Process Safety Beacon: Not Sure? Ask

▲ The left column illustrates how operators removed the gearbox on the day of the incident, unnecessarily removing the entire support bracket. The right column illustrates how the gearbox should be disassembled, which includes removing the two horizontal bolts on the side of the bracket to disconnect the gearbox and handwheel from the support bracket. Image courtesy of the CSB.

I sobutane was released and formed a flammable vapor cloud that reached an ignition source within 30 seconds. The subsequent fire seriously injured four workers at the refinery in Baton Rouge, LA, in Nov. 2016. The incident occurred as operators were removing an inoperable gearbox on a plug valve. The operator removed critical bolts that secured the pressure-retaining components of the valve, i.e., the toe-cap. The operators had not been given a written procedure or training on safe gearbox removal from plug valves and the associated hazards of improper removal. Instead, they were forced to perform the task based on what they thought was correct. (Read U.S. Chemical Safety Board (CSB) Report No. 2016-02-I-LA for more information on this incident.)

There can be a vast difference between what you “think” and what you “know.” Operating based solely on past experience, assumptions, guesses, or what you think increases the chance your actions could be wrong. Knowing means acting on what has been determined to be correct based on accurate information and procedures. It is better to delay the operation and confirm the correct actions than proceed and potentially cause an upset, spill, or worse.

Did You Know?

• Operations in a chemical facility require a high degree of discipline, which includes doing the right thing the right way every time.
• The chemical process industries (CPI) are working to computerize basic control systems. If personnel do not understand the processes and system capabilities, they make take the wrong action and problems can become worse.
• No matter what job you perform, doing it correctly is important. Some errors are more detectable than others. If an error is less obvious, the consequences may not be immediately evident.

What Can You Do?

• If you do not know, ask. Feeling that you look stupid for asking a question is far less problematic than if you were to cause an accident. Your question may benefit others, as well as the overall process.
• Stay informed about all procedures related to your job and follow them. If you see contradictions, ask for clarification.
• Respect the advice of others if they point out your mistakes. When you see others about to make a mistake, ensure they understand the potential issue you see.