Borouge 2014 Lessons Learnt Booklet

Learning from Incidents
2014
Learning from Incidents
Jan – Dec 2014
“The real mistake is the one from

which we learn nothing”
John Powell
CONTENT
Borouge Values 03
Borouge Sustainability Policy 04
Message from CEOs 06
Message from VP, CHSE 07
HSE Performance 2014 08
Overview of 2014 Incidents 13
Lessons Learned 14
Watch out! The danger does not always
come from where you expect
Borouge
Values
We are one family, building upon our multicultural diversity.

We care for the health, safety and environment of our communities.
We act ethically and responsibly with integrity.
We treat everyone fairly, rewarding contributions and encouraging growth.
Respect
We go beyond expectations.
We set challenging goals and take ownership of our performance.
We strive for excellence and continually raise the benchmark.
We win through our commitment and passion to be the best.
Exceed
We thrive on creativity and innovation.

We respond to global challenges with sustainable innovative plastics solutions.
We explore “out of the box” solutions that drive continuous improvement.
We encourage and reward new ideas.
Create
We understand our stakeholders and deliver what is expected of us.

We build long term partnerships with our customers and the value chain.
We work together to achieve optimal results.
We lead by example.
Focus
03
Borouge Sustainability
Policy
We are committed to the well-being of society and preservation of the environment, while addressing
the economic expectations of our shareholders.
We are a leading provider of sustainable, innovative and value creating plastics solutions and we
conduct our business within the framework of our values, vision and mission, and in accordance
with applicable laws, regulations and industry standards. As a signatory of the Chemical Industry’s
Responsible Care® Global Charter, we apply best practices and pursue continuous improvement.
In line with the three Pillars of Sustainability, we commit to:
People: Social Responsibility

• Pursuing a goal of no harm to people and society
• Contributing to solutions that deliver a positive and sustainable impact on people’s lives
• Promoting the health and welfare of our people and the communities where we operate
• Building diverse and multi-cultural human capabilities and creating opportunities for individual
growth
• Fostering mutually beneficial partnerships and social initiatives within the industry and society
• Respecting and conforming to relevant social, cultural, legal and ethical aspects of society
Planet: Environmental Stewardship

• Addressing global challenges, such as climate change, water, food, energy, healthcare and
waste, with innovative solutions
• Minimizing waste and emissions, enhancing energy performance and optimizing the use of
natural resources, especially water
• Ensuring that energy performance improvements are considered throughout the duration of
the intended lifecycle of our assets
• Optimizing the positive health, safety, environmental, energy and societal impacts of our
plastics throughout their lifecycle
Profit: Economic Growth

• Maximizing shareholder return throughout the value chain
• Enhancing the reputation of Borouge and the image of the plastics industry
• Ensuring that the design, operational and technical integrity of our assets are sustained
throughout their lifecycle
• Identifying major operational hazards and minimizing associated risks to a level which is ‘as
low as reasonably practical’
• Establishing appropriate security measures against identified vulnerabilities
• Optimizing global procurement opportunities in cooperation with Industry Partners
• Our commitment to this Sustainability Policy is demonstrated through visible leadership
and effective communication, a proactive sustainability performance culture supported by
transparent monitoring and reporting systems, and continuous investment in our people,
innovation and assets. Furthermore, we encourage all our Stakeholders to commit to this
Policy and align their operations and activities accordingly.
Abdulaziz Alhajri Wim Roles

Chief Executive Officer Chief Executive Officer
Abu Dhabi Polymers Co. Ltd. Borouge Pte Ltd.
05
Message from
CEOs
Abdulaziz Alhajri Wim Roles

