1. September 6, 2002 Mathura Refinery SAFETY MANAGEMENT SYSTEM IN INDIAN OIL

2. Why Safety  To protect human life  To protect company property  To protect surrounding environment/ community  To enhance corporate image  To efficiently run the business  To enhance productivity  To build up morale & team spirit

3. Special Risks Association with Petroleum Refining  Highly flammable material  High Temperature/Pressure  Modern Technologies use Hydrogen extensively  Corrosivity/Reactivity  Self Ignition on Leakage from System  Uncontrolled Process Reactions  Loss of Containment/Accidental Releases

4. Safety Management  In the early stage of industrialization safety was managed through training and following safe procedures, compliance with rules and regulations, etc.  Next stage witnessed enhanced safety feature through technological upgradation - safe processes, safety features in built in design and prescriptive statutory rules.  Finally safety is managed through systems approach. The ‘Cullen Report’, 1990 on Piper Alpha Disaster stressed the need for formal safety management system.

5. A Case Study Piper Alpha Incident

6. Piper Alpha The Piper Alpha platform was located in the Piper field in North Sea, some 110 miles north-east of Aberdeen. Major function was to separate the fluid produced by the wells into oil, gas and condensate. Other facilities included modules for compression, separation, utilities etc. and also for accommodation.

7. Piper Alpha Two other platforms were connected to Piper Alpha Two flares Fire and gas detection system Fire water deluge system Emergency shut-down system, evacuation and escape system

8. Piper Platform before explosion

9. Piper Alpha At 1000 pm on 6.7.88, an explosion occurred in the gas compression module. 167 persons died167 persons died, mostly in the quarters. 62 men escaped mainly by climbing down knotted ropes or by jumping from a height.

10. Events prior to explosion Two pumps for condensate injection - A & B. Pump B was in operation for condensate injection. Pump A was under maint. for –24 months Preventive Maintenance –Repair of pump coupling –Rectification of PSV. The pump was isolated by closing suction discharge valves but not blinded. At this condition of the pump, access was given to remove the PSV for testing.

11. Events prior to explosion The PSV was taken off on 6th July morning by a two-men team from the specialist contractor but could not be restored by that evening. In the evening, the supervisor suspended the permit-to-work and the team then went off duty, intending to put the PSV back the next day.

12. Events prior to explosion At about 9.50 pm, pump B tripped and could not be restarted. Since the other pump was under maint., flash drum level will increase and within 30 minutes shut down of the gas plant had to be taken. There was a possibility that if the gas supply to the main generator was lost and if the changeover to the alternative diesel fuel failed, the wells also have to be shut-down. It would then be necessary to undertake a ‘black start’.

13. Events prior to explosion It was attempted to start Pump - A which was under maintenance. At about 9.55 pm, signals for tripping centrifugal compressors came to the control room. Thereafter, a group of alarm came up. The operator had his hand out to cancel the alarms when he was blown across the room by explosion.

14. Explosion Initial explosion occurred at 10.00 pm. Followed almost immediately by a large fireball and large oil pool fire. The oil pool fire gave rise to a massive smoke plume. The escape routes from the module to the lifeboats were impassable. The fire water drench system did not operate. The explosion disabled the main communication system which was centred on Piper. So other platforms continued production and pumping of oil for sometime which supplied additional fuel to the fire at Piper.

15. Fire on the Platform before riser rupture

16. Fire on the Platform after riser rupture

17. Effects of explosion The entire deck was destroyed. By the morning of 7th July, only A module, the wellhead, remained standing.

18. Investigation Investigated by Lord Cullen, a Scottish judge. Piper Alpha Report concludes - Fuel : Condensate leaked from the PSV line of pump A from which the PSV was removed for maint. - Ignition source could not be identified. The lead operator who went to run pump A was not aware that its PSV has been removed for maint.

19. Investigation The contractor supervisor who suspended the permit was on his first tour and did not have any training in the operation of permit to work system. It appears that the production operator also did not inspect the job site.

