IVAN STEVANUS CHANDRA

HSE and Process Safety Practitioner

What’s up Indonesia: Industrial Disaster

Unraveling the Blast: Investigating and Technical Review on Barriers Management for Furnace
Smelter Explosion
Objective for this presentation:
• To know Major Accident Event (MAE) resulted in
Indonesian Industries in specific about furnace
explosion.

• To get overview of Furnace application in Mining and

Oil&Gas Industry. Unravelling
• To comprehend risk factors about furnace explosion. the Blast
• Lesson learn: What can go wrong? How bad could it be?
And How often might it happen?
Presentation Objectives
Empat Chapter Utama: Investigation and
Chapter 1 – Introduction about Major Accident Event and Technical Review
General Application of Furnace
on Barriers
Chapter 2 – Critical Task and scenario based for Furnace Management for
Incident
Furnace
Chapter 3 – Hazard identification and Risk Assessment
Explosion
Chapter 4 – Barrier Management Approach and Lesson
Learn
What to learn?
Conclusion
Unravelling The Blast
Chapter 1 – Introduction about MAE and General Application
of Furnace

Indonesian Major Accident Event

What is Furnace
How is it working
 Indonesian Major Accident Event
Related to Industrial Risk
❖ Major Accident Event Definition (Industrial Risk)
• A fire, explosion or the release of a dangerous substance involving death or serious personal
injury to person on the installation or engaged in an activity on or in connection with it.
• An event involving major damage to the structure of the installation or plant affixed there to or
any loss in the stability of the installation or a collision of a vehicle within the installation where
the cost damage more than 100 million USD.
• In some companies, any other event arising from a work activity involving a single fatality or
injury to five persons on the installation or engaged in an activity in connection with it.
• In some companies, any other event arising from a work activity involving unwanted
situation/condition where the environmental impact or national or international notification.
→ For HSE point of view, people consequence or fatality is considered as intolerable risk or for
other risk category (to Asset, to Environment, to Public Notification) aligned accordingly. Therefore,
risk reduction measure (RRM) must be accomplished where the measures taken aligned with
ALARP (As low As reasonably Practicable).
Keyword: Tolerable and ALARP
 Indonesian Major Accident Event Portfolio
Disclaimer – inexhaustive
❖ Indonesian MAE Portfolio (since 2010)
• Indonesian people is a “pardoning people”.

Incident
Incident Incident Plumpang,
Incident Buyat, Kembang Api Balongan, 2023
Minahasa 2012 Tanggerang, 2021 Incident Sawah
2017 Lunto, 2022

2012 2017 2019 2020 2021 2022 2023 2024

Incident Incident
Pengelasan Incident
Smelter 2
Incident Bijih Plastik Smellter Smelter
Morowali, 2022
Tanggerang, 2019 Morowali, 2023 Morolali, 2023
 What is Furnace
Furnace in Mining and Oil&Gas Industry
❖ Furnace (Tungku/Tanur Tiup) Definition
• A container that is heated to a very high temperature so the substance that put inside will
burn/melt then to some extent this substance technically get a physical condition separation.
❖ Furnace in Mining Industry
• Known as Furnace smelter (Tanur Tiup) for doing the metal casting/purification.
• 4 steps for furnace smelter in general:
• Raw Material Intake
• Furnace Heating
• Reduction process
• Separation between product and waste

❖ Furnace in Oil & Gas Industry

• Known as Furnace or fired heater system for heating HC e.g. Crude Oil.
• Fueled with Off gas/Natural gas or Fuel Oil.
 Furnace Smelter in Mining Industry
How the Furnace Works and Past Incident
❖ Animation of EAF or ESF
 Furnace in Oil and Gas Industry
How the Furnace Works
❖ Basic Function of Furnace

Vital Equipment inside the

furnace:
1. Burners and source of
fuel
2. Stack and Refractory
Unravelling The Blast
Chapter 2 – Critical Task and scenario based for Furnace
Incident