Chief Executive Officer Chief Executive Officer
Abu Dhabi Polymers Co. Ltd. Borouge Pte Ltd.
At Borouge, we are guided by our vision to provide and create an atmosphere of trust and pursue the
path of excellence in health, safety and environment.
Our operations are structured around HSE systems that put people first. From a business perspective,
focusing on HSE is an incredibly prudent activity. Inherently, safer operations reduce risk in a variety
of manners which is significantly rewarding to the sustainability of our business and interest. It is our
belief that every incident is preventable and with a combination of proper education and training, we
can continue to operate without incidents. This belief is engrained in every decision we make as an
organization. After all, only a safe decision is the correct decision.
In everything we do, safety should be the focus, everywhere at all times. We need to take care of
ourselves and our colleagues and should never forget the loved ones that are waiting for us to return
home safely.
We believe that experience is the best teacher and by learning from past mistakes, we could build a
better and safer future by taking proactive actions to avoid the same or similar mistakes.
We strongly encourage you to read this booklet to equip yourself with the knowledge and apply the
learnings in the day-to-day activities.
Thank you
06
Message from
VP, CHSE
Hussain Al Hammadi
VP, CHSE
We have released the 1st edition of Learning from Incident booklet for 2013 to acquire the benefit of
past lessons and considering the concept of continuous improvement in mind. Now, we are pleased
to release the 2nd edition of Learning from Incident booklet which covers the lessons learned of
significant incidents reported in 2014.
We have witnessed that the highest number of incidents were related to Golden Safety Rules on
Land Transportation, Permit To Work and Personal Protective Equipment. Our focus for year 2015 will
be to prevent these incidents being repeated.
This book is recommended for all to learn from the past experiences and apply these learnings while
doing their day-to-day work activities.
Thank you
07
HSE Performance 2014
ADP
s
tor
Fatality
ica
0 Target
PSI (Tier 1&2): ≤ 6
Ind
LTI: 2, RWC: 1 Flaring: 276 KT

PSI (Tier 1&2): 2
g
Flaring: 174 KT
gin
Target
TRI Freq.: 0.15 TRI Freq. ≤ 0.3
Lag
MTC: 5 FAC: 10
FI: 1 PD: 46 VI: 12
NM:125 UA: 140 UC: 907
Pro
PSI(Tier 3): 117
Target
a
70%
ctiv
KMS Actions Closed Out: 90%
eM
Target
% Serious Potential Incidents and TRI 90%
Investigations: 100% eas
s
Target
tor
ure
HSE Critical Equipment Tested: 89% 90%
ica
s to
Target
Ind
Management of Change: 91% 90%

Red
g
din
Target
u
ce
HSE Audits undertaken as per plan: 100% 80%

Lea
Inc
Target
ide
SOT Conducted: 4270 60%

Observation Tours (UA & UC Closed): 59%
tsn
ETP Performance: 64 ppm Target

(based on weighted average of COD) 80ppm (max)
Target
HSE Training Sessions conducted: 295, Contractor Employees Trained: 2703, 85%
Employees Trained: 2281, HSE Training (% of Trained people versus plan): 91%
Total Man-hours ADP {Ruwais (excluding SSC) + Abu Dhabi}: 54.89 Million
Safe Man-hours since last LTI: 6.40 Million
LTI Lost Time Injury PSI Process Safety Incident FAC First Aid Case
PD Property Damage NM Near Miss UC Unsafe Condition
RWC Restricted Work Day Case MTC Medical Treatment Case FI Fire Incident
VI Vehicle Incident UA Unsafe Act
08
Unsafe Condition 907 62% Utilities & Off-Site 1/2 235 16%
Unsafe Act 140 10% Ethylene Unit 2 210 14%
Near Miss 125 9% Polyethylene 1/2/3 192 13%
PSI Tier 3 117 8% Laboratory 148 10%
Event Mgt-Eqpt Failure or Damage 78 5% Polypropylene 1/2 143 10%
Property Damage 46 3% Olefins Conversion Unit 107 7%
Vehicle Incident 12 1% Ethylene Unit 1 85 6%
First Aid Case 10 1% Ethylene Unit 3 68 5%
Medical Treatment Case 5 0.30% Utilities & Off-Site 3 62 4%
Security Incident 3 0.20% Plant Availability 56 4%
PSI Tier 1 & 2 2 0.14% Administration 46 3%
Environmental Spill 2 0.14% CHSE 47 3%
Lost Time Injury 2 0.14% Borouge 3 15 1%
Fire Incident 1 0.07% Polyethylene 4/5 18 1%
Occupational Illness 1 0.06% Polypropylene 3/4 13 1%
Restricted Work Case 1 0.06% Low Density Polyethylene 7 0.48%
/Crosslink Polyethylene
HSE Incident HSE Incident

Type Wise Area Wise
Hydrocarbon 44 Land Transportation 39%

Chemical 9 PTW 20%
Acid 6 PPE's 16%
Steam/ Water 5 Working At Height 13%
Polymer 4 Lifting Operations 8%
Oil 3 Excavation 4%
Nitrogen 2
Loss of Primary Containment Golden Safety Rules

