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CPP
HINDUSTAN ZINC LTD
TABLE OF CONTENTS:
1. Cover Page
2. Table of Contents
3. Membership Signature Page
2. Introduction
1. Summary of Process Description and Scope of Review
2. Summary of Recommendations
3. Team Membership and Qualifications
4. Field Tour
3. Discussion
1. Process Description
2. Process Diagrams
3. List of Hazards
4. Detailed Discussion of Recommendations
5. Inherently Safer Process Considerations
6. Discussion of Items Not Resulting in Recommendations
7. Discussion of Consequence Analysis
8. Discussion of Consequences of Failure of Engineering and Administrative Controls
9. Discussion of Human Factors
10. Discussion of Facilities Sitting
1. Charter
2. Hazards Identification Details
3. Technology Package Documentation
4. Management of Change Documents
5. Serious Incident Reports
6. List of Prior PHAs and Recommendation Status
7. Consequence Analysis
8. Human Factors
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9. Facilities Siting
10. Hazard Evaluation Methodology Documentation
11. PHA Completion Checklist
12. References
13. Additional Tasks Documentation
14. Communications Package
15. Transmittal Letter to Emergency Response Committee
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This report represents the consensus of the full-time PHA team. Based on the information analysed in this study, to
the best of our ability we believe this process to be safe to operate1 in its present condition.
B L Chouhan ---------------------------
(PHA Team Member) Date
HAZARD IDENTIFICATION:
Process Description
1. Filtration is the process of passing liquid containing suspended matter through a suitable
porous material (filtering medium) to effectively remove the suspended Impurities in the liquid.
Filtration is the final step in the solid removal process which includes coagulation, Flocculation and
sedimentation . The purpose of filter as mentioned earlier is to remove the particulate impurities
and floc from the water being treated
2. Pressure Filters are closed cylindrical vessel either vertical or horizontal (mostly vertical)
containing the filter media over a collector system. Water flows from top downwards percolating
through the media and is drawn off through the collector system at the bottom. Cycle of
operation are service, back wash with or without air scouring, short rinse to waste and return to
service. Increase in pressure drop indicates that filter media is fouled and requires backwashing.
The following materials are normally used as filter media - Quartz sand, silica sand, anthracite,
coal, garnet etc.
Filter which uses only sand is called sand filter. Filter which use two media (normally sand and
anthracite) is called dual media filter. Multimedia filter uses more than three or more filter media.
Dual media and multimedia filter operate at higher velocity and require less backwash water.
Back wash water for filters should always be filtrate water.
3. Trouble shooting of Pressure filter - Pressure filters are basically very simple in operation and
normally does not give much problem. The final effluent from filter if is not of required quality
then the reason could be more because of preceding steps and if there is only filter & no
coagulation then it is because of Pressure filter not being backwashed regularly. A chart for
trouble shooting is shown below.
Mud ball formation change in raw water quality 1) Air scour and give extended
backwash
2) Check pretreatment steps if any.
Adjust if Necessary.
3) Decrease Velocity
4) Change media if required
4. Water testing- Turbidity Turbidity and suspended solids are two things which are measured to
see if the filter is operating properly. Turbidity is simply an expression for cloudiness of water.
Turbidity is caused by suspended matter like Silts, finely divided organic & inorganic matter and
microscopic plant like algae. In larger plants there is generally an online turbidity meter and in
smaller plants the test performed is basically a visual one i.e. by comparison. A standard water
whose turbidity is known is taken in a glass tube .This becomes the reference and the filtered
water is compared with this water. If more rigorous testing is required than the water is sent to
sent to a laboratory.
1. Carbon filtering is a method of filtering that uses a bed of activated carbon to remove
contaminants and impurities, using chemical adsorption.
Each particle/granule of carbon provides a large surface area/pore structure, allowing
contaminants the maximum possible exposure to the active sites within the filter media. One
pound (454 g) of activated carbon contains a surface area of approximately 100 acres (~40
Hectares).
2. Activated carbon works via a process called adsorption, whereby pollutant molecules in the
fluid to be treated are trapped inside the pore structure of the carbon substrate. Carbon filtering
is commonly used for water purification, in air purifiers and industrial gas processing, for example
the removal of siloxanes and hydrogen sulfide from biogas. It is also used in a number of other
applications, including respirator masks, the purification of sugarcane and in the recovery of
precious metals, especially gold. It is also used in cigarette filters.
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3. Active charcoal carbon filters are most effective at removing chlorine, sediment, volatile organic
compounds (VOCs), taste and odor from water. They are not effective at removing minerals, salts,
and dissolved inorganic compounds.
4. Typical particle sizes that can be removed by carbon filters range from 0.5 to 50 micrometres.
The particle size will be used as part of the filter description. The efficacy of a carbon filter is also
based upon the flow rate regulation. When the water is allowed to flow through the filter at a
slower rate, the contaminants are exposed to the filter media for a longer amount of time.
5. Testing - Turbidity Turbidity and suspended solids are two things which are measured to see if
the filter is operating properly. Turbidity is simply an expression for cloudiness of water. Turbidity
is caused by suspended matter like Silts, finely divided organic & inorganic matter and microscopic
plant like algae.
6. Trouble shooting -
Problem Cause Action
1. It will contain free mineral acidity (FMA ) nearly equal to equivalent Mineral
acidity (EMA) in the feed water.