Process Step of Furnace

Critical Task
Scenario Based Incident Carbide Incident
 Process Steps in Furnace System (in General)
Critical tasks for Furnace
❖ Critical Tasks of Furnace in Oil & Gas Industry
• 3 Tasks: During Start-up/Operation/Maintenance.
• Start-up and Operation will be the critical task for Furnace Operation.
• Most known incident with fatality occurred during start-up where operator activate the Furnace.
❖ Critical Tasks of Furnace Smelter
• Depend on what type of Furnace.
• Operation
• Slag/Raw material entering the Furnace Chamber – Dumping in the molten
• Water Introduction (Leak, Spill) by IF (Instrument Failure) or HE (human error)
• Swing/broken support during molten metal/Lava
• Maintenance
• Dust/Powder/Liquid explosive during cleaning

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 Critical Task for Furnace Operation
Furnace in Mining and Oil&Gas Industry
❖ Critical Tasks of Furnace in Oil & Gas Industry
• 3 Tasks: During Start-up/Operation/Maintenance.
• Start-up and Operation will be the critical task for Furnace Operation.
• Most known incident with fatality occurred during start-up where operator activate the Furnace.

❖ Critical Tasks of Furnace Heater

• Start-up (Excess of HC in the firebox)
• Instrument failure (burner isolation valves [Main and Pilot] passing.
• Instrument malfunction (Pressure controller on FG Line or Pressure regulator on Pilot Line)
• Human Error (Fuel Gas valve inadvertently open)
• Instrument failure (failure of inlet FG valve and FG feed fluctuation) – Liquid carryover scenario.

• Operation
• Instrument malfunction (Force Draft fan trips; Air dampers open to non lit burners) – Flame out scenario.
• Upstream upset (unstable feed of Fuel oil) – Liquid carryover scenario.
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 Scenario Based – EAF Explosion, Carbide Industry – Kentucky, USA.
2 FAT, 2 Injured – Exposed to 2000 F Molten Metal and Steam
❖ Incident Description
• Monday, 21 March 2011, Electric Arc Furnace (EAF) overpressured
and emitted powdered debris, hot gasses and molten calcium
carbide from the furnace reactor to the double pane reinforced
glass window of control room.
• Cooling water leaks from the furnace cover into the furnace leading
to Furnace Overpressure, ejecting molten/solid and powdered
debris, hot gasses of Calcium Carbide with T near 3800 F (2100
C).
• Cloud of debris & smoke traveled high enough to obscure the five
story building.
❖ Immediate and Underlying Causes
• Refractory lining thinning/fouling.
• Sudden eruption of hot liquid from furnace → Water leak (Boil-up).
• Accumulation of solid inside the hollow chamber when water leaks.
• Cooling water leak in furnace cover with ceramic lining worn.

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 Simplified Diagram of Calcium Carbide Process
Process and Chemical Reaction

CaO + 3C → CaC2 + CO

By product, coke contains of H2

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Unravelling The Blast
Chapter 3 – Hazard Identification and Risk Assessment

HIRA Definition and Tool

Introduction for Bow-tie Method
Scenario based – Bow-tie Assessment
Process Safety Tool
HIRA MODEL
IDENTIFY ASSESS CONTROL RECOVER

Limit the number and

Identify all threats, hazards,
and effects of activities and
operations
Assess and rank the HSE
risks of activities and
operations
Develop and implement risk
severity of the
control plans for activities
consequences of risks to
and operations
activities and operations

RECORD

Five Steps of PS HIRA: Identify, Assess, Control, Recover and Record.

- These steps are often described sequentially, in practice they overlap and are not always
distinct.
- This workflow shall be conducted for new assets, facilities, and/or activities as well as
regularly for existing facilities or operations whenever major changes take place.
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 Risk Assessment Tool
BowTie MODEL

Bowtie Assessment.
- Identify the Hazard and
Top event (e.g. Loss of
control/Loss of
containment) with all
credible initiating events
and potential
consequences.
- Review all the preventive
or existing barriers and
potential escalation and
recovery controls.