Leak Material Violation
09
HSE Performance 2014
PTE
s
tor
ica
Fatality: 0
Ind
LTI: 1
RWC: 0
g
gin
Target:
Lag
TRI Freq.: 0.23

TRI Freq. ≤ 0.3
MTC: 0 FAC: 7
PD: 97 VI: 9
Pro
NM: 33 UA: 53 UC: 143
a
ctiv
Target
eM
% HSE Action Closed Out: 100% 90%
eas
s
Target
tor
ure
% Serious Potential Incidents and 100%
TRI Investigations: 100%
ica
s to
Ind
Target
Red
HSE Committee Meeting: 203 190

g
din
u
ce
Target
Lea
Borouge Golden Safety Rules Implementation: 100% 90%

Inc
ide
Target
n
Site Observation Tours Conducted: 2,428 1,565

ts
Employees accepted the invitation: 1,626 Target

No. of employees attended: 1,543 90%
HSE Training Attendance (Training Invitation Accepted versus Attended): 95%
Total Man-hours PTE : 4.34 Million

Safe Man-hours since last LTI: 4.19 Million
LTI Lost Time Injury NM Near Miss FAC First Aid Case
VI Vehicle Incident MTC Medical Treatment Case UC Unsafe Condition
RWC Restricted Work Day Case UA Unsafe Act PD Property Damage
10
Unsafe Condition 143 42%
Property Damage 97 28%
Unsafe Act 53 15%
Near Miss 33 10%
Vehicle Incident 9 3%
First Aid Case 7 2%
Security Incident 1 0.30%
Lost Time Injury 1 0.30%
HSE Incident
Type Wise
Ruwais Distribution Center 118 35%

Terminal Loading 58 17%
Material Handling 56 16%
Khalifa Port 45 13%
Jebel Ali Port 41 12%
Borouge Innovation Centre 11 3%
Middle East and Africa 6 2%
South East Asia Logistic Hub - 6 2%
Singapore
Shanghai Logistic Hub 1 0.3%
Mumbai 1 0.3%
Compounds Manufacturing 1 0.3%
Plant
Land Transportation 47%

HSE Incident
PPE's 23%
Lifting Operations 18% Area Wise
PTW 8%
Working At Height 3%
Confined Space Entry 1%
Golden Safety Rules

Violation
11
Personal Protective Equipment
(PPE) compliance is mandatory
12
Overview of 2014 incidents
Applicable Golden
Sr.No. Date Location Title Type Page
Safety Rule
Innovation Medical Treatment
1 16-Jan-14 Falling inside a pit Not applicable 14
Centre Case
Personal protective
2 5-Mar-14 Laboratory Frostbite injury First Aid Case 16
equipment
Singapore
3 25-Mar-14 Forklift rolled out Vehicle Incident Land transportation 18
Hub
Restricted Work Personal protective
4 30-Mar-14 PP1 Finger injury 20
Case equipment
5 15-Apr-14 CMP Burn injury First Aid Case Permit to work 22
Material
6 6-May-14 Man-lift hydraulic failure Near Miss Working at height 24
Handling
Manual hoist falling
7 13-May-14 LDPE Near Miss Lifting operations 27
from overhead beam
Personal protective
8 1-Jul-14 U&O 1/2 Acid splash incident First Aid Case 28
equipment
9 5-Jul-14 RDC Collapsed pallet Property Damage Lifting operations 30
Hydrocarbon leak from
10 2-Aug-14 EU1 Process Safety Not applicable 32
exchanger channel head
11 2-Aug-14 PE4 Nitrogen hose burst Process Safety Not applicable 34
12 13-Aug-14 U&O 1/2 Flare system failure Process Safety Not applicable 36
Innovation Personal protective
13 26-Aug-14 Thumb injury First Aid Case 38
Centre equipment
Personal protective
14 14-Sep-14 OCU Acid splash incident First Aid Case 40
equipment
15 16-Sep-14 EU1 Fire incident Process Safety Not applicable 41
16 17-Sep-14 SEALH Thigh injury First Aid Case Not applicable 42
Innovation Door glass panel
17 23-Sep-14 Property Damage Not applicable 43
Centre shattered
18 22-Oct-14 PE5 Leg fracture injury Lost Time Injury Working at height 44
Training
19 28-Oct-14 Finger injury Lost Time Injury Not applicable 46
Centre
Medical Treatment Personal protective
20 29-Oct-14 PP1 Burn injury 48
Case equipment
Personal protective
21 9-Nov-14 Laboratory Thumb injury First Aid Case 50
equipment
Underground cooling
22 12-Nov-14 OCU Property Damage Not applicable 52
water pipeline failure
Technical Late Response to
23 17-Nov-14 Near Miss Not applicable 53
Building emergency gas alarm
24 8-Dec-14 XLPE Fall from height First Aid Case Working at height 54
Personal protective
25 9-Dec-14 PP3 Finger injury First Aid Case 56
equipment
26 15-Dec-14 Laboratory Finger injury First Aid Case Not applicable 57
13
2014
16
JANUARY Falling inside A pit
APPLICABLE GOLDEN SAFETY RULE
Not applicable
Key learnings Incident summary

