A working BF containes several hundreds of molten metal and semi finished raw materials inside its vertical shaft and its bottom belly. This is kept hot and reactive with the action of huge volumes of hot air blast that is is blown inside through the huge bed of raw material stock contained in the furnace shaft through nozzles called tuyeres. The air blast is the most vital process of the blast furnace that is accomplished through large air blowing machines.
Besides, large quantities of cooling water is continuously required to cool the BF shell. Any failure to supply the air blast or the cooling water can cause serious damage to the BF. If air blast is stopped for some time there is the danger of the molten iron and molten slag getting solidified in the furnance that could cause irrepairable damages. Similarly, stoppage of cooling water can cause the BF shell made of steel plates to melt down.
ISP operators and management consider BFs as the most critical production facility and ensure all they can to keep the BFs in operation through out is operating life till it is taken out of service for any planned repair period.
Such pressures often cause some engineers to postpone some maintenance functions which they deem as non-vital to some later maintenance time, only to keep them postponed further in a similar way. Such management pressures also cause some engineers to neglect or by-pass some systems which they consider as irrelevant. Lack of proper understanding of the plant systems by new engineers and teams enhances such risks. This is because the old ISPs have production facilities with operating life exceeding several decades.
Some operating personnel of the Water Management Department had been aware of a minor leak in the common collector pipe located in the main pump house to which the three GCP supply pumps were connected, for some time. The leak had happened in the lower side of this fairly large pipe with a diameter of about 900 mm. This pipe piece was supported on the floor of the pump house and there was hardly any space between the pipe bottom side and the floor. This restrained the operators and the shift managers to assess the real condition of the pipe. While the pipe was quite okay on the top side, there was some corrosion at the bottom side and there was some pin-holes from which water had been leaking.
In the last several decades, this pipe piece was never replaced during any maintenance and the concerned department knew about its old age and probable deterioration due to ageing and corrosion. The pipe bottom was specially vulnerable to external corrosion as this side was difficult to be painted due to the small working clearance. Besides, this side was exposed to water accumulations in the pump house floor that happened occassionally due to various reasons. This also was one of the reasons for the probable external bottom side corrosion of the pipe.
For replacing this pipe piece, the Water Management Department needed to take a shut down to the GCP water supply main header pipe which invariably affected the production from six BFs. The production managers over the years had developed a type of technical superiority in all decision making due to which it was difficult for the Water Management Department to convince the top authorities about the necessity for a production shut down for replacing a small length of old water pipe. The engineers of the Water Management Department had developed a submissive attitude over the years which prevented them to talk authoritatively about their technical requirements and convince the top authorities of the steel plant. They had almost developed a withdrawn attitude towards their professional vigilance to critically study the various kinds of risks involved in their functions!
The inter departmental meetings, for quite some time, had been stressed towards achieving production targets and better production performances with attention towards removing bottlenecks. Perspective assessments and critical analysis of risk scenarios had undergone a decline.
This caused the top officials of the Water Management Department taking temporary actions for rectifying the leak, instead of reporting the issue to higher management authorities with a proper risk assessment study to convince the authorities for an immediate shut down of the BF-GCP systems for taking up the work of replacing the leaking old water pipe. The temporary leak plugging acts done by the department by welding etc further aggravated the condition of the leaking pipe.
And within another couple of days, in one shift, all of a sudden the pipe ruptured. Water splashed out from the rupture and the GCP water supply pressure dropped. The shift personnel of the water management department informed their seniors and the matter got communicated to all the other concerned engineers and managers of the Energy Management Department and the BF Department. The heavy leakage of water from the ruptured pipe was now flooding the pump house and the pumps had to be stopped to prevent flooding. Those concerned officers, engineers and operating people of the steel plant rushed to the pump house to physically assess the rupture in the collector pipe.
But without them ever realizing, a major tragedy was about to happen shortly. As the water pressure in the GCP water supply pipe decreased due to the rupture and the subsequent pump stoppage, the water in the pipe line began to drain out through the rupture as the rupture point was the lowest point. Soon the water in the supply main got emptied and the toxic BF gas began to fill the water pipe from the scrubbers and began to leak out through the pipe rupture in the pump house.