2. It also contains free CO2 generated by the alkaline salts present in raw water.
3. Hardness of cation effluent will be nil.
4. The only cation from the feed that is present in the effluent is the sodium ion that has slipped
through column .
5. The difference between the EMA in the feed and the FMA in the effluent gives the sodium
slip from the cation unit .
6. The sodium slip from cation unit is a function of Regeneration level, the sodium content of
the raw water and the EMA of water .
7. Therefore For a given water & Regeneration level the sodium slip is fixed. This is the
average value of the sodium slip over a cycle .
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8. The actual slip characteristics shows high slip at the start of a run and thendrops to a
constant value for a major portion of the run and then rises again near exhaustion .
9. This pattern of slip is true for Co – flow units .
10. The slip for counter current unit is constant throughout the run .
11. The FMA in the effluent drops at exhaustion and the pH rises indicating that
exchanger should be removed from service.
R SO3 H + MgSO4 R Mg +
NaCl Na H 2 SO4
Ca CaCl 2
R Mg + HCl RH + MgCl2
Na NaCl
Over exhaustion of unit Normal acid will not restore capacity increase acid
quantity.
beads.
Higher flow greater than normal Increase Na/TC has more profound effect on leakage
design range increases leakage from increased flow rate
Low flow rate The flow rate should be maintained above 0.5
GPM/ft3 of resin.
Temperature Does not have much effect except for very low
temperature
Hardness in Raw water Valve leakage, High flow rate, change in Raw water
composition . Inefficient regeneration
WATER ANALYSIS –
In SAC conducted analysis pH , Conductivity , Hardness and Sodium.
4. DEGASSER
1. The function of degasser is to remove CO2
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2. The residual CO2 in degassed water corresponds to the solubility of CO2 in water at that
temperature . The analysis of degassed water will be same as that of cation effluent but
the CO2 content will be about 5 ppm, dependingupon the actual ambient condition .
Problem Cause Action
High residual CO2 from Choked suction filter Check and Clean
Degasser.
discharge pressure.
Broken air seal. Air seal not Check and replace fitting
fit. Results in Short circuiting provide air seal.
Dirt/Dust in air(Normally Degasser sucks dust and dirt Install air filter Periodic
in Cement and Allied into water This can lead to cleaning of suction filter.
Industries clogging of Anion unit.
1. All Anions including silica are absorbed by Strong base Anion exchanger .
2. The effluent is demineralised water having trace cation & Anion .
3. The SBA effluent will Not contain chloride and sulphate.
4. At normal regeneration level , the silica of SBA outlet water will be less than 0.5 ppm as
SiO2.
5. Silica leakage is a function of regeneration level, temperature of regenerant SiO 2/ TA ratio
and the sodium slip from the cation unit .
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6. There will be some amount of P Alkalinity which will be depend upon the sodium slip from
the preceding cation unit.
7. P Alkalinity directly reflects the sodium slip from the cation unit . A slip of ppm sodium gives
P value of 1 ppm.
8. Conductivity and pH are also dependent on sodium slip . One ppm of sodium slip will give
a conductivity rise of 5 to 6 Micro Siemens / cm2 and a pH of 8 to 9
9. The functioning of anion unit is largely depend upon the functioning of the preceding cation
unit.
10. A conductivity of 30 micro mhos and pH of 8- 9 is considered satisfactory for a two bed
system.
11. A rise in conductivity at anion outlet will indicate exhaustion of either cation or anion unit .
12. Rise in conductivity with a drop in pH of anion effluent indicate exhaustion of anion unit .
13. Rise in both conductivity and pH indicates exhaustion of cation unit .
14. If silica is considered for determining the breakthrough point of anion bed than actual silica
determination must be done at regular intervals .Basic titration equipment are necessary
for smooth operation of DM plant.
15. ANALYSIS , pH , conductivity , sodium , Hardness, Silica to be conduct for performance of SBA.
16. TROUBLE SHOOTING
Loss of capacity Increase in EMA in raw water Add more Resin, Increase regenerant
chemical for plant in use.
Poor treated water Chloride in treated water Check cation, Analyse regenerant for
quality chloride, Regenerant valve leaking
(Check). Chloride leaking to sodium
leakage normal.
regenerant valve).
High sodium content in treated Resin escapes from cation unit to WBA
water unit due to Broken laterals. Check, give
more rinse.
Mixed bed is better than using first one ion exchange resin to remove cations and then
another to remove anions because having both resins in very close proximity creates a
stronger driving force as the hydrogen ion exchanged at one resin attracts a hydroxyl ion
from the other resin to form water.
Deionised water is usually an excellent substitute for distilled water and is less expensive.
The mixed bed process is conducted in plastic vessels to resist acid corrosion, and faulty
balancing of flows during regeneration can generate so much heat from acid reacting with
base that steam forms and the plasitic melts, but with proper flow adjustments and
automation, mixed bed ion exchange is quite reliable.
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List of Hazardous
Skin or Cancer
MSD Flammabl Dust Corrosive to
Chemical Toxicity Reactive Eye agent or
S No. e Explosion human body
irritant Mutagen
CORRO
SIVE
TO
EYES &
NON SKIN.
