed in a safe and timely manner”. When resources are removed from the unit/process for an emergency elsewhere on the facility how will the process operators respond if they need to go into emergency shutdown mode?