While conducting testing and commissioning activities at the
All risks should be properly Innovation Centre, one person from the team misjudged his
identified, evaluated and step and fell into a 1.1 meter deep pit, resulting in a sprain in
controlled before the start his left leg.
of any activity.
What went well?
Knowing about hazard is not • Swift response from the ambulance.
enough; control measures
must be implemented to Why did it happen? Cause(s)
avoid accidents.
• No hard barricade around the pit.
• Inadequate risk assessment by contractor.
Remain vigilant at the work • Lack of concentration of the injured person.
place; keep your focus on
potential hazards of your Actions to prevent re-occurrence
surroundings and report
• Temporary barrier to be maintained in place until the
concerns. permanent equipment is installed in the pit.
• Conduct joint periodic HSE walkthroughs with the
Raise you perception of the Contractor and Borouge representatives in Innovation
possible risks and intervene Centre building and ensure control measures are in place
to avoid accidents.
when you observe any
• Carry out awareness training on hazard identification and
unsafe act or condition. mitigation measures for Innovation Centre personnel.
• Communicate lessons learned from this incident to all
Borouge PTE employees.
• Organize Hazard Identification and Mitigation measures
training at Innovation Centre.
14
Ensure that open pits are always barricaded
with posted warning signs
Survey your work area to identify hazards

before the start of any activity
2014
5
March Frostbite injury
Personnel
protective
equipment

The laboratory technician received a cold burn injury on his
Any modification should only left hand middle finger, when the rupture disc of the liquid
be carried out with approved ethylene sample cylinder burst in the gas chromatography
Management of Change. room in laboratory.
Ensure that effective What went well?

incident investigation is • Injured person prevented the further exposure of liquid
carried out and its actions ethylene by placing the cylinder under the fume hood.
are implemented. • Initial first aid was provided to the injured person in the
laboratory.
• Injured person was taken to the hospital for further
Strictly implement the
medical treatment.
preventive maintenance
program as per Why did it happen? Cause(s)
the manufacturer’s
recommendations. • Liquid ethylene sampling point was modified from the
original design without Management of Change (MOC).
• Lessons were not learned from the previous similar
Strictly implement the incidents.
Golden Safety Rule on PPEs. • Current sampling Standard Operating Procedure (SOP)
for liquid ethylene was not updated as per the current
sampling configuration.
• Preventive maintenance program was not followed as per
manufacturer’s recommendation.
• No pre-task hazard analysis was conducted to identify the
PPE requirements.
Actions to prevent re-occurrence

• Perform hazard analysis.
• Establish and communicate leadership expectations and
accountabilities for incident reporting and management.
• Revise the SOP of liquid ethylene sampling, handling &
analysis by incorporating the results of the hazard analysis.
• Implement a preventive maintenance program for sample
cylinders.
• Train employees on new SOP requirements.
16
Use gloves for handling chemicals in laboratory
Ensure the door of the fume hood is always closed

2014
25
March Forklift rolled out
Land
transportation

During the transfer of forklift at warehouse from level 3 to 5,
Staying focused and alert the forklift rolled out due to loosened lashing belt that caused
of any abnormal situation the forklift to move out of its position.
could prevent serious
accident. What went well?
• Timely response by respective departments and
Only competent personnel personnel.
shall execute the task • No injury.
assigned. • Driver was aware and alert of abnormal situation.
Avoiding forklift transfer

Why did it happen? Cause(s)
activities could minimize or • It was discovered that the lashing belt used to secure the
eliminate re-occurrences of forklift (prevent movement) was not properly tightened.
similar incidents. • The loose tension of the lashing belt was not discovered
by the warehouse coordinator.
• The warehouse coordinator missed the forklift lashing
training session so he was not trained to check the tension
of the lashing belt.