Aluminum ORAL (LD50):
FLAMMA SKIN
Sulphate , CAS# NOT Acute: >9000
BLE NOT Reactive with CONTA
Hydrated :7784- APPLICABL mg/kg [Mouse]. NA
APPLICABLE oxidizing agents, CT
(ACS & 31-8 E >9000 mg/kg
(IRRITA
FCC) [Rat]
NT,PER
MEATO
R) EYE
CONTA
CT(IRRI
TANT
Skin
Conta
ct:
Remove Wash
exposed with
person soap
Poly and
electrolyte Not to fresh
EC 50 (Alga, 3 No data water CARCINOG
, Flammabl air if Not applicable
d): 307 mg/l available ENIC
ClearFloc e adverse . If
34 skin
effects
are irritati
observed on
occur
s, get
medic
al
HINDUSTAN ZINC LTD
attent
ion.
Eye
conta
ct:
Any
mater
ial
that
conta
cts
the
eye
shoul
d be
wash
ed
out
imme
diatel
y with
water
. If
easy
to do,
remo
ve
conta
ct
lenses
with
cyano
sis or
pale
color
Eye
conta
ct:
Sever
e eye
irritati
on,
wateri
Water, ng,
Acids, redne
NAWear Flammabl
full face ss
Inhalation, e liquids, and
respirator Corrosive to Organic
acute and swelli
s mucous halogen
repeated ng of
approved membrane, compound
exposure, rat, the
by eyes and s, Nitro
target organ: eyelid
NIOSH/ skin. compound
respiratory s.
MSHA if Fatalities s,
system, Burns
dusts are have been Amphoteri
CAS corrosive effect. . Risk
Sodium Not expected observed c metals,
No- Oral route, after of
Hydroxide Applicabl or repeated after a such as seriou Not listed
1310_
(NaOH) e exceed exposure, rat, single aluminum s or
73_2
establish target organ: dose of 5 erod, perm
ed gastro-intestinal grams and magnesiu anent
system, more taken m,zinc, eye
exposure
corrosive effect. copper lesion
limits. by an adult
In vitro, no and alloys. s.
Leather weighting 70
mutagenic Reacts Risk
is not kg.
effect with all of
recomme blindn
materials
nded ess.
to release
Skin
hydrogen conta
ct:
Painf
ul
irritati
on,
redne
ss
and
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swelli
ng of
the
skin.
Risk
of
sever
e
burns;
slow
healin
g.
For easy identification of the inherent hazards, the main units in the boiler section are classified as unit
operations and/or processes and listed in Table below.
Special Hazards:
Appearance: clear colorless - oily liquid. Danger! Corrosive. Causes eye and skin burns. May
cause severe respiratory tract irritation with possible burns. May cause severe digestive tract
irritation with possible burns. Cancer hazard. May cause fetal effects based upon animal studies.
May cause kidney damage. May be fatal if inhaled. May cause lung damage. Hygroscopic. Strong
oxidizer. Contact with other material may cause a fire. May cause severe eye, skin and
respiratory tract irritation with possible burns.
Target Organs: Kidneys, heart, lungs, respiratory system, cardiovascular system, teeth, eyes.
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CONSEQUENCE ANALYSIS:
Operation of DM plant capacity 15 m3 X 2 ,divided in two part one stand by one in operation. Normal
operating procedure , one stream run continue after reaching OBR running stream will goes into
regeneration where we are using 98% H2SO4 sulphuric acid & 48% NaOH caustic. Those chemical are very
dangerous which effect in all kind of hazardous inhalation, skin injury, eye injury, ...etc.
In spite of the effective process control systems integrated with this operation, many of the hazardous
situations listed above could be realized and cause damage and injury to personnel. Hence the
consequence of these hazards are discussed below under the following headings,
Receiving bulk chemical tankers, as per SOP we have to collect the sample for purity test analysis before
start any offloading chemical from the tanker. Sampling of the bulk chemical is handling a manual process ,
person has to take sample him self from tanker top manhole with help of appropriate ppe’s .
Sampling process involve two hazards, fall protection and chemical handling.
1.1 Normally whenever received new chemical operator should visit to tanker verified that everything
from the tanker are on place well, like sealed of all valves, manhole, driver does have knowledge of
the hazardous chemical which he is carried with , Trump card of tanker., driving lincese, does driver
have proper ppe’s ....etc.
1.2 Next step , after verifying all things operator start activity to take sample , first of all operator will
come up with all required ppe’s and sample bottles, with help of tanker driver/helper operator is
start collecting sample.
1.3 Operator will claim on the tanker with safety harness and ppe’s along with Sample bottles. Put
down the sample bottle from the top manhole and collect the saturated sample.
1.4 Collected sample will bring it down manually by operator which dangerous, sample bottle may slip
from the falling device and injure to involve personal nearby.
Sample bottle may possible fall down & spillage to person who is near by offloading area.
As part of SOP after collecting sample , & verification of result operator will start offloading of bulk
chemical from the tanker to DM plant storage tank with help of offloading pump and offloading PVC hose
pipe.
2.1 First connect the hose pipe from offloading pump to tanker drain point with help of flange.
2.2 After connection of hose , operator should verify all the system in place properly.
2.3 Open the valve from the tanker , and pump suction valve, discharge valve. Priming need to be done
prior to start pump to avoid any damaged.
2.4 After priming start the offloading pump , while running or starting of offloading may chances of line
rapture , flange leakages, pump gland leakages, etc... which are the hazard for the person who are
involve in the offloading activity. It may also spill to person body and make harm injury.