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 Lesson Learn from Furnace Smelter Explosion
Threat Protection Layer Top Event Mitigative Consequence
Barrier
Redundant
Multiple Location for sensors Inadequate
sensors Loss of Control Emergency Response
Management
Procedure with
4eyes principles

Pressure/
A. Water leak (tube Flow Fire and Explosion
rupture, refractory Sensor of With multiples
fouling) water line Fatality
Over Emergency
pressurization Response
of Furnace
B. Human Error Procedural Emergency leads to
(Dumping RM/Slag) Monitoring Credit Shutdown Deflagration
Sensors System and Lava Mechanical
(Weight, relesaed Integrity
C. Instrument failure Temperatur Program Loss of Containment
(Electrode e, Camera) leads to
overheated; broken Fire/explosion With
support) Asset Damage

Depend on the
type of furnace
 Lesson Learn from Furnace Explosion in Oil & Gas
Threat Protection Layer Top Event Conditional Mitigative Consequence
Modifiers Barrier

No Secondary Level Inadequate

sensor Loss of Containment Emergency Response
Management
Bypassed

Operator
response to Loss of Containment
A. Human Error Instrument leads to Fire and
Sensor Explosion
Purging Emergency With multiple Fatality
system Probability of Response
HC
Ignition (POI)
accumulation
Hydrocarbon
B. Instrument failure Operator leading to fire
Probability of Gas Detector
response and Explosion Loss of Containment
Explosion
to Procedural (POE) Mechanical leads to Fire and
Secondary Credit Protection explosion
Level With Asset Damage
C. Process Upset Sensor more than 100 mio
USD

Inadequate
filling procedure
Unravelling The Blast
Chapter 4 – Barrier Management Approach and Lesson Learn

Barrier Management
Key important factors to be tolerable risk
 Definition
What is Barrier and ALARP
❖ Barriers/Safeguards
• Barriers or safeguards are put in place to reduce risk from hazards
• Barriers can be PREVENTIVE or MITIGATIVE
• PREVENTIVE barriers reduce the LIKELIHOOD.
• MITIGATIVE barriers reduce the SEVERITY.
• Equipment or hardware barriers – PSVs, SIFs (preventive), F&G detector, firewater pump
(mitigative)
• Human barriers – Operator executing a procedure, doing surveillance rounds
• Mix – Operator (human) responding to an Alarm (equipment)
• Not Barriers – training, preventive maintenance, procedure in itself
❖ ALARP
• ALARP is the point at which a further risk reduction in the form of an additional barrier or
mitigation (considering the cost, time, and effort to put such in place) becomes grossly
disproportionate to the extent of risk reduction achieved.
 ALARP demonstration
Risk Cost of
Barrier

Tolerable Criteria

ALARP
May not?
Barriers

Incident model
 Barrier Management
❖ What is Objective a Barrier Management (BM)?
• BM helps companies identify human, technical and organizational barriers and to manage those
barriers to secure stable, safe and predictable operations using an integrated system of bow tie
analysis and barrier dashboards.

❖ Determine the Independent Barriers

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 Barrier Validity Criteria
❖ Effective, Available, Survivable and Reliable
• Strong, Fast and Big Enough.
• Active barriers (normative have to have a sensor, logic and control system).

❖ Independent
• Not dependent of any other barrier.
• Not having a common sensor or logic in common with another barrier.
• Not related to the threat.

❖ Auditable
• Being maintained/inspected

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 Conclusion
5 Important things in Major Accident Prevention
❖ HAZARD Identification and Risk Assessment
Backbone for Accident Prevention and HSE Program
❖ Eliminate or reduce hazard through design
Understand the process and familiar with the system
❖ Learn from the Others “Incident”
Engage people for any “deviation” and share the incident as lesson learn
❖ Document and Communicate
Require Attention and put effort to all employees (Top, middle management and
shopfloor team)
❖ Develop the culture
Shared values, attitudes, behaviors, and standards that make up a work
environment.
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In summary, there will be always a way to prevent accident/incident

Strong in Risk Assessment Application will help you to better understand the Hazard and Risk
Technology speeds and AI rising to help human so keep greedy on the knowledge and always passionate in life.

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 Salam Sukses dan Semangat Belajar.

Kejarlah Mimpi mimpi mu hingga terealisasi dikehidupan dan

inspirasimu membara buat orang disekelilingmu

Ivan S. Chandra
Process Safety and HSE Practitioner

CHANDRA Ivan Stevanus | LinkedIn

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