Lessons and Learnings

from
Vizag Gas Leak-Disaster

Efficaz Consulting & Solutions

Nov 2020
Facts
A Chemical plant located at  Visakhapatnam, 
Andhra Pradesh, India, had a gas leak incident on early
morning of 7th May 2020
The resulting vapor cloud spread over a radius of
around 3km (1.86 mi), affecting the nearby areas and
villages.
Uncontrolled Styrene Vapor Release from M6 Tank
(2450 KL)
Police, Legal and other key agencies
response..
National Green Tribunal bench ordered Company to deposit an amount
of INR 50 crore (US$7.0 million) as an initial amount with the 
District magistrate of Vishakapatnam to mitigate the damages caused due to
the incident.
FIR was filed against Company by the local police on
IPC 278 (making the atmosphere noxious to health),
IPC 284 (negligent conduct with respect to poisonous substance),
IPC 285 (negligent conduct with respect to fire or combustible matter),
IPC 337 (causing hurt by act endangering life or personal safety of others),
IPC 338 (causing grievous hurt by act endangering life),
IPC 304 (causing death by doing any rash or negligent act not amounting to
culpable homicide
National Human Rights Commission of India (NHRC) gave notice to the
Andhra Pradesh Government and the central government that it considered
the incident a gross violation of India's constitutional right to life.
Consequences
As per the reports,
Five villages got affected
The death toll was 13 (thirteen)
25 people are critical
More than 1,000 people became sick after being exposed
to the gas.
585 citizens got hospitalized
Issues face by villages are breathing difficulties and
sensations of burning eyes due to gas leak
Lessons and Leanings
Factor How might have been avoided and Subsequent
Lessons

 Insufficient Maintenance. Tank Cleaning was Maintenance shall not be perceived as cost
done 5 years back. Possible corrosion. centre. Risk Based Maintenance is the key.
 Improper Storage like OISD 108 (Recommended Practices on Oil
•Inside lining was not there. Storage and Handling) and AICHE
•Constriction of Material is not Carbon Steel. compliance are critical.
Operation Errors, Temperature data taken from Training on Process Safety Management
bottom where cold material is expected. (PSM)
This plant was originally established in 1961 Merges and Acquisition tends to ignore the
as Hindustan Polymers, Then merged with Critical Safety aspects.
McDowell Holdings on 1978, then acquired
by the South Korean company in 1997 which Old facilities risk is underrated due to “no
operate the plant until now. accident history”
Time of the incident was pandemic and Onsite Emergency Plan shall be realistic.
lockdown. Unplanned shutdown shall be a scenario
which every premises shall be planned.
 Factor How might have been avoided and
\ Subsequent Lessons
Company believes that they don’t need Clients tends to under estimate the risk and
MoEFCC approval for expansion but compliance.
MoEFCC insists other wise

State Government doesn't insisted for There are some gray areas, where it is not
central approval all along, till the year 2018 clear on legal compliance requirement for
particular plant or scenario. But for any
mess-up client will be at the receiving end.

Between 2006 to 2018 no central Companies shall go beyond legal

environmental clearance available with requirement and look ahead for safety and
company, first time applied in 2018 for environment compliance voluntarily
expansion

Entire issue was because material has Adequate care needed continuously for
Polymerization property Unstable chemicals, rapid reacting
chemicals and incompatibility of chemicals.

Valve malfunction, as in odd time (3.45 pm) Firm knowledge and assessment on Layers
Refrigeration Unit was OFF of Protection Analysis required.
 Factor How might have been avoided and
Subsequent Lessons
STEL (Short Term Exposure Limit) of It might have been for STEL value as the
Styrene is 100 ppm, chemical is not only flammable but also
toxic
IDHL (Immediate Danger to Health and
Life) is 700 ppm Toxic chemicals are more dangerous than
flammables.
Gas detector kept for 20% of LEL i.e 2200
ppm
As per company's version, CCTV, DCS and Calibration and integrity among different
IST time was not matching. The delay of 12 instruments are very critical.
minutes between the CCTV & DCS and
delay of 4 minute between the DCS and IST Instrumentation team shall be sensitize on
Safety aspects of gaps, failure, malfunction,
showing of incorrect data.
Change in design of cooling system which Brainstorming Sessions with third party
lead to huge difference in material safety consultant, design team, operation
temperature in top and bottom of tank. staffs needed for this type of change. In
short HAZOP might have done for change
Previously flow type now it is bottom of design.
discharge
 Factor How might have been avoided and
Subsequent Lessons

Temperature sensor at bottom but Temperature from different levels of tank

refrigerated material also discharge at might have taken for correct assessment of
bottom. tank temperature, effectiveness of cooling
system or to ensure no polymerization is
Only one temperature sensor. taking place.
From vent, no condensing unit for the escape No chemical shall escape the environment
gas or flare arrangement or collecting without neutralizing specially from Storage
arrangement Tanks.
High Temperature Alarm was not available Alarms and Trips are essential part of Process
Safety.
Plant expanded its capacity five times If production capacity is expanded then
between 2006 and 2018. safety, integration, utilities, man power,
layout etc will get impacted. Study like
Hazard Identification Study (HAZID) might
have address safety loopholes if any on every
stage of development
Company head office is South Korea Most of the time HO or other plant replica
followed without considering the local
factors. Like here, temperature in south
Korea is much cooler than Vizag.
 Factor How might have been avoided and
Subsequent Lessons
Tank not been coated with inorganic zinc Plant has not conducted the Fire and
silicate linings to provide electrical Electrical Risk Assessment on annual basic
grounding. which might have been address in regular
audits and its respective compliance.
35C is maintained as per SOP where as flash Recommended storage temperature of
point itself is 31C and polymerization start chemical is 20 C. Hence selection of right
at 33.9 C. critical for control is critical for safety.
Thank You
Maintaining the temperature is manual. For aspects of process need to be made
automatic for improvised safety.
Unattended for longer time Having the right skill set of people, training
on Emergency Handling, Mock Drill is very
essential for plants.

Off site emergency planning, off site mock Quantitative Risk Assessment (QRA) for
drills are not conducted. toxic release might have given the tentative
surrounding area which might get affected.
Accordingly preventive actions might have
been planned.
 Thank You

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