(116af) Bouncing Back from a Heart-Wrenching Process Safety Incident

During startup of Urea Fertilizer Plant after a brief shutdown, due to recurrence of a leakage, the field maintenance team was inspecting top head gasket of condenser on a 31-ft high platform when Carbamate solution splashed on the workers. They tried to escape via monkey ladder but fell down one after the other resulting in loss of life of one of the employees and hospitalization of other four.

Detailed incident investigation by a multi-disciplinary team highlighted number of gaps related to human elements, job handover/execution and crisis management. The incident occurred due to failure of multiple layers of protection including management of change, mechanical integrity, risk assessment, PTW, job supervision, fatigue element, over-occupancy, communication, training & development, emergency response, PPEs etc.

Interestingly, this happened in less than 3 years after successful compliance certification of Process Safety Management System but raw material unavailability and resulting financial crunch hugely jeopardized organization’s process safety management system and safety culture.

The paper will cover this eye-opening case of huge PSM deterioration in very short time due to financial factors and how did the organization bounce back from that desperate situation. It will shed light on causes of incident, lessons learning and results achieved after revamp of the process safety management program. It will enable other participants to learn from story of our setbacks & revival, and implement similar cultural shift programs in their respective organizations.