20. Some critical findings Regulatory control is not enough for safety. Safety audits failed to reveal the weakness of work permit system. Positive isolation for maintenance not followed. Contractor supervisor was not trained on work- permit system. Production supervisor did not inspect the job site. Operating personnel were under pressure to avoid ‘black start’. Protection system and communication system was affected in explosion.

21. Safety Management System An integrated approach of Management, Leadership Commitment and Coordinated Technical Interventions from concept to commissioning to commercial operations

22. Safety Management Systems  EPA Risk Management Programme  API RP 750 : Management of Process Hazards  CMA ( Chemical Manufactures Association) Systems  CCPS Guidelines for Technical Management of Chemical Process Safety  OSHA - Process Safety Management

23. Safety Management Systems  Exxon OIMP (Operations Integrity Management Practices)  Caltex PSM (Process Safety Management)  Dupont PSM  MOBIL SMS  ICI Standards

24. Safety, Health & Environment (S, H&E) Policy of Indian Oil Indian Oil Corporation is committed to conduct business with strong environment conscience ensuring sustainable development, safe workplaces and enrichment of quality of life of Employees, Customers and the Community. We, at IndianOil, believe that good S, H&E performance is an integral part of efficient and profitable business management. We shall:  Establish and maintain good standards for safety of the people, the processes and the assets.  Comply with all Rules and Regulations on Safety, Occupational Health and Environmental Protection.  Plan, design, operate and maintain all facilities, processes and procedures to secure sustained Safety, Health and Environmental Protection.

25. Safety, Health & Environment (S, H&E) Policy of Indian Oil Remain trained, equipped and ready for effective and prompt response to accidents and emergencies.  Welcome audit of our S, H&E conduct by external body, so that stakeholder confidence is safeguarded.  Adopt and promote industry best practices to avert accidents and improve our S,H&E performance.  Remain committed to be a leader in Safety, Occupational Health and Environmental Protection through continuing improvement.  Make efforts to preserve ecological balance and heritage.

26. Elements of S, H & E Management Systems ( Indian Oil) 1. S, H & E Leadership and Commitment 2. Employee Participation 3. Process safety Information 4. Risk Analysis and Management 5. Reliability of Critical System and Devices 6. Facilities Design and Construction 7. Operation and Maintenance Procedure 8. Occupational Health and Hygiene

27. Elements of S, H & E Management Systems (Indian Oil) - Contd. 9. Environment Management 10. Personal safety 11. Training 12. Contractors and Business Associates 13. Work Permit System 14. Management of Change 15. Emergency Planning and Response 16. Incident Investigation and Analysis 17. Safety Audits

28. 1. S, H & E Leadership and Commitment  Corporate safety policy  Approved by Board of Directors  Periodical updation  Made available to all the employees, contractors, business associates  Establishment of S, H & E Management Systems at all locations  Monitoring of S, H&E Performance  Formation of Safety Committees  Management Safety Committee - headed by Unit Head. Meeting once in a quarter  Shop-floor Committee - 50% workmen. Meeting once in a month

29. 1. S, H & E Leadership and Commitment - Contd.  Promotion of S, H & E Culture  Safety Award Scheme  Allocation of resources to improve safety, health and environment performance  Personal Protective Equipment - Punishment for non- compliance  Surprise checks  Safety Promotional activities - display of poster, quiz, safety talk to contractor workmen etc  Assessment of Safety Awareness Level - once in a year  S, H & E Manual  Safety  Fire  Occupational Health  Environment Management

30. 2. Employee Participation Employees shall be involved in all the elements of S, H & E Management System  Plant Manager - Overall responsibility  Training Co-ordinator - assess training need, ensure skill and refresher training  Supervisor - encourage for reporting of potential hazards

31. 2. Employee Participation - Contd.  Scope of Employee Participation  Compliance of S, H&E rules and regulations  Follow safe operating practice  Involvement in development and updation of operation/maintenance procedure  Inclusion in pre-startup safety review team  Involvement in development of training material  Imparting training to fellow workers  Use of PPE  Updation of emergency planning and response procedures  Involvement in incident investigation  Involvement in safety audit  Help in controlling safety and environmental incidences