2.5 Immediate action to be taken in case of spillage on human body, person should know the
Depotherene kit use, immediately have to use the depoterene kit and safety shower.
2.6 Leakages will spill on the floor or ground , that case used to spill kit to immediate neutralized the
high concentrated solution.
As part of SOP we are transferring high concentrated sulphuric acid 98% to preparation tank which
is located in DM plant house near by storage tank of sulphuric. Normal operation we used solution
from the Acid preparation tank to do the regeneration of Ion exchanger in DM plant , Acid
preparation tank is made for dilution of the required concentration to the Ion exchanger where we
are doing makeup with water in Acid.
3.1 Open the filling valve at sulphuric acid preparation tank,
3.2 Open Bulk storage tank discharge valve to acid preparation tank.
3.3 Acid preparation tank capcacity 1 m3, where we normal operation used to prepare chemical as
follow,
30% of Acid from the acid storage tank &
70% of water from the DMST .
3.4 During this transfer / preparation – there are chances for leakage from flanges, level guage, tank
leaks…. Which is most critical hazards to the personal who involving in the activity,
3.5 Immediate action to be taken in case of spillage on human body, person should know the
Depotherene kit use, immediately have to use the depoterene kit and safety shower.
3.6 Leakages will spill on the floor or ground , that case used to spill kit to immediate neutralized the
high concentrated solution.
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As part of the SOP DM plant ion exchange vessels are fully loaded with respective resin, resin are
required to do chemical cleaning as per its own ion exchange capacity. Normal operation every 24
hour we have to do regeneration of ion exchanger, during the regeneration we used 5% sulphuric
acid to regenerate resin, which involve hazards, like during the regeneration isolation valve may
leak, tank leak, flange leak….etc.
Worst case analysis
1. Human injury , burning hazard
2. equipment damaged due to spill on the floor on equipment.
3. Land contamination-environmental hazards
4. Causes cancer.
The “what if“methodology is a powerful process hazards evaluation technique that results in
1. Comprehensive identification of a broad range of hazardous incidents
2. Consensus by a wide range of disciplines on the recommended path to safely controlling hazardous incidents
The “what if” approach combines the strengths of a ªwhat ifº review and a checklist review into one methodology that
effectively avoids the weaknesses of using either methodology by itself. The finished product of a “what if” process
hazards evaluation is an understanding by the organization of the potential hazardous incidents associated with a given
process, the lines of defence in place, the consequences of breaching the lines of defence, and the controls needed to
ensure safe operation.
The PHA team selected the “what if” methodology for the hazard evaluation in the process.
HINDUSTAN ZINC LTD
WHAT IF
LIKE
Session/ RISK
Consequen Safeguard SEVER LY- Rema
node/ What-if Hazards RANKI Recommendations
ces s ITY HOO rks
system NG
D
1. SOP /
SMP
no……
2. Acid
proof
1. Blind on
1. Land suits
offloading hose
contaminat 3.
pipe after
ion. dephoter
completion
2. Burn ene kit
offloading,
Release injury 4. Spill kit
Spillage 2 5 10 SOP/SMP to be
Acid 3. 5.
revised
Equipment Secondary
accordingly.
damage containm
2. SOP to be
4. Cause ent
prepared for acid
cancer 6. Acid
spillage.
proof
floor
7. Safety
Acid shower
Offloadi
ng
1.
dephoter
ene kit
1. Land 2. Spill kit
1. Provision to be
contaminat 3. N-
made for new level
ion. pit/dyke
switch installation
2. Burn wall
2. High level
tank Release injury 4. Acid
4 3 12 interlocking to be
overflow Acid 3. proof
provide
Equipment floor
3. High level alarm
damage 5. Safety
, siren
4. Cause shower
cancer 6. Level
transmitt
er
7.Level guage
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1. Standard
offloading hose to
be used.2. 100%
Flange guard
availibility.3.
Above points to be
1.
covered in PMI,
1. Land dephoter
SAP based.4.
contaminat ene kit2.
Monthly availibility
ion.2. Burn Spill kit3.
record of
Release injury3. Safety
Leakages 3 5 15 Dephoterene kit &
Acid Equipment shower4.
spill kit.5. Acid
damage4. Flange
proof full face
Cause guard5.
Respirator to be
cancer SAP Based
procured. 6.
PMI
Diphoteren
cylinder
availibility7.
Periodic thickness
measurement of
Pipe line.
1. Purity
Acid
analysis
tanker
1. Property 2. 1. SOP to be
connect to
Explosio damage Chemical revised
other 5 2 10
n 2. Serious document 2. Color coding of
chemical
injury s tanks & hose pipe.
offloading
varificatio
point
n.
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1. Property 1.
Tanker Release damage SOP/SMP
2 3 6
squeezing of acid 2. Serious 2. Tanker
injury inspection
Chemic
Awarness to
al
concern for
Re use of Contact 01.Minor
2 5 10 using(Rinse after
PPE with Injury
using) of acid
Human
proof suits.
Body
1. SOP /
SMP
no……2.
Chemical 1. Blind on
1. Land proof offloading hose
contaminat suits3. pipe after
ion.2. Burn dephoter completion
Caustic 1.
injury3. ene kit4. offloading,
Offloadi Spillage Release 1 5 5
Equipment Spill kit5. SOP/SMP to be
ng caustic
damage4. Secondary revised
Cause containm accordingly.2. SOP
cancer ent.6. to be prepared for
Safety caustic spillage.
shower.7.
