Justine Shaira N.

Tangpuz
Engineering 4
CHE428N 5:00-8:00 PM Th
3, 2015

BS-Chemical
December

T2 Laboratories Tragedy and the 14 Process Safety

Management Elements
PSM
Actual
Must
Employee Participation
The people
People running the
assigned failed to
process should have
report the problem been made aware of
to the authorities
the existence of the
which led to the
reactive chemistry
explosion.
hazard and of the
potential magnitude
of the consequences
associated with the
chemical hazard. At
the first sign of the
problem, the
employees should
have immediately
reported or prompted
to shut down the
operation to prevent
further damage.
Process Safety
Chemists and
Equipment and
Information
Chemical
Operation systems
Engineers
should be regularly
especially, should
checked to avoid
be aware of the
malfunctions. In this
hazards associated case, knowing about
with the
the reactive chemical
manufacturing of
hazards, the cooling
the reactive
system should have
chemical MCMT.
been more developed
Knowing these, the and provided with a
workers did not
back-up.
examine for any
anomalies that
could threaten the
safety of the
industrial
workplace.
Process Hazard Analysis
The Engineers and A process analysis
Process Operating should have been

Operating Procedures

Training

Contractors

Pre-startup Safety Review

Experts did not

conduct a
comprehensive
what-if
evaluation. They
did not take into
account the
possibility of the
clogging of the
cooling system
during exothermic
operation.
Maintenance was
not involved in
addressing the
problem.

conducted by a team,
including a review of
the facility siting
possible hazards. The
engineers shall
identify, evaluate, and
control the hazards
involved in the
process.

The technician
assigned in the
control room was
not fully trained on
the procedures to
be undertaken in
case of emergency
such as the cooling
system
malfunction.
The contractor was
not evaluated
regarding his
safety
performance and
programs. Lack of
education on
possible hazards
and emergency
response
procedures led to
the explosion.
There was poor
safety
management and
no pre-startup
check up was
conducted to

All who are operating

a process must be
fully trained for all the
functions they are
performing and must
be fully equipped with
knowledge on Safety
and Emergency
procedures.

An emergency
shutdown has to be
taken if first signs of
problems are
observed. If a plant

The employer should

inform contract
employers of the
known potential fire,
explosion, or toxic
release hazards
related to the
contractors work and
the process.

The employer should

always perform a prestartup safety review
for the facilities for
maintenance and to
check up for possible

ensure no
malfunctioning
systems were
present.
Based on the
tragedy, no
machinery
inspections were
conducted to avoid
possible
equipment
malfunction.

anomalies.

Hot Work Permits

Perhaps a hot work

permit was
secured but the
Fire prevention
and Protection
requirements were
not strictly
implemented.

The employer shall

issue a hot work
permit for hot work
operations conducted
on or near a covered
process. The
personnel should be
trained on how to
verify the aspects
they are responsible
for.

Management of Change

Modifications to
operating
procedures were
not addressed. It is
a fact that the
explosion was
caused by poor
maintenance of
the cooling system
which had no
back-up in case of
emergency.
The malfunction of
one of the
operating systems
was not
anticipated and
not addressed in

The employer should

establish and
implement written
procedures to manage
changes to
technology,
equipment and
changes to facilities.

Mechanical Integrity

Incident Investigation

Mechanical Integrity
inspections should
have been done
frequently. Pressure
vessels and storage
tanks, piping systems,
relief and vent
systems and devices,
pumps, controls, etc
Should be periodically
inspected.

Maintenance and
engineers must shore
up their what-if
scenarios in the
Process Hazard
Analysis to guard

the PHA.

against even the

slightest incident.

Emergency Planning
Response

The employees did

not immediately
relay the problem
to the authorities.
There was no
emergency action
plan taken.

Employers should
have established and
implemented an
emergency action
plan. Perhaps and
emergency shutdown
could have been
done.

Compliance Audits

The procedures
and practices were
no longer verified
if it were still
developing under
the standards.

Employers should
certify that they have
evaluated compliance
to verify that the
procedures and
practices developed
under the standard
are adequate and are
being followed for
safety purposes.

Trade Secrets

Maintenance
personnel are
typically involved
in all aspects of
the process but
might be lacking in
the knowledge of
the details of
production. Some
industries keep
process
information secret
from their own
employees, in
essence to protect
their trade secrets.

Operations and
maintenance
employees have the
expressed right, to be
made aware of those
secretive processes
that might affect the
health and safety of
the employees.