Revelations from  an "old" audit carried out on a facility where Pyro compounds were being handled.

By Mervyn Traut

It is always useful to reflect on findings from previous audits and those from other facilities and then, from these, to assess whether there has been an improvement in one’s own operations.
When delving into an archive containing historical audit documentation, the following was revealed and it made me wonder how many operational areas out there, may have similar deviations that were captured in this audit.
The operational details relating to the specific operation have been edited but the audit findings are very real !

AUDIT FINDINGS

As a start to this audit, the Process, and Instrumentation Drawings (P&IDs) were interrogated to ensure that they reflected the process being audited. These also served to give the team a route/direction to follow during the audit.

ENGINEERING BASED FINDINGS

A. P&ID DRAWINGS FINDINGS.

1. When the P&ID drawings were checked, the version given to the audit team, was one that did not fully reflect the actual plant and was out of date.
2. Changes had been manually made to it and these changes had not been through the mandated management of change (MOC) process.
3. The critical trip systems had been ill-defined and not all of these were reflected on the drawings.
Following on the above, the Service Schedules were audited

B. SERVICE SCHEDULE FINDINGS

1. When interviewing the engineering personnel on the details of how service schedules were carried out, it transpired that the present system appeared to be a “paper exercise”.

The schedule was found to consist of 23 pages which listed>700 items that needed to be checked, while the time allocated to the journeyman to do this was only 7 hours for completion.
FOR THIS SYSTEM TO BE REALISTIC AND EFFECTIVE, A COMPLETE REVIEW AND update WAS URGENTLY REQUIRED.
As the service schedules included compliance with the electrical zoning of certain sections to the plant, these were included in this audit as well.

C. ELECTRICAL ZONING

Several areas of the complex were susceptible to the generation of dust and in some reactions hydrogen. Therefore, electrical zoning was mandatory.
Regarding the zoning, there were significant non-compliances and adherence to specifications for both the instrumentation and electrical systems. THEREFORE, IT WAS RECOMMENDED THAT THE ELECTRICAL ZONING NEEDED AN URGENT REVIEW.

OPERATIONAL BASED FINDINGS

D. OPERATIONS

The plant was designed to be fully automated and was supposed to be controlled, monitored by a SCADA system.
Apparently due to financial constraints at the time, this was never installed. Thus, whilst parts of the system were automated and some systems were coded, manual intervention often had to be taken when serious safety issues required intervention.

• It was evident that about 80% of the plant was MANUALLY operated i.e. not automated.
• The only way of handling any NEW formulations or additions, was by manual intervention.
• The agitation speeds on the mixing/slurry tanks were not automatically coded and were adjusted manually by the operators.
• The transfer of the heel from one tank to another was carried out by overriding the system.
• The hydrogen detector for the silicon slurry area is still to be purchased.
• Operator competency was found to be seriously in doubt while operators had not been trained to use the system’s “Admin Mode” but were required to use it to on a regular basis, make certain adjustments.
• The Safe Operating Procedures (SOP’s) were incomplete and did not always reflect the actual operations on the plant. This was because changes had been made to operations and the procedures had not been updated and many had not gone through the management of change process.
• A function for calculating and making water additions to the mixing tanks is known was previously assigned to the Shift Manager and is routinely being carried out by the Operators who have not been formally trained to do.
• The Operators had not been passed out or retrained on the latest safe operating procedures (SOP’s).
  THE VERY URGENT NEED FOR UPDATING THESE WAS RAISED BY THE AUDIT TEAM.
• It is not possible to easily recover historical data on raw materials used, quantities used, operational parameters such as temperature and pressures etc. (these would have been captured on the SCADA). Measurements and figures are on graphs, in logbooks and on various reports but there is no formal reporting system in place to do so.
• Transfers of materials are made from one tank to another by using a quick coupling. The implication of doing this is that if the tank is coded as an “F” tank and now contains “Y” composition, the system must be “fudged’ to send it to the relevant section of the plant, by calling it F and not Y!!
• Sampling has become a major issue as the reaction vessel/mixer must be shut down while testing takes place. The proposed system of using a mobile miner was found to be inaccurate and no solution to that was found or attempted.
• After processing, the material is dried and from the drier, the material is dispensed into predetermined quantities and removed automatically. Product handling became a bottleneck when it was decided that each bucket needed to be sampled and tested. There have been reports of operators now moving empty and full buckets of pyro material manually to speed up operations.

THE AUDIT TEAM INSISTED THAT THIS UNSAFE PRACTICE BE STOPPED IMMEDIATELY.
FINDINGS DEALING WITH UNUSUAL EVENTS/OCCURENCES

E.THE HANDLING OF UNUSUAL EVENTS/OCCURENCES

During the questions raised by the audit team, operators mentioned that the formulation mixing tank legs had cracked and that they then had been strengthened by engineering. However, after that, there was evidence of further cracking. Further discussions revealed that the agitation stirrer speeds to the tanks were difficult to control and it appeared that” since adjustments had been made by engineering” and that the stirrer shaft speeds were now higher than before. (They were now at a maximum of 343rpm versus 229rpm which they were previously. It appeared that this may well have exacerbated vibration on the tanks and could well have increased the possibility of the legs cracking. There was no evidence that the change was documented.
2. The audit team raised the question wet any other problems, and this revealed that,

there had been a recent incident where a shaft had bent. This however was not regarded by the plant to be reported as an Unusual Occurrence (UOR)!

There were reports that the mountings to the shaft gear boxes have been strengthened and that the gear boxes are not fit for purpose. These were not seen as unusual
The above led to a discussion on what the plant regarded as an UOR. It was very evident that this was a very “grey” area and that there needs to be some very clear guidelines for defining UORs on the plant.

F. SOME ADDITIONAL ISSUES

1. The training of senior personnel was highlighted. Managers who are managing the operational staff often appear, to know less about the plant operations than those operational staff they are manging. This is mainly because the Managers do not receive the same degree of on plant training as the operators and when this does occur, training is being carried out using out of date SOPs with no formal training documents being used or with no training personnel input.
2. For operators person to person training was being carried out and here no formal training documents were being used and there was little or no training personnel input.