• To review and update training records and conduct
refresher training courses to ensure that all staff are
trained on proper forklift lashing.
• To emphasize the importance of proper forklift lashing
during transfers to all warehouse coordinators.
• To develop and implement a checklist for lashing of forklift
during transfers focusing on adequate techniques and
secure points.
• To prepare and share the lesson learned from this Incident.
18
Always secure the load with
properly tighten lashing belt
Do not take shortcuts. Use Ensure work area

the right mode of material is properly barricaded
transportation
Conduct toolbox talk before

the start of any activity
2014
30
March FINGER INJURY
Personnel
protective
equipment

While removing the bolts of the man-way of PP1 Gas Phase
The end user is responsible Reactor-2 using a wedge and brass hammer, the hammer head
for ensuring that each dislodged from the wooden handle and struck a contractor
tool is fit for use before technician’s left hand finger.
commencement of any job.
What went well?
Impact resistant gloves • Job was immediately stopped.
provide proper protection • Incident reporting initiated and the transfer of injured
for hammering activities. person to the hospital was done effectively.
Toolbox talk on previous

lessons learned is a must • Defective hammer was used.
before the start of any • Impact resistant gloves were not used.
similar work activity. • Tool room procedure PA-PR-135 which includes tools
inspection was not applied in the satellite maintenance
workshop.
• Prior incident lessons learned relating to the regular
inspection of hand tools and disposal of defective tools
were not fully implemented.

• Tool room procedure PA-PR-135 should be extended to
cover all satellite workshops.
• Implement an inventory and recording system of all tools
being used at site.
• Conduct a campaign on the use of impact resistant gloves.
20
Use impact resistant gloves for hammering activities
Inspect tools regularly and do not use damaged tools
Use ladder or platform for accessing out of reach location

2014
15
APRIL BURN INJURY
Permit to work

An operator sustained a minor burn on his hand when welding
All risks should be properly slags fell from a welding activity on top of a 5.2 meter high
identified, evaluated and platform at the CMP production Line 2. He was wearing cotton
controlled by applying good gloves but the slag penetrated and burned its way into his skin.
control measures before
starting the job to avoid What went well?
accident. • Injured person reported immediately to his line manager
and proceeded to the nearest hospital.
All risks and ongoing jobs
should be communicated Why did it happen? Cause(s)
and highlighted during shift • Failure to follow PTW procedure; PTW was approved
handover. without site verification.
• Task Risk Assessment was not implemented.
Strictly follow the Permit To • Safety guard assigned for this job did not enforced the use
Work system. of fire blanket covering.
• Changing shift hand over was not done properly.
Always use full fire blanket Actions to prevent re-occurrence
covers in all hot works that
produce sparks, molten • Conduct refresher training on Permit To Work and Task
Risk Assessment to Permit Issuer, Approver and Receiver.
slags and open flames.
• Conduct refresher training to all safety guards at site.
• Organize awareness session on “Importance of shift hand
over” targeting the Operation Team.
• Share lessons learned of this incident.
22
Ensure hot work area is effectively covered with fire blanket
Ensure proper cable

Smoke only
management to avoid
in the designated area
tripping hazard
2014
6
may man-lift hydraulic failure
Working
at height

While performing light mast maintenance using man-lift, two
Immediate notification of workers got stranded in the man-lift basket at a height of
emergencies to Fire Control approximately 25 meters due to its hydraulic failure.
Room (72555 / 72999) is
essential. What went well?
• Man-basket and crane were arranged (on stand-by) for
Always follow the rescue.
manufacturer’s recommended • The man lift hydraulic system was rectified by hose
maintenance schedule on replacement and the workers were safely lowered to the
equipment. ground.

Emergency rescue drills
shall take into account high • Hydraulic hose failed due to ageing.
elevation rescue scenarios • Fire Control Room was not notified immediately by
to ensure timely and proper contractor, resulting in delay in rescue.
• Task Risks Assessment (TRA) was not performed for this
actions. activity.

