Pena 2, Seco" MON 7804 Savi 91 102353000 2a. meat ew ogo Date, 28/05/18 CRIES OIL INDUSTRY SAFETY DIRECTORATE Ref O1SD/PRE/GEN/O7 To Director (Refineries) TOCL, BPCL, HPCL, MRPL MD-CPCL,MD-BORL,MD-NRL Sub: Shortcomings/deficiency observed frequently during OISD audit. Dear Sir, 8 As you are aware, OISD, through industry experts conducts safety audits of Refineries and the audit observations are shared. While communicating the audit observations, OISD advises thé Oil Companies that the findings of this inspection may be shared/disseminated to all concerned including other Refineries for corrective actions, if any at their end. However, it 1s observed that despite this, there are still some common shortcoming/deficiencies observed during. the OISO audits which can be addressed after a vigorous review at respective Refineries. Some of such observations are detailed below: A. Process Safety: = During the last few months incidents have significantly increased in Refineries and same resulted into fatalities. Such accidents could have been avoided by adhering to the extant systems & procedures and taking additional precautions in operations and maintenance. It is observed that many incidents are due to disregard of SOP and not having proper job safety analysis (JSA). + Before every start-up of the unit functionality test the ROSOV necessarily carried out and recorded. = Hazop study to be carried out every five years or wherever there are changes in « process / layout whichever is earlier. Pending Risk Analysis / HAZOP recommendations need to be liquidated which are not followed religiously. + To ensure the safety interlocks are not kept bypassed for enhancing operational safety In exceptional cases, bypassing of interlock if required to be done with proper approval and availability of mitigation plan. It is observed that autherity level of bypassing the interlock in all Refineries are not consistent and also relaxed in many Refineries ( one typical policy for bypassing interlock is attached as annexure-I as a ready reference which may be followed.) + For LPG, Propylene, Propane etc storage vessels, the draining connection shall be given at downstream of ROV at bottom line and water shall be drained through a Dead man valve( ball valve with spring return handie) to enhan :e safety. The same is not installed in some of the refineries. ” xh rage otaBreak-away Coupling was not provided in the LPG loading aris. ur ny locations The toading arm shall be provided with breakaway couplings to safequert catastrophic hose failure as per clause 6.3) of OISD-STD 144, An isolation valve shall also be provided before the breakaway coupling Use of non-comatible end connections for nitrogen lines at Utility station to eliminate and avoid inadvertent opening and usage of Nitrogen instead of Air or vice versa. The ‘same is not fully implemented across the refineries. Double mechanical seals are not provided in many locations for pumps handling fluid containing Toxic, Carcinogenic and Corrosive Fluids, Lighter hydrocarbon, fluids having Potential for auto Ignition/ Vaporization at operating temperatures as per OISD-STD- 125(Clause n0:4.4.1 84.4.2). The vent height of OWS shall be 3 metre above the nearest tallest structure within 15 ‘metre radius as per O1SD-STD-109 which is not meeting many locations, Close loop sampling system should be provided for all sample points with an objective to avoid/minimize Hydrocarbon draining / venting to atmosphere which is not available many places and it is to be strictly implemented for all petroleum products and hazardous/toxic chemicals as per OISD-STD-109 (clause no:5.2.4) . Asset Integrity: Overdue M&I of tanks is a perennial problem in many refineries. M&I of overdue storage tanks / sick tanks (eg roof perforation, bottom plate leakage, shell plate leakage.) shall be completed on priority. It is observed that clamps in hydrocarbon fines in many locations are not attended. Clamps in hydrocarbon lines shall be eliminated. Repair / replacement of the clamped hydrocarbon lines shall be carried out on priority to avoid risk of leakage and consequential fire hazard. Integrity of gasket and flange joint of critical areas needs to be focused as many incidents are due to failure of the same. Monolithic isolation joints shall be provided for mounded bullets for effective cathodic protection. Maintenance of cathodic protection system of LPG mounded bullets are not in’ order in many locations of the refinery to be ensured all the time so that mounded bullets are protected from corrosion. : Redundant pipelines / assets are kept idle and use in future is also uncertain in many locations. The same is to be identified and removed from the Refinery to make the area clean and to avoid safety hazard. Metallurgy mismatch observed in pressure equalization valve of high pressure line and small bore piping. Hence, Positive Material Identification (PML) of the same needs to be carried out to ensure metallurgy compatibility. Page 2084C: Fire and Safety «provision