Acid proof
Floor
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1.
dephoter
ene kit
2. Spill kit
1. Land 3. N-
1. Provision to be
contaminat pit/dyke
made for new level
ion. wall
switch instalation
2. Burn 4. caustic
1. 2. High level
tank injury proof
Release 4 3 12 interlocking to be
overflow 3. floor
caustic provide
Equipment 5. Safety
3. High level alarm
damage shower
, siren
4. Cause 6. Level
cancer transmete
r
7. Level
guage
1. Purity
caustic
analysis
tanker
1. Property 2. 1. SOP to be
connect to
Explosio damage Chemical revised
other 5 2 10
n 2. Serious document 2. Color coding of
chemical
injury s tanks & hose pipe.
offloading
varificatio
point
n.
1. Property 1.
Release
Tanker damage SOP/SMP
of 2 3 6
squeezing 2. Serious 2. Tanker
caustic
injury inspection
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1. SOP /
SMP
no……2.
1. Land
Acid proof
contaminat 1. SOP to be
suits3.
Samplin 1. ion.2. Burn prepared for acid
dephoter
g during Release injury3. spillage.2.
Spillage ene kit4. 1 5 5
offloadi Acid/Ca Equipment Acid/caustic proof
Spill kit5.
ng ustic damage4. full face Respirator
Secondary
Cause to be procured
containm
cancer
ent6.
Safety
shower
1.
dephoter
ene kit
1. Spark testing to
2. Spill kit
1. Land be done on yearly
3. Safety
contaminat basis for inspect
shower
ion. rubber coating.
4.
1. 2. Burn 2. Tank thickness
Unauthori
Release injury inspection on
Leakages zed entry 2 4 8
chemica 3. yearly basis, SAP
5. dyke
l Equipment based .
wall
Chemica damage 3. Silica gel to be
6.
l storage 4. Cause installed in
Neutraliza
tank cancer required chemical
tion pit
tanks.
7.
Chemical
specific
PPE's
Acid /
Caustic
1. Property 1. N-pit.
tank 1. Seperation dyke
Explosio damage 2. Spil kit
leakages 5 2 10 wall to be provide
n 2. Serious 3. dyke
& mix at upto tanke hight.
injury wall
the same
point.
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1. Property
Release
damage 1. Structure
tank of
2. Serious 5 1 5 inspection to be
collaps chemica
injury doen periodically
l
3. Fatality
vapour 1.
release Carcinogen
1. vent
while Release ic 1. Fume observer
line 2 5 10
chemical fume 2. lungs to be installed.
2. PPE's
preparatio damaged
n 3. cancer
1.
dephoter
1. Land 1.Feasblity for
ene kit2.
contaminat Contact Free level
Spill kit3.
ion.2. Burn trnasmitter to be
Leakages Release N-
injury3. installed.2.teflon
from Level chemica pit/dyke 2 5 10
Equipment gasket to be use.
guage l wall4.
damage4. Need to replace
Acid proof
Chemica Cause perdically with
floor5.
l cancer update in SAP.
Safety
preparat
shower
ion for
regener
ation
1.
dephoter
1. Land ene kit
contaminat 2. Spill kit
ion. 3. N-
Realase 2. Burn pit/dyke
1.SOV intelocking
Tank Over of injury wall
2 5 10 with Level switch.
flow Chemic 3. 4. Acid
als Equipment proof
damage floor
4. Cause 5. Safety
cancer shower
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01. Complete
1. Land
automation of all 3
contaminat
chemical(HCL,Naoc
ion.
l,Naclo2) So that
Clo2 Realase 2. Burn
01. PPE,s manual handling
Chemical of injury
02. Spill 3 5 15 can be avoided.
Manual Chemic 3.
Kit 02. Acid brick
Handling als Equipment
lining in handling
damage
area.
4. Cause
03.Safety shower
cancer
in Clo2 Area
Manual
Chemica Manual Slip &
1.Major 01.Manual Forklift
l Handling trip 4 3 12
Injury for Lifting Alum.
Handling of Alum Hazard
Manual
Handling Slip &
1.Major 01.Manual Forklift
of trip 4 3 12
Injury for Lifting Alum.
Polyelectr Hazard
olyte
Manual
Handling
of 01. Auto Burrate
Burn Minor
flammable PPE's 3 4 12 Avaialablity for
Injury Injury
chemical transfer chemical
in
Labortary
CT sump Railing Fall Damage Railing to
Fatal Railing 5 2 10
Railing Collapse hazard Replaced
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The human element is common to every aspect of a process safety management system.
Accordingly, human error can be a significant factor in process safety incidents. This checklist
provides questions intended to promote team discussion on human factors. It is not intended to cover
every situation in every element of PSM; rather, it is provided to stimulate study teams to identify and
eliminate error-likely situations in those areas most usually covered during the course of a process
hazards analysis. Other areas are more appropriately the province of PSM audit teams.
PHA teams should look for trends in need of improvement. Some examples are provided for certain
questions. These examples are not meant to limit discussion but to help clarify the intent of the
question. This checklist was developed primarily from the 1993 Maydown Works list and the 1994
CCPS list.
1 Management systems
Management sets the tone for the importance of human factors in day-to-day operations by
establishing and administering policies that demonstrate commitment to eliminating error-likely
situations. This is typically best done by establishing clear expectations around accountability,
providing resources, promoting understanding of human factors, and, most importantly, establishing a
blame-free atmosphere. Concerns identified in connection with the questions below are potentially
symptomatic of problems in the area of management systems.
3. Are differences between the actual worker practices and the written policies and procedures
tolerated? Do verbal, informal (e.g., “black book”), or unwritten practices exist that supersede written
procedures?
NO
4. Is the work environment, including, for example, general housekeeping and congestion, maintained in
an acceptable manner, or is there a pattern of tolerance until conditions become unbearable? Is there
a deteriorating trend evident?
NO
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5. Are incidents identified (e.g., any “stories” of events in the night without formal investigation)? Where
an investigation is done, does the report drive to root cause (not superficial or symptomatic)? Is follow-
up completed?
Yes
6. Are the various elements of process safety management audited? How well is the business
responding to recommendations made?
Yes.
7. Are safety rules understood by all? Are personnel held accountable to them? Have personnel been
fully apprised of safety priorities and disciplinary practices for failure to follow procedures?
Yes
Yes
9. Is there an effective means to detect and correct situations when a person’s physical abilities or
mental capability are not compatible with the requirements of the task?
Physical abilities are being checked by medical officers & mental abilities are being checked
under on job training & skill mappings.
10. Does the organization have an effective means to provide relief to individuals who feel their
performance may be compromised by excessive fatigue?
11. Does the area have a means to identify situations where error is likely to occur? How promptly does
the organization respond if one is found?
Yes- immediately
12. Do workers have clear, documented criteria for shutting down a unit or discontinuing an activity, so
that the fear of being “second guessed” does not interfere with decision making?
Yes
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13. Is the personnel turnover rate maintained at a tolerable level? Is there a policy to manage personnel
change?
Yes
2 Procedures
Lack of clear, well-written procedures significantly increases the risk of human error. The following
questions are intended to help a PHA team think about the completeness and quality of procedures
that may have a significant impact on process safety.
14. Are there procedures available for the tasks involved, including, for example, start-up, shutdown, idle,
normal operation, and emergency situations?
15. Has the area identified major emergency situations? Do procedures exist to mitigate the event,
coordinate with site responders, and minimize personnel and property impact? Are they available and
understood?
Yes
16. Are the procedures clear and complete? Are they written in consistent terminology compatible with the
comprehension level of the user?
Yes
17. Are the procedures kept up-to-date? Are they routinely checked, compared with user actions, and
revised as appropriate?
Yes
18. Are the users of the procedures included in the review and development process?
19. Do the manuals have the most recent revision level of the procedures? Are the procedures
maintained as controlled documents where unauthorized copies are prevented?
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20. Are the procedures easily and quickly accessible? Are they properly indexed?
Yes
21. Are checklists used for critical or complex tasks? Are the checklists consistent with instructions within
the procedure manual?
Yes
22. If colored pages are used for certain sections of the procedure, is the color code consistent and
understood by the users? Is the color code discernible by individuals who may be colorblind?
YES
23. Do the procedures tell “why” as opposed to just “what” to do? Are warnings, cautions, or explanations
of hazards included within the procedures?
Only operation hazards included. System hazards or location hazards not included.
24. Are there any “procedure traps” (i.e., are actions described in the proper sequence, for example,
providing an explanatory warning before, rather than after, the requested action step)?
No
25. If different recipes or configurations are used on the same equipment, do the procedures clearly state
when and how to apply the instructions? Are there checks to ensure the correct procedure is being
applied for the recipe and or configuration?
No
26. Are troubleshooting, upset response, or emergency procedures realistic in terms of the time allowable
to diagnose and correct a problem? (That is, can the situation get out of control before an effective
response can be mounted?)
YES
27. Are there so many outstanding variance documents (e.g., test authorizations, temporary procedures)
that individuals cannot keep track of them all?
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No
28. How good is the quality of communication when changes to operating procedures are made?
Excellent
3 Training
Good training goes beyond simply following and practicing the procedures. It incorporates an
understanding of the reasons for the procedures, as well as a knowledge of the consequences of
deviations from the procedures.
1. Do personnel understand:
c. What the key safety devices, interlocks, mitigation equipment, and administrative controls are?Yes
d. Why these controls exist and how they are supposed to work?Yes
2. Are personnel entering an area trained on both generic and area-specific safety rules and
critical emergency response procedures?
Yes, all training passport has been provided w.r.t. their training
Yes
4. Are recovery procedures (for use in the event of an operating error) included as part of the
overall training program?
Yes
5. Are operating teams trained together in the transfer of information and responsibility?
Yes
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6. Are infrequently used but important skills and knowledge included in refresher training?
Yes
Yes
8. Are the operators trained to recognize when an emergency situation exists? Are realistic drills
conducted to test organization response to such events?
Yes
9. Do the training requirements (or skill demonstrations) for a job accurately reflect the
requirements for both routine and nonroutine operations?
Yes
10. Have people been assigned to jobs based upon a demonstration of required skills?
Yes
11. Is there an effective monitoring or mentoring program for operators undergoing on-the-job
training?
Yes
Yes
Proper design of tasks and clear understanding of accountability can do a great deal to reduce the
risk of error-likely situations.
29. Are operators’ job descriptions well defined (e.g., do overlaps or gaps in responsibility exist, having
the potential to result in important tasks being left undone due to confusion regarding responsibility)?
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Yes
30. Are there parts of the process where split/shared ownership can lead to a lack of accountability?
No
31. Where several different tasks are assigned to one person, can these run unattended for a limited time
so that attention can be given to any single one?
No
32. Are mental and physical workloads reasonable (i.e., at a level that can be maintained without undue
strain for hours)? If high stress levels can occur, are they limited to short periods with sufficient
recuperation time in between?
Yes
33. Does the job environment involve long hours of continuous mental or physical inactivity, or social
isolation (e.g., lack of help if needed, urge to wander off to seek company/assistance, dulling of
senses by long periods of uneventful vigil)?
No
34. For “systems” that require constant monitoring (e.g., a panel board, DCS, standby for vessel entry,
heat permit work), is there an enforced policy to ensure coverage of the system at all times it is in
operation?
Yes
35. Are any high-speed, high-accuracy, or highly repetitive tasks done manually? Does this make an error
more likely? Are the consequences acceptable?
NO.
36. For manual ingredient preparation tasks (e.g., for charging a reactor), is there a means to prevent
adding the wrong amount or multiple charges?
Yes
37. For manual ingredient preparation tasks, are ingredient scales and metering devices controlled (i.e.,
verified for accuracy on a set frequency)?
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Yes
38. Are there aids to help personnel find their place in an operating sequence if the sequence has been
interrupted? What are the consequences of confusion?
Yes
5 Ergonomics
Attention to the operating environment, as well as the human-machine and human-systems interfaces,
are of significant importance in the prevention of error-likely situations.
39. Are critical equipment controls (e.g., shutdown switches, valves) placed in such a way that they can
be reached successfully in an emergency? (For example, does one have to wade through the spill or
a fire to reach the emergency stop?)
Yes
40. Does successful use of emergency equipment require physical skills or training beyond the capability
of some of the people likely to respond?
No
41. Have environmental conditions (temperature, illumination, weather) been considered in the design of
the facility? Has their impact relative to successful activation of critical or emergency equipment been
assessed?
Yes
42. Do any tasks require the prolonged wearing of excessive or burdensome personal protective
equipment, such that it may interfere with an individual’s ability to safely complete an operation in an
adequate amount of time, either due to physical constraints or interference with the ability to stay
mentally focused?
43. Would area congestion play a role in tasks where speed is of the essence (e.g., emergency access to
shutdown devices, evacuation routes, etc.)?
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No
44. Is enough space provided around equipment to perform the desired maintenance tasks? (For
example, is it difficult to tighten one bolt on a particular flange because the surrounding area is too
congested?)
No
45. Are proper tools provided to complete the required task? (For example, in one area, flammable vapor
leaks from a high-pressure heat exchanger were common because no one was strong enough to
properly torque the head bolts. Procurement of a hydraulic bolt tensioner eliminated the problem.)
Yes
46. Is it easy to work at or move past control panels without accidentally altering settings? (For example,
are there cover plates over emergency shutdown buttons? If so, make sure the cover plates don’t
restrict access in case of emergency.)
Yes
47. Does the layout of different but similar-looking equipment lend itself to misidentification? (Two
examples are working on unit “A” instead of “B” and hooking a tank truck unload line to the wrong
station.)
No
48. Are such things as key piping, valves, vessels, and field warning lights labelled clearly and
unambiguously? Is it clear who is responsible for maintaining the labelling?
49. Is there background noise or any other distracting/disruptive factor(s)? Does hearing protection
prevent proper communication?
50. Have employees made modifications to existing systems that may be symptoms of design failures?
(For example, a piece of cardboard covers a video screen to cut down on the lighting glare, or tape is
placed over a nuisance alarm horn.)
No
6 Control systems
1. Are there nuisance alarms that distract workers or make it likely an important alarm is
ignored?
2. Are the control schemes properly documented and understood by the users?
Yes
3. Is the control system labeling terminology consistent and compatible with the comprehension
level of the user? (For example, does “0% valve loading” always mean the valve is closed?)
Yes
4. Are such things as alarms, warning lights, and horns consistent in appearance (or sound) in
various areas of the process?
Yes
5. Are such things as critical controls and overrides likely to be confused with ordinary ones?
(Hint: Look at the arrangement and proximity of controls.)
No
6. In an emergency, can operator overload occur from many alarms sounding simultaneously? If
so, is there a way to prioritize the most important?
No
Simple
8. Are the designs of any controls counter-intuitive or do they violate populational stereotypes?
No
Note: A population stereotype is a behavior pattern ingrained in a group of people; for example,
expecting a valve to close when turned clockwise.
9. Are there area process control/alarm color or sound conventions used that run counter to
conventions used elsewhere on the site?
No
Note: This may be a significant issue for workers migrating into or out of the area.
51. Are the criteria clear and unambiguous for taking over manual control from automatic? Is it understood
when a system can be placed into automatic or supervisory control?
Yes
52. Is all the relevant information required to effectively run the process under routine and upset
conditions supplied?
Yes
53. Can instrument (or video display terminal) lag/update time be slow enough to create a potential for
operator overcontrol?
No
54. Is there an effective means to detect instrument failure? What errors might be likely if key instruments
give false readings?