• Ensure compliance to manufacturer’s recommendations
for maintenance of hydraulic hoses.
• Communicate the importance of notifying emergencies
immediately on occurrence.
• Carry out TRA for any non-routine maintenance activity to
identify the potential hazards and control measures.
• Evaluate the emergency preparedness on high elevation
rescue emergency scenarios.
24
Ensure equipment
Always notify the emergency
are inspected,
to Fire Control Room
certified and tagged
DO NOT take short cuts. It can hurt you

Always keep the access ways clear from obstructions
Ensure safety signs are well maintained

Manual hoist falling 2014
from overhead beam 13may
Lifting
operations
Incident summary Key learnings

While preparing the hoist for a load test activity in the LDPE
Before using any hoist,
project site, the hoist was operated to run along the monorail
beam. But when it reached the end plate stopper, it did not always check and test it for
stop and fell down on a barricaded area below. There was no operability and safety.
load attached to the hoist. There were no injuries or damages
to equipment. Monorail end stopper should
What went well? be sized and positioned to
suit the actual hoist trolley.
• All safety requirements were in place such as Job Safety
Analysis, PTW, toolbox talk and area barricading.

• Design error - Dimension of the monorail end stopper was
not correct.
• The ITP (Inspection and Test Plan) failed to identify the
I-beam end stopper size problem.

• The monorail end stopper design error should be rectified.
• Carry out a design review survey of all similar monorail end
stoppers to ensure that all components are compatible
and tested.
• All similar monorails should not be used until they are
inspected and ensured safe.
27
2014
1
july acid spLash incident
Personnel
protective
equipment

Two Mechanical Technicians received diluted acid splash while
Ensure that effective opening the end blind bolts of acid line. While removing the
decommissioning of system face shield for using the safety shower, one of the technicians
is carried out before any got traces of liquid on his neck. The other worker also got traces
hand-over to maintenance. of the liquid around his neck while removing his chemical suit.
What went well?

Ensure that site inspection
and verification is carried out • Injured persons were wearing chemical suits, chemical
to identify the hazards and boots and face shield during the job.
mitigate the risk. • Injured persons have used the nearest safety shower.
• Injured persons were taken to hospital for further medical
treatment.
Always use eye wash and
safety shower for removal of Why did it happen? Cause(s)
splashed hazardous chemical
materials before removing • Decommissioning checklist was not available and MIC
(Master Isolation Card) was found inadequate.
the PPEs. • Effective site inspection and verification was not carried
out by operation before handing over the system to
Permit receiver should maintenance.
also assess the risk before • Positive isolation was not done for the acid system.
undertaking the activity. • The technicians were unaware about the safe way of
decontamination after acid splash.
• The chemical suit is not covering the neck properly, leading
to seeping of diluted acid.

• Develop a checklist for the decommissioning of acid
system.
• Train the relevant employees on new SOP and checklist
requirements.
• Conduct tool box talk with the operators and technicians
to share the lesson learnt from the incident.
• Provide awareness to the technicians on how to
decontaminate after hazardous chemical splash.
• Review the design of the chemical suit.
28
Always work on acid system with properly worn PPEs
Know the correct way of decontamination in

case of chemical splash
Ensure effective Isolation of the system before

start of activity
2014
5
july collapsed pallet
Lifting
operations

While the forklift operator was off-loading the polypropylene,
Dispatchers and forklift the top deck of the pallet snapped resulting in the stock falling
operators should inspect the down. As a result, six bags were damaged and the material
pallets for breaks, cracks or scattered on the floor.
damages before off-loading.
What went well?
Inferior wood quality is a • No injury sustained due to pallet collapse.
significant factor in pallet • Incident was notified, investigated and reported.
collapse
Forklift operators to look and • Inferior quality of the pallet wood.
listen for any of the ordinary • The knots in the pallet planks weaken the strength of the
sounds on movement when pallet.
handling pallets.
• Wood quality of the pallets to be improved.
• Pallet quality should be inspected before loading onto the
production packing line.
30
Inspect the pallet before its use
Never use any damaged pallet for shifting materials

2014
2 Hydrocarbon leak from

august
exchanger channel head
Not applicable

A hydrocarbon leak was observed from the insulation of
Leak test to be carried out channel head cover for heat exchanger in Ethylene Unit.
for all disturbed flanges and
documented. What went well?
• Fire and Rescue team was informed and they responded
Establish an inspection
immediately.
program for long running • Nitrogen was applied to dilute the leaking gas.
heat exchanger to ensure • Heat exchanger was isolated.
the integrity of all bolted
connections and structures.
• Loss of sealing function due to gap between channel
cover and the gasket.
• Thermal expansion cycles caused the loosening of the
bolts.

