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Fire incident at Jaipur was a wakeup call

08.01.2012  |  Dutta, H.,   Oil Industry Safety Directorate, New Delhi, India

After the 2009 accident at Indian Oil's lubricants terminal, new safety standards were developed to help avoid future tragedies. The focus is as it should be, on people, process and technology.

Keywords: [safety] [accident] [incident] [fire] [regulations] [India] [Oil Industry Safety Directorate] [recommendations] [implementation]

The 2009 fire incident at Indian Oil’s Jaipur petroleum oil lubricants (POL) terminal happened while reversing the hammer blind during transfer of POL to the pipelines. Unfortunately, while this reversal was taking place, the tank body’s motor operated valve (MOV) was open. The oil spillage and vapor cloud formation that followed resulted in a devastating fire and loss of property and human life. As per normal practice, the MOV should not have been kept open while reversing the hammer blind.

The episode led to the loss of 11 lives and a property loss of around $60 million. The root cause of the incident revealed that plant personnel did not follow standard operating procedures. This terrible tragedy was a wake-up call for the industry.

Refinery vs. marketing operations

Marketing locations are spread across the nooks and crannies of India; in order to be in the vicinity of the customer base. With more than 660 marketing installations and 22 refineries in the country, the geographical spreads of marketing locations are enormous. Refinery operations are complex, with high temperature, high pressure operations taking place constantly. Marketing operations, in contrast, are not so complex, with practically no source of ignition. Refinery operations are uninterrupted seven days a week, whereas marketing operations in most of these locations are two shift operations. Marketing locations do not have their own full-fledged fire-fighting crews at their disposal, nor do they have a training center attached to the location. Furthermore, many of them are located in highly congested and densely populated locations.

Given these scenarios and constraints, it seems that marketing is perhaps more shambolic compared to refining in terms of infrastructure and environment. However, this poses a great challenge to the oil marketers in India.

Primary and secondary factors

To mitigate unsafe situations, oil companies’ approach to safety management must be systemic, encompassing both primary and secondary factors (Fig. 1). Primary safety management factors include risk analysis, hazard and operability (HAZOP) study and risk assessment. Safety measures should also be built in at the design stage, incorporating safety in instrumentation (including safety interlocks), while following best engineering practices like API and ASME codes. In addition, walk-throughs of the plant—using 3D modeling and other techniques, overseen by multi-disciplinary teams with engineers from chemical, mechanical, instrumentation, electrical backgrounds—are also helpful. Operating manuals should not only cover normal start-up, shutdown and emergency procedures, but also include disaster preparedness issues so that employees are prepared to manage smooth and safe operations under any conditions.

  FIG. 1. Safety management systems in the
  hydrocarbon processing sector. 

Secondary safety factors include fire-fighting infrastructure and facilities to address any development once an incident or accident happens due to a failure of the primary safety systems, as outlined previously.

The Oil Industry Safety Directorate has developed a number of safety standards (112) to be implemented by the oil industry in India. The directorate undertakes audits at regular intervals, including surprise safety checks, to oversee the implementation of the safety standards and to point out gaps that may exist in a particular company’s approach. Accidents are investigated and root cause analysis is shared with the industry, not for the sake of fault finding, but rather to learn from the mistakes and avoid recurrence. Thanks to this approach, the number of accidents in India has been reduced over the last three years.

A close analysis of the accidents that took place in the last three years shows that a majority of the incidents have taken place due to:

  • Not following the standard operating procedures
  • Poor upkeep of equipment and assets
  • Knowledge gaps.

To meet the objective of no incidents in the oil industry, the leaders of the industry recognized the need for a paradigm shift in safety management approaches. Foremost is the belief that accidents can be prevented. The second is a renewed focus on learning, unlearning and re-learning (applicable not only to full-time employees but also to the large number of contract laborers that work in oil installations), coupled with strict adherence to standard operating procedures. The third important factor is that of asset integrity management.

Emphasis on learning

The successful absorption of any technology or process depends on how it has been assimilated by the plant personnel. Accidents take place due to:

  • Incorrect operations
  • Not properly maintaining the equipment or facilities
  • Not following procedures
  • Knowledge gaps.

Thus, it is evident that the success of any improvement effort, namely managing safety or improving productivity or gross refining margin, depends upon the employees.

In India, it is mandatory that all new entrants to oil installations must successfully complete fire and safety training. The training encompasses both classroom inputs and onsite drills. Refresher programs are conducted at all the installations. The training materials are critically reviewed, radar charts are developed for each operating crew, and needs-based training sessions are included.