32. 3. Process Safety Information  Complete and accurate information about  Process Chemicals  Process Technology  Process Equipment

33. 3. Process Safety Information - Contd.  Process Chemicals  Physical Properties like vapour pressure, boiling point etc  Fire & Explosion Hazards like flash point, auto- ignition temperature, explosive limits etc.  Reactive hazards (tendency to react violently)  Health hazard (toxicity)  Corrosive properties

34. 3. Process Safety Information - Contd.  Process Technology  Written down process description  Process chemistry  Safe Operating limits  P&ID

35. 3. Process Safety Information - Contd.  Process Equipment  Materials of construction  Design Specifications  Electrical classification

36. 4. Risk Analysis and Management Risk Analysis - Major components  Hazard Identification  Cause-consequence Analysis  Hazard & Operability Studies (HAZOP)  Quantitative Risk Analysis  Safety Audit Studies  Individual and Societal Risk Assessment  Risk Contour Mapping

37. 4. Risk Analysis and Management - Contd.  Appropriate review of risk once in three years for existing plants based on  Internal/external safety audits  HAZOP Study  Previous risk assessment  Regulatory compliance  Accident Investigation Reports  Risk Analysis and assessment of new projects  Utilisation of risk analysis study  Compare the estimate against acceptance criteria (Govt. of India is yet to stipulate. The Netherlands or UK criteria is used)  Implement risk reduction measures based on recommendations  Development of Emergency Management Plans

38. 5. Reliability of Critical System and Devices  Safety critical systems and devices to be identified and approved by management to:  Prevent serious process accident  Mitigate the results of loss of containment  Identification shall be based on:  The identified system/device is the final element  Consequence of failure is large  Environmental critical systems and devices  Prevent release of material that would cause serious environmental impact  Mitigate the environmental impact

39. 5. Reliability of Critical System and Devices - Contd.  Requirements  Identified systems/devices are periodically tested and undergo maintenance  Procedure for testing and maintenance exists  Testing/maintenance is properly documented and analysed  Temporary deactivation/bypassing facility exists  Approval procedure for bypass/deactivation exists  System exists to communicate operation personnel/others likely to be affected.

40. 6. Facilities Design and Construction  Initial hazard review for the new projects  Plant layout  Operating and design condition  Basic specifications  Operating philosophy  control philosophy and redundancy  Toxicity and hazard potential of the material involved  Quantity of the material in process and storage requirement  Safety review by a specialised group during detailed design stage  HAZOP Study on the final P&I drawings

41. 6. Facilities Design and Construction - Contd.  Some of the important items for consideration:  Automatic valves at key locations in the plant and utility system  Automatic deluge sprinkler system in LPG storage/bottling/ pumping facilities  Water spray on hot pumps  Arrangement of fire fighting for tall structures  Fire protection system and arrangement for draining water used in fire fighting  Water draining facility from LPG storage and location of ROV (shall be first from the vessel)  Access and exit from plant/equipment  Earthquake resistant construction  Electrical installations based on area classification  Gas detection system  Compliance of OISD-GDN-192 (Safety Practices during Construction)

42. 7. Operation and Maintenance Procedure Comprehensive operating, inspection and maintenance Manuals should be prepared and made available to the concerned personnel. Shall be updated once in a year.  Operating manual shall contain  Equipment operation, normal start up and shut downs, emergency handling procedures  Limits of operating parameters and consequence of crossing the limit  Interlocks and safe shut-down instrument functions & its special features  Contains work permit system, equipment hand-over, fire protection/fighting facilities etc.

