A refinery is a dangerous workplace where disregard for safety or avoidable maintenance hazards can cause tragic and catastrophic events.
State oil and gas giant Petrotrin knows this better than most. It has recorded serious safety and production incidents and as many deaths over the last decade. Yet, despite these costly and tragic outcomes to its cavalier disregard for safety, Petrotrin has failed to rein in the culture of risk or heed the warnings of its own technical experts or recommendations contained in numerous internal accident reports, including workplace fatalities, Sunday Express investigations have revealed.
Accident reports, maintenance records and other company data show a reckless disregard for workers’ safety and a high and dangerous level of risk-taking on the part of those entrusted to manage the company which is critical to the financial well-being of the country.
Petrotrin’s own documents paint a damning picture of criminal negligence where operators fail to follow basic safety rules, where serious mechanical integrity maintenance issues that cost money are pushed aside or deferred and where the same recommendations on how to avoid a repeat of the same catastrophic incidents, including workplace fatalities, are ignored only to happen again with the same tragic results.
Report after report echo the same safety concerns: critical plant and equipment found to be in a condition that made it unreliable, inoperable fire detection systems, failure to manage risk and take care of outstanding maintenance issues, poor system of enforcement and flagrant violations of company GFIs (General Field Instructions) and industry codes and best practices.
As reported previously in this series, a lot of the incidents, including the December 17 oil spill, are self-inflicted Petrotrin setbacks. The company had full knowledge of serious identified safety hazards yet recklessly and dangerously continued to use aged and severely corroded pipelines to move hazardous product.
It did the same thing three years ago, ignoring the advice of a March 2011 inspection report to immediately change out severely corroded and pitted tubing of the fractionator overhead system at the No 2 HTU (Hydrotreater) plant at Pointe-a-Pierre. Subsequent events showed that Petrotrin ignored the advice to its peril.
On July 2, 2011, a power failure led to the loss of the overhead cooling fans and a reflux pump which caused a sudden and dramatic rise in system pressure and temperatures sparking a fire that cost the company $1.2 million, including production losses.
Clyde Rambaran, a senior refinery official and lead investigator appointed to review the circumstances surrounding the fire, in a report on the incident, pointed to the company’s failure to act on important maintenance advice, specifically replacement of worn tubing.
He found the primary cause of the fire to be “the auto-ignition of a mixture of combustible material that was released from leaking tubes from the coolers”. The company appointed prober said a number of contributing factors created the perfect environment for the fire, namely—high pressures and temperatures, unavailable cooling capability and a “ready source of combustible material from leaking flanges, tubes and plugs as a result of heat exposure from the fire”.
The overhead system which operates on an ordinary working day at 10psi and about 335-400 degrees Fahrenheit on that fateful July day experienced pressures above 15psi and temperatures exceeding 615 degrees Fahrenheit.
“The abnormal process conditions in combination with the condition of the tubes in the coolers provided the correct recipe for the fire,” said Rambaran, noting that the integrity of the coolers was compromised by “the outstanding recommended repairs.”
He noted that the fractionation overhead system was inspected in November 2010 but the inspection engineering report recommending an “immediate re-tubing” was not forthcoming until five months later. The fire broke out five months after the report was produced—ten months after the problem was first identified. The Rambaran report also identified gaps in the emergency response, fire fighting systems, regulatory breaches under the OSH Act and maintenance of equipment integrity.
“Each gap,” he said, “highlights the importance of Process Safety Management to the organisation. Therefore increased attention and action to strengthen the mechanical integrity programme to the appropriate level of detail, strict adherence to Petrotrin’s Management of Change procedure, operating procedures, provision of a dedicated hydrant system and enhanced training for the fire department were the principal recommendations to prevent a recurrence of a similar incident.”
The report to vice president, Refining and Marketing, Mado Bachan urged: “In the field of maintenance and reliability it was recommended that Petrotrin do not procrastinate doing preventive maintenance on high criticality assets. Without data, there is little chance of reaching correct conclusions. Decisions, both those made and those avoided, bring major negative consequences. The decision to not manage operational risk can ultimately result in disasters.”
Rambaran warned: “To manage Petrotrin’s operations more efficiently and to continue the drive to sustainable development all stakeholders must focus on the targets at hand and the conviction to purport safe work practices or run the risk of business interruptions that could pose a threat to the economic viability of Petrotrin.”
Luckily, there were no reported injuries but an inspection done after the fire found that 64 plugs were of the wrong type. Instead of high quality carbon steel, monel plugs were used. Rambaran said: “It was an area of concern.”
But there was plenty of concern all around. He found several safety breaches under the OSH Act and a planned plant turnaround for the No. 2 HTU unit in February 2011 had been pushed back to August, one month after the fire broke out. Also, the recommended “immediate re-tubing” was not done.
The report noted a long history of problems associated with startup of the spare reflux pump. The company prober said had the spare remote pump facility been available; the sudden rise in temperatures would have been averted.
Systemic safety issues and failure to follow proper protocols have led to avoidable tragedies over the last decade. Two accident reports of workplace fatalities obtained by the Sunday Express show clear breaches of company-issued GFIs, HSE (Health, Safety and Environment) and OSHA violations, among other things.
Safety lapses at the refinery led to the deaths of contract workers Joseph Carrington (July 24, 2012) and Finbar Adonis (December 9, 2007). In the case of Carrington, some of the same unsafe conditions, GFI violations, inadequate supervision and inattention to hazards that led to Adonis tragic end in 2007 happened again six years later.
Carrington died following a blowout of a valve bonnet during pre-commissioning plant activities on a process pipeline at the Fluidised Catalictic Cracking Unit (FCCU). The investigation report by Garry Solomon found the blowout was forceful enough to knock Carrington’s safety helmet clear off his head. The valve bonnet blew, in part, because the pipeline had not been depressurised and was under an operating pressure of 85psi at the time of the incident.
Carrington was knocked off the scaffolding support after being slammed against the top rail of the platform which bent on impact. Solomon cited serious work safety flaws, including non-compliance with the Permit to Work System, absence of body harness for scaffolding supports over six feet high and failure to identify the specific job tasks, among other things.
The Solomon report said the line pressure “constituted an unsafe condition for removing the bolts on the gland and the valve bonnet. The task was not specifically stated on the work permit. This is a breach of the Permit To Work System, section 2.2: role of the site official, a breach of GFI 63, GFI 80 and a breach of section 6 (2) (a) of the OSH Act.”
He noted that the probe team found it “very strange and unusual that during the process of removing all the bonnet flange stud bolts estimated to be over one hour that no plant official observed this activity, especially if this activity was not to be undertaken.”
Adonis died after falling off a scaffolding support after being sprayed by a gush of steam condensate from an overhead six inch vent pipe at the No. 2 Catalytic Reforming Unit at the refinery. Improper administration of Permit To Work System, non-compliance with GFIs, safety harness violations and failure to provide a safe workplace were among the contributing conditions that led to his death.
All three accident reports and subsequent events at the state oil and gas company highlight a persistent management failure to implement important maintenance repairs.
Petrotrin fatalities over the last decade
Kenneth Merrique (Trinmar) — August 16, 2004
Dave Namdeo (ER80 explosion) Grande Rivine, Forest Reserve — March 11, 2007
Ricardo Felix (Trinmar) — May 21, 2007
Finbar Adonis (Pointe-a-Pierre) — December 9, 2007
Victor Roberts (fireman, Penal) — October 14, 2011
Chanardath Ramsaroop (Santa Flora) — November 22, 2011
Joseph Carrington (Pointe-a-Pierre) — July 24, 2012
Asim Jamal Arthur (Santa Flora) — August 3, 2012
Nicholas Ali (Morne Diablo Farmout) — February 27, 2013
Avitar Ramkhelawan — March 2014