of clean agent firefighting system 14 not available wn some control rooars and should be provided to enhance safety = Simultaneous hot work and commissioning activity should not be allowed as a increases the hazard potential arid chances of accidents at site «Water sprinkler to be provided for pumps handling hydrocarbons above auto ignition temperature and for the column with height more than 45 meter which are missing in some locations. D: Safety Gaps: «Use of non-sparking tools 1s mandatory particularly while working in hydrogen / LPG ‘environment. The same is not being followed in many locations. «= Deviation in inter distance norms as per OISD STO'118 particularly for old installations leading to significant risk. Appropriate gap analysis and risk mitigation measures are needed. «Use of spark plug vehicles shall be restricted in Refineries as per M B Lal Committee recommen ‘already prevailing in many Refi panera = Storage tanks Dykes are not made impervious for avoiding ground contamination which may be planned in Refineries. 5 + Many places, control room are not single storied building as per OISD-STD-163. Also tst floor Is occupied by engineers/operating persons in some control rooms, This needs to be discontinued with immediate effect. : «Health monitoring to be done’ for hydrocarboh pipelines passing through public places * outside the boundary of the facilty/Refineries to maintain integrity. «At many location, hydra was found to be used for transportation of Pipes, Valves, Exchangers ete which is unsafe and leads to accidents. Hydra shall not be used for transportation of materials. E, Electrical : «In case of floating roof tank, the tank shell should be bonded to the floating roof through bypass conductors in line with API-RP-545. Bypass conductors should be evenly spaced not more than every 30 meters around the tank circumference with 2 mrinimum of two. This recommendation was given in IOCL Vadinar Oil Terminal Tank fire. = LOTO (lock out tag out) must be implemented wherein production & maintenance {groups shall provide individual locking & tagging on isolated HT/ LT switchgears to gheure avoiding untoward incident & exercise control over the hazardous situations There should be frequent verification of work permit system by higher level official w.r.t OISO-STD-10S to ensure no deviation. F. Tank Lorry Filling - Tank lorry filing gantry wherever applicable, the following needs to be ensured: | Pope 3 of 4working at hewht for cera + Provision of fail arrestor not ensured whil oper ation like TT sealing and TT calibratio - Gantry swing ladders are not having standard cesign #9 NO provision of Nand railing. = Leakage / spillage observed during loading operation G. Suggestions for improvement / modernisation: + As-a modernization plan for fire extinguishing system, Refinery should consider trolley mounted water mist cum compressed air foam (CAF) technology for the critical locations such as hot pumps having fluids above auto ignition temperature like CDU, VOU, Coker, FCCU, HCU etc. bottom pumps. Refer OISD STD 116 clause no. 11.1 (vii) = Good practice to use fire retardant suits / coverall by all the personnel while working inside the operating plant. This is already in practice in various organizations. + Good practice to earmark the area of parking the ambulance near the process units/facilities to avoid panic during emergency. + Automatic recorded announcement on activation of manual call point (MCP) is also ‘good practice. This is already in practice in some organizations. Neutralizing agents available for various hazardous and toxic chemical like H2S, CO etc. to be explored for immediate and quick solution so as to eliminate/avoid hazard potential at the site. 2 = It is observed that presently conventional SCBA cylinders which are being used are heavy and made of MS and prone to corrosion, crack. Equipment should be light weight with comfortable shoulder hamess as per clause 8.7 of OISD-115. In order to overcome this, composite cylinders are also available which are light weight and corrosion free. These light weight composite cylinder based SCBA can be explored for effective usage by Fire/working personnel. «DCP Fire extinguishers which are presently being used are made of steel. These conventional fire extinguishers are having some practical problems like heavy weight, atmospheric corrosion etc. Fire extinguisher made of HOPE/composite are also available now a days having various capacities with less weight and longer life. These extinguishers are very useful for offshore assets, refineries in coastal areas etc In order to provide renewed impetus for safety improvement, reguler quality Internal Audit must be carried out by muti-disciplinary teams to identify the gaps so as to eliminate hazards and achieve “Zero” incidents in industry, We trust suitable advisory to this effect would be issued for enhancement of safety. Ae se (V.) Rao) Executive Director Thanking you, CC:35(R), MOPNG, New Delhi: for information please. Page 4 of 4