Carbon monoxide is an odorless gas and a swift acting toxin. The pump house is a closed enclosure and the toxic gas was getting mixed with the air in the pump house. This posed a two fold danger. First the pump house became a toxic gas chamber. Any one who inhaled now got affected by carbon monoxide with imminent lose of consiousness and possible death. Secondly, the pump house was getting an explosive mixture of fuel gas. Certain low concentrations of monoxide gas with air is highly exlosive and it could explode like a bomb causing major damage with a minor spark any where!
The people who rushed to the pump house now was getting affected by the toxic gas and they were simply falling down unconscious. It took others who followed those went earlier down to the pump house some time to realize what was happening. And when they realized it, a number of persons were already affected. Fortunately, the rest of the engineers realized what was happening and they could take immediate preventive measure that could save the pump house from exploding!
Several people got affected and about seven lost their lives due to gas poisoning. It took the steel plant a few days to restore normal production! What production they obtained earlier by post poning a planned shut down all wiped out now due to this accident.Perhaps the loss was much more including precious lives of people!
A series of enquiries followed. Some by the statutory authorities, some by techincal empowered groups of the company. All enquiry committees and commissions brought out their own findings and suggestions. While the technical cause was pin-pointed, the committees apparently failed to recognize the root cause of the problem- the cumulative effect of technical management errors that had been happening for a long period!
I will now discuss some of these errors that keep happening in Indian process industries which most of the Indian engineers assigned with the task of factory management routinely seem to ignore or do not consider as some thing important to be addressed properly:
1. Indian engineers are not very much comfortable with the concept of unit wise operation of multiple process units and systems. If there are more than one process equipment or system for achieving higher production, the Indian engineers quite often force the plant suppliers and designers to interconnect those systems for higher flexibility of operation and maintenance. For example, it was much safer in the above mentioned case to operate and maintain each of the BF systems as self contained individual systems instead of an interconnected system of six BFs. The interconnections enhance system complexity for engineers to understand and comprehend causing new comers be confused about all the functions of the plant systems. This causes neglect of some parts of equipment and systems, especially those that are to be operated only during exigencies! Whenever, a plant accident or breakdown take place, the subsequent actions would be to have more interconnections and more stand by units which enhance the system complexity rather than reducing it in actual practice.
2. Indians quite often are not very comfortable with record keeping. They seldom make efforts to keep all technical drawings concerned with the plant process and systems. Even if such drawings and documents are available, hardly any effort is made to ensure that all concerned engineers study those drawings and documents carefully and comprehend those fully.
3. Design engineers and plant operation and maintenance engineers work in isolated pockets. They are seldom encouraged to understand the philosophies and technicalities involved in each others' area of work. This often causes erroneous assumptions and subsequent errors. For example, in the case discussed above, the original design engineers had provided certain provisions of water sealing and siphoning arresters in the pipelines that prevented any gas to escape through the water lines when water got emptied in the pipelines under rare situations as had happened. But many such systems got removed or erroneously fixed in later years as the concerned maintenance engineers did not understand their functions or principles of operations.
4. The steel plant management had adopted a system of inter departmental transfers of engineers without ensuring availability of experience and competence of engineers and technicians with regard to their own area of work. This had caused experience vacuums in many areas with the teams handicapped with understanding of technical issues and technical communications. In some cases, the junior engineer felt difficulty to communicate a problem to his senior as the senior had less experience in the field and vice versa. In the case discussed, such a situation had caused the concerned people to foresee the problem in advance. Had there been the required experience and competence at all levels, this problem would have never got escalated to a major mishap like what had happened.
5. Of late, the Indian managements of technical facilities are more and more becoming non technical in attitude and nature with the top managements losing their capacities to understand the complexities involved in technical works. As finance, marketting and other non technical fields are becoming more and more important at the board levels of decision making, the voices of technocrats in companies are getting diluted and they no more get any chance to make the non technical board members to understand the technical problems. This causes the top technocrats to either discard their technical thinking and behave like non technical persons. They in turn discourage technical issues to be discussed at top levels. Real technical and engineering problems now get reduced to lower level issues. This seriously enhances the technical risk levels of Indian process plants. This attitude then percolates downwards and adversely affect the technical thought processes of all engineers working in Indian factories and process plants. Indian engineers working in processing facilities of companies now seldom get any reward for proactive or creative professional thinking. On the other hand, erroneous technical conclusions and erroneous punishments to engineers are on the rise now in India making professional engineering and technical work something not preferred by brilliant engineers.
I hope eminent engineers from India would open up their minds to express their thoughts and comments on the above.