Training for all contract employees has also been made mandatory. Identification of critical workers like riggers, welders, electricians, crane operators, and drivers selected by outsourced agencies includes periodically monitoring and assessing their competencies.

The directorate demanded that industry identify and give a critical task analysis of high-risk jobs. It encouraged periodic observation of the critical tasks by a supervisor, followed by a discussion with the operating personnel.

Mock drills have become a regular feature of safety preparedness training for employees, as the outcome of each drill is critiqued for lessons learned, and then action items are discussed, corrected and completed in a timely manner.

Another aspect of the renewed focus on quality assurance and preventive maintenance programs examines: pressure vessels and storage tanks; piping systems, including valves; relief and vent system devices; emergency shutdown systems; monitoring devices; sensors, alarms and interlocks; inspection techniques; and pumps and compressors.

Standard operating procedures

Each element of standard operating procedures (SOPs) is now discussed with the plant operators and technicians to provide clarity for all participants. It is vital to have SOPs that are properly understood by the personnel who are responsible for following and implementing them. The SOPs should be regularly updated and displayed at a location near critical equipment.

The concept of equipment ownership and “know your equipment” (KYE) was brought in. This is aimed at improving ownership and accountability. More emphasis on visual management and its display at appropriate locations to eliminate operational mistakes has been put into practice.

Asset integrity management

Employees and supervisors should constantly be concerned about proper facilities maintenance. While it is easy to build facilities, it is more challenging to maintain them in a “like new” condition. Unless asset reliability is monitored consistently, the various safety devices associated with the plant may not work.

The remote operated device that was supposed to shut off the MOV at Jaipur did not function properly. A similar thing happened at the Buncefield, UK, terminal, where the high-level tank indicator did not work appropriately. If it had, it could have prevented such a huge loss of life and property.

Oil companies today are putting more emphasis on safety through intense reliability testing, properly scheduled maintenance of rotary equipment and inspection of static and rotary equipment. Storage tank maintenance and inspection schedules are followed and not unnecessarily delayed. Pipelines are receiving periodic health checks and troublesome equipment replaced wherever necessary. This shows that the the emphasis is on maintaining assets in a “fit-for-use” condition all of the time.

The significant aspect of asset integrity involves people and their development. Unless the human assets are equipped with adequate knowledge and skills, motivation and a climate for fostering innovation, it is impossible to achieve the desired results.

Post-Jaipur: Other safety measures

Reversing a hammer blind is always problematic, as there are chances for accidental spillage. To eliminate hammer blind reversal as a potential hazard, India decided post-Jaipur that all hammer blinds throughout the oil industry would be replaced by double block and bleeder valves or plug valves. At many locations, this has already been implemented. Another post-Jaipur safety decision was to replace the tank MOV with remote operated shut-off valves (ROSOVs), which can be operated from the control room (with the cable leading to the control room being fireproof). ROSOVs also have the additional benefit of operating the same from the field through a switch located outside the tank dike. This changeover from tank MOV to ROSOVs is underway across the country.

To prevent tank overflow, a separate hardwired independent switch with a high-high level alarm in the control room has been proposed to bolster the normal high level alarm from the radar gauge. The additional high-high level alarm from the independent switch would actuate an emergency shutdown switch to shut off the ROSOV. These additional layers of protection, which are under various stages of implementation, are aimed at further enhancing the safety of oil installations.

Visible change

A visible change has taken place in the attitude of top management. The attitude toward safety has changed from being reactive to being proactive, following philosophical shift from preventive to predictive. Routine training programs have been expanded to increase learning opportunities for employees, and top leadership is now accepting dissent views as a valuable resource.

The focus is as it should be, on people, process and technology. Industry management should recognize that when people, process and technology work in cohesion, surprises can be eliminated, safety can be improved and profitability can be increased. HP

  FIG. 2. The safety triangle illustrates that when
  people, process and technology work in tandem,
  there is always a significant reduction in surprises. 

The author

Hirak Dutta has a bachelor’s degree in chemical engineering from Jadavpur University in Kolkata, India. He is currently executive director of India’s Oil Industry Safety Directorate. Mr. Dutta has over three decades of experience in the oil industry, including operations, process engineering, troubleshooting, project management and human resources management.

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Hemant Sharma

Very nice informative article for oil field personnel.

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