• Do not insulate heat exchanger until operational
temperatures are achieved. Retighten the bolts if required
and fix back the insulation.
• Follow guideline TID-GU-035 (Critical Flange Joints
Integrity Management) for critical flange maintenance.
• “Disturbed flanges leak test - checklist“ is to be prepared
for each maintenance activity to ensure the disturbed
flange is properly leak tested and signed off.
32
1
Stop unsafe act – It is everyone’s obligation

2014
2
AUGUST Nitrogen hose burst
Not applicable

A flexible nitrogen hose burst while being lined up at 7 bar
Using uninspected hose pressure during purging activities from a utility station to the
could lead to an accident. gas recovery condensate line going to the light gas splitter in
Polyethylene Unit 4 (PE-4).
Flexible hoses should be
used for their intended use What went well?
only. • No one was injured.
• Few people were at the work area as specified in the work
All flexible hoses should instruction.
be inspected before use • Proper nitrogen hose connectors being used at utility
station and at the vent line.
and should be re-inspected
annually. Why did it happen? Cause(s)
Visual check should be • The nitrogen hose was contaminated with hydrocarbons.
conducted before using • Uninspected hose was used for purging activities.
flexible hoses. Actions to prevent re-occurrence
Reportimmediatelyto • All uninspected hoses should be removed from the plant
the Shift Controller any site.
• Only inspected and tagged hoses are to be used.
untagged, damaged or
• To communicate this lesson learned to operations team.
contaminated hose found in
the plant area.
Remove and dispose

contaminated and
damaged hoses as per
HSE procedure, handling
of flexible hoses (HSE-
PR-028).
34
Visually check the flexible hose before its use
Ensure hoses are inspected, tagged and color coded along with
proper hose management
2014
13
AUGUST Flare system failure
Not applicable

The Borouge-1 flare system failed, releasing to the atmosphere
Isolation of process approximately 45 tons of unburned hydrocarbon gases.
equipment should only be
carried out by operation What went well?
personnel.
• Operation On-Call Engineer was informed immediately
about the incident.
Health, Safety and • No fire, explosion or personal injury was incurred.
Environmental Critical
Equipment Systems Why did it happen? Cause(s)
(HSECES) gaps and failures
• Fuel gas supply to the flare pilots was isolated.
should be given high • There was a design deficiency since the isolation of fuel
importance and should be gas supply to ignition chamber is not possible without
corrected before they could interrupting the supply of fuel gas to all flare pilots as
lead to major incidents. there is only one isolation valve installed.
• Fuel gas isolation valve was not identified as Lock Open
(LO) valve.
• Limited understanding on ignition of flare system.
• Immediate response to incident was inadequate.

• Fuel gas and air isolation valves should be kept in locked-
open position.
• Toolbox talks to be conducted to all maintenance
personnel emphasizing that isolation of any process
equipment should only be carried out by operation staff.
• Conduct training sessions for managing the operational
emergencies e.g. flare system and utility failures.
• Review the current design of flare pilot fuel gas system to
ensure continuous supply during maintenance activities
through an efficient by-pass or redundant system.
36
2014
26
AUGUST thumb injury
Personnel
protective
equipment

While assisting the routine pipe pressure testing operation,
Always assume that a one person suffered a minor injury when he misjudged the
replacement tool operates strength of a power tool, losing control and causing an abrasive
not exactly the same way cut to his right thumb.
as a previous version.
What went well?
Use PPE at all times and if • First aid box was in place and used immediately.
needed.
• New power tool was used.
• Although already trained, the injured person assumed
that the new tool would behave in the same way as the
previous one.

• Revise the test method procedure to include the safety
precautionary measures needed to use the power tool
safely.
• Review and document who is trained to perform the
various laboratory procedures.
• Include in the revised test method, an instruction to
support/clamp small pipes to prevent possible sudden
rotation in response to the power tool.
• Conduct refresher training to all authorized personnel on
the correct use of power tools.
38
Never use damage PPEs.
It can’t provide the required protection.
2014
14
september acid splash incident
Personnel
protective
equipment

A mechanical shifter was splashed by acid on the left side of the
PPE should be worn neck while emptying the remaining acid and sludge inside the
properly when handling tank into a plastic drum using a portable pump.
chemical, i.e. drawstrings
need to be tightened for What went well?
hood cover to ensure
• The injured person was wearing PPE so the whole body
maximum protection. was protected except the neck.
• First aid was administered by flushing water to the burned
Always use new drum skin using a safety shower & applying antiburn gel.
for handling or storing • Shifter was sent to hospital for further medical treatment.
chemicals, if it is necessary
to use used drum, the
drum must be free from • Exothermic reaction between acid and the remaining
contaminant. chemical inside the drum.
• PPE was not worn properly. The drawstring of the hood
was not tightened so the neck got exposed to acid while
he was evading the splash.
• Sludge accumulation in acid tank.