Yes
55. Can the indicators (e.g., strip chart pens, dials, video displays) become stuck in position, thereby
failing to indicate the true process value?
No
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56. Are there underlying assumptions in control system design that might become invalid under process
upset conditions (e.g., a false level signal because fluid density changed)?
No
57. Is the user always informed if a control setting or screen has been changed?
Yes
Yes
59. Are systems designed to avoid overly sensitive controls? In other words, is there a reasonable range
of control movement? (For example, error would be likely if attempting to regulate flow at 50 GPM with
a control knob that changed flow 1000 GPM for each half-turn.)
Yes
Yes
61. Do instrument checks verify the entire instrument loop? (For example, drive the signal from the field
transmitter rather than drive the signal into a pressure switch that activates an alarm within the CCR.)
Yes
62. Are instrument malfunctions promptly repaired? Is there evidence of chronic use of interlock/alarm
bypasses?
Yes
63. Are automatic interlock bypasses or alarm inhibits designed into the control system? If so, what
controls are in place to avoid abuse?
Yes
b. Color coded as needed? Color coded consistently? (Is colorblindness an issue?)No color coding
c. Is similar layout used on similar equipment? (Is there enough distinction to avoid confusion
between units?)Yes
a. Is there a redundant means of accessing the information should the screen fail?
b. When it is possible to access multiple screens from the same control panel, could an adjustment be
made while looking at the wrong screen? Are there similar screens for different (but identical-looking) units?
c. Can the user quickly tell if the screen has stopped updating information?
e. Does the user have time to determine the source of the alarm, or will the alarm scroll off the screen
too quickly?
g. Are there a sufficient number of video displays to show enough of the process simultaneously?
a. Are there proper checks and balances to prevent computer programming errors?
b. Is there a procedure to introduce and follow-up after installation of vendor-supplied software or new
software revisions?
c. Are the controls adequate to ensure software modifications are made only by qualified and competent
individuals?
d. If safety interlocks are included in the PES, are redundant and different logic schemes employed
(reference DuPont Engineering Standard DX3S)?
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e. If older manual (or lower order semiautomatic) control systems are maintained as a backup to the
primary system, is operator refresher training and skill demonstration on the use of the older
equipment/controls done?
f. Are software safety interlocks well-documented, including a written description of how they work?
g. Can the PES fail in a way that generates random output signals? How would such a condition become
known to an operator? Is there a recovery procedure?
64. Describe the worst credible event that should be considered in the unit (usually the same as the one
considered for Consequence Analysis). What is the emergency response for this event?
Burn injury/Explosion
Emergency response plan available: Not mentioned separately for the event
2. What are the potential effects that this event will have within this unit?
Death
Major/minor injury
Emission
3. What are the potential effects that this event will have on other units within the complex (what is the potential
domino effects)?
Equipment damage
4. What are the potential effects that this event will have on off-site property and populations? What is the
potential off-site impact of the domino effects?
Emission
pollution
Chaos
5. Is there adequate spacing within the unit for normal operating and maintenance requirements?
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6. Does the spacing within the unit allow for safe evacuation of personnel working within the unit in the event of
emergency?
Yes
7. Are the control room and any other process support buildings (like maintenance shelter, workshop etc) which
are normally populated located a safe distance from a high hazard unit?
Yes
Yes
9. Are firewalls, blast-wall, etc. provided where needed to protect personnel and equipment from high hazard
equipment within the unit?
Not Available
10. Are units of high risk separated, wherever possible, from each other by units having mild, low, or medium risk?
Yes
11. Are units located appropriate distances (100 ft-250ft) from identified ignition sources such as furnaces,
electrical switchgear, flare stacks, etc.?
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yes
12. Are units handling highly toxic materials located at a suitable distance (use distance estimate of toxic
concentration from Consequence Analysis) from all buildings containing appreciable concentrations of
personnel and also with regard to similar areas outside of the complex?
No
13. Are units having a high vapor cloud explosion potential located away (use distance estimate of blast
overpressure from Consequence Analysis) from the site boundary and away from on-site areas of populations?
No
14. Are units having a high vapor cloud explosion potential located away from major plant traffic routes? Is traffic
through such units controlled using gates, etc.?
NA
15. Are major pipeways and process areas located or protected such that they are at a minimal risk from transport
accidents arising from the regular movement of vehicles?
Yes
16. Are storage areas separated from loading/unloading areas, major plant traffic routes, and process areas?
Yes
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IV. Access
17. Are units having a moderate or high fire risk provided with road access for emergency vehicles from at least
two locations?
Yes
18. Is a secondary safe-haven area accessible from the unit, in case the primary area is blocked off? Is more than
one escape route available to all personnel working in a area during emergency?
Yes
V. Mitigation
19. Are areas that are normally populated (control rooms, amenity buildings, workshops, laboratories, etc.) located
adjacent to mild or low risk units? Are they provided with the appropriate protection against fire, explosion or
toxic gas release (like SCBA/ escape packs, gas masks, fire suits etc)?
Yes
20. Are adequate gas and fire detectors provided to allow for prompt emergency response?
NO
Yes
22. Are hydrocarbons and firewater drained away from the process area? How are these areas protected from
becoming a potential source for spreading of the fire?
yes
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23. Is the provided mitigation adequate given the inherent hazards and siting considerations?