43. 7. Operation and Maintenance Procedure - Contd.  Maintenance manual shall contain  Procedure for carrying out preventive maintenance  Procedure for carrying out predictive maintenance  Shut-down/emergency maintenance  Job description  Interface with other functions  Details of major and critical equipment  Details of special maintenance procedures  Testing procedures  Materials specifications  Methods of documentation

44. 8. Occupational health and Hygiene  Objective  Promote health care of the man behind the machine  Early detection of occupational disease  Identify, evaluate and control of hazard at work environment  Occupational health monitoring shall be in line with OISD-GDN-166  Hazardous substances/operations classified under Schedule-I of The Factories Act, 1948 shall be identified. Employees working in these areas forms the target group.

45. 8. Occupational health and Hygiene - Contd.  Major requirements  Pre-employment medical examination  Periodical medical examination - target organs  Biological monitoring  Well person screening of employees above 40 years  Thorough examination of food handlers - skin infection, chest infestation, worm infestations  Sound level monitoring in high noise areas - once in 6 months  Checking and surveillance of First Aid boxes  Provision of safe drinking water  Proper disposal of Bio-medical waste  Auditing - once in 2 years

46. 9. Environment Management  Compliance of statutory requirements  Identify sources of water pollution. Reduce generation of waste water and recycle  Identify sources of atmospheric pollution. Reduce generation  Adopt cleaner technology  Safe disposal of hazardous wastes  Waste water treatment - compliance with MINAS  Ambient air quality monitoring

47. 9. Environment Management - Contd.  Compliance of NOC/EC conditions  Documented oil spill response  Development of green belts/tree plantation  Training and awareness to all employees, family members and local community  Establishment of Quality Management System - continual improvement

48. 10. Personal Safety  Provide appropriate type of Personal Protective Equipment (PPE) for protection of  Head  Eye  Face  Respiratory system  Hearing  Hand  Foot  Enforce and ensure correct use  Provide fall protection while working at height  Communicate exceptions/limitations of PPE

49. 11. Training  Training of new entrants  Training on operating instructions  Emergency response training  Skill of trainers  Training effectiveness  Change of assignment/retraining  Certification

50. 12. Contractors and Business Associates  Constitute large proportion of work-force  Engaged in construction, repair and maintenance jobs in hazardous areas  Evaluation of S, H&E Performance of Contractors  Trained for safe operation  Personal Protective Equipment (PPE)  Information about potential fire, explosion and toxic release hazards  Contractors are responsible for organising their work and maintain tools/tackles in such a manner that risk of accident is minimised.

51. 12. Contractors and Business Associates - Contd.  For project construction jobs, contractors to deploy full time safety officer  Frequent safety talk to contractor labours to raise their safety awareness  Contractors to ensure that their employees follow safety rules of the corporation  Regular safety meeting with the contractors  Ensure that the contractors comply OISD-GDN- 192 (Safety Practices during Construction)  Carry out construction safety audit

52. 13. Work Permit System  Duly authorised written permit is a pre-requisite for carrying out any job in hazardous premises other than by the operating personnel  Formal work permits system as per OISD-STD- 105  The system operates on ‘Owner-Incharge’ concept. Management issue appropriate authority limits - Gas Safety Inspector & Fire Permit Signatory  Permits are printed, serially numbered and colour coded

53.  Before issuing permit, proper isolation of equipment, gas test, oxygen deficiency tests to be ensured.  For the jobs to be carried out by the contractors, permits are issue to the company supervisors.  For critical jobs like dyke cutting approval from higher level officers are required.  Ensure that after completion of the job, area is cleaned and the permit is returned to the issuer who also signs and keeps record for one month. 13. Work Permit System - Contd.

54. 14. Management of Change  Ensure evaluation of potential impact, authorising and control for changes in process technology, equipment, instrumentation and procedures  Proposed changes to be reviewed by related functions/departments  Operating/maintenance personnel are to be trained on changes  Same control to be exercised for temporary as well as permanent changes. Temporary changes should not be permanent by default  Documentation and communication to all concerned

55. 15. Emergency Planning and Response  Dedicated Fire fighting facilities  Fire tenders/Nursers/Hydrant system/Fire Water Storage/Pumps/Alarms etc.  Detectors for Early Warning  Well trained fire crew round the clock  Mock drill every month

56. 15. Emergency Planning and Response - Contd.  Regular running of equipment & tests on facilities  Emergency Management Plans - on site - off site  On site drills once in 6 months  Off site drill with Dist. Administration once in a year  Mutual aid Agreements with Neighbouring industries/District Fire Services.  Updation of plans - once in 3 years

57. 16. Incident Investigation and Analysis  Incident reporting  To ascertain cause, recommend remedial measures to prevent recurrence and document lessons learnt  Investigation by multi disciplinary team  Implementation of recommendations  Near-miss situations  Case studies for in-house training programmes

58. 17. Safety Audit  To check and affirm System Effectiveness  To be carried out on structured check list by Multi Disciplinary Teams  Internal Audit - Every Year  External Audit (once in 2/3 years) & Surprise Audit (once in a year) by OISD  Pre-commissioning safety audit - internal and OISD  Implementation of recommendations  Review - Unit Head/Divisional Director/Board of Directors

59. Statutory Compliance Though not an element of IOC S, H & E Management System, compliance of following rules are mandatory:  The Factories Act, 1948, as amended in 1987  The Petroleum Rules, 2002  The Gas Cylinder Rules, 1981  The SMPV (U) Amendment Rules, 1999  The Manufacture, Storage & Import of Hazardous Chemicals (MSIHC) Rules, 2000  The EP Act, 1986 and other relevant rules like Indian Electricity Act, Boiler Regulations, Central Motor Vehicle Rules etc. to be followed.

60. Safety Management Rating Systems

61.  International Safety Rating Systems (ISRS)  5 Star Audit - British Safety Council, UK

62. ISRS  Developed by DNV in 1978  20 elements  126 sub elements  650 requirements  10 levels

63. ISRS Elements  Leadership and administration  Leadership training  Planned inspections and maintenance  Critical task analysis and procedures  Accident/incident investigation  Task Observation  Emergency preparedness  Rules and work permits  Accident/incident analysis  Knowledge and skill training

64. ISRS Elements  Personal Protective Equipment  Health & Hygiene control  System evaluation  Engineering and change management  Personal communications  Group communications  General promotion  Hiring and placement  Materials and services management  Off-the-job safety

65. 5 - Star Audit Assesses management and staff practices Measures safety performance Recommends courses of action Encourages continuous improvement

66. Objectives Detailed examination of the premises Identifying all areas of potential risk and loss Courses of action suggested to prevent accidents and injuries

67. FIVE STAR AUDIT KEY ELEMENTS (5) SUB ELEMENTS (82) SAFETY ORGANISATION - 26 MANAGEMENT CONTROL SYSTEMS - 26 FIRE CONTROL SYSTEMS - 12 MEASUREMENT & CONTROL SYSTEMS - 6 WORK PLACE IMPLEMENTATION - 12

68. 82 key elements are examined in 5 major areas MAX. MARKS Safety Organisation1510 Management Control Systems 1315 Fire Control Systems 830 Measurement & Control Systems 475 Work Place Implementation 470 TOTAL4600

69. Five Star Grading System 92% - 100% Excellent 85% - 91.9% Very Good 75% - 84.9% Good 60% - 74.9% Average 50% - 59.9% Below Average Very Low Risk Low Risk Acceptable Risk Unacceptable Risk Remedial Action Required

70. The Sword of Honour Organisations who achieve a five star grading from their Five Star Audit are invited to apply for the Sword of Honour. Approximately 200 organisations apply for the award and the safest 40 are given ‘Sword of Honour’.

71. Performance of IOC Refineries RefineryISRS5 - Star Guwahati 6 Barauni 6 5 (Nov’01) Gujarat 8 5 (Aug’02) Haldia 6 4 (Jun’00) Mathura 5 5 (Sep’02) Panipat 7 5 (Mar’02) Digboi 5

72. Sword of Honour Barauni, Gujarat and Panipat Refineries have received Sword of Honour – 2002 in Nov’02

73. Thank You