• To issue a Technical Group Support Request (TGSR) to
investigate the cause of sludge formation and find a
permanent solution.
• To segregate and identify used chemical drums with new
empty drums.
• To share the lesson learned across the organization.
40
2014
fire incident 16
september
Not applicable

A fire erupted at the bottom flange connection at a Primary
During shut down, make
Quench Exchanger (PQE) C of Furnace 3. The operator
responded immediately and extinguished the fire by using dry sure that the steam system
chemical powder fire extinguisher and later applied nitrogen to is positively isolated and
dilute the HC leak. drained.
What went well? Furnace Area, especially
• The operator responded immediately and extinguished in PQE platform which
the fire. has the potential for a fire
• Fire crew was informed and responded to the location. incident to occur, must be
• Furnace feed was shut off. thoroughly checked for any
visible leak.
• Water soaked the refractory of PQE bottom cone due to
process steam valve passing.
• During furnace start-up, bottom cone refractory got
damaged (dislodged and fallen) which lead to direct
exposure of bottom cone to hot gases, causing thermal
expansion and subsequent leakage at the flange.

• Update furnace shutdown Standard Operating Procedure
(SOP) & Master list of Isolations, with the requirement
of opening low point drains at downstream of process
steam control valves.
• The area operator should thoroughly inspect PQE platform
for any visible leaks just before cracking while in Hot Steam
Stand by (HSSB), during cracking and after cracking, when
the feed flows and when the Coil Outlet Temperatures
(COTs) are increased to their operating values.
• Check if the process steam block valves are passing.
During individual furnace shutdown, take the opportunity
and plan for the maintenance.
41
2014
17
september Thigh injury
Not applicable

A 2.4 meter long steel bar which secures the front side of the
Sea bulk container container liner, slid down and struck the operator’s right thigh
discharge rate depend on resulting in minor bruises during sea bulk container unloading at
the size of your transfer South East Asia Logistics Hub (SEALH).
system. Tilting too quickly
would disturb the liner steel What went well?
bars. • Work stopped immediately and IP was taken to hospital.
• Incident was immediately reported to SEALH Manager.
All liner bars should be
properly fitted in the Why did it happen? Cause(s)
shoring slots to ensure • Unloading was done at a faster rate.
safe discharge during the • Disturbing the liner bag for discharging the residual pellet.
unloading process.
• It is recommended to keep one door closed while offloading
to avoid any liner failure. This helps to reduce the impact of
product gravitational pressure exerted on the liner & it also
facilitates unloading at a gradual rate.
• Risk assessment of sea bulk container unloading to be
reviewed.
42
2014
Door glass panel 23
shattered september
Not applicable

A glass door of the Application Hall at the Innovation Centre
Access control system
was shattered caused by the sudden slamming of the door.
should always be in good
What went well? operating condition and
should be utilized to serve
• Incident site was barricaded and cleaned. its purpose.
• Investigation team formed.

Why did it happen? Cause(s) Ensure adequate risk
assessment is carried out
• A false fire alarm triggered the automatic activation of the before impairment of any
central smoke exhaust fan at maximum speed, creating
negative pressure in the building.
fire protection system.
• The back pressure caused the door to slam close resulting
in the damaged door glass frames. Fire control panel should
• The door was kept open since the access control system be always manned by
was not implemented. competent personnel
Actions to prevent re-occurrence to facilitate immediate
investigation and response.
• Assign personnel to man the fire control panel at all times.
• Conduct risk assessment to mitigate the effects of false
alarms and failures in the fire protection system.
• By-passing of the logic (roller shutters) should only be
authorized by designated personnel.
• Activate the access control system in the building and
maintain its effective operation.
43
2014
22
OCTOber Leg fracture injury
Working
at height

A Borouge 3 sub-contractor worker was coming down from
Shortcut or unsafe act could the back of the trailer, jumped on to a gearbox case which was
lead to an accident. below the trailer and subsequently, attempted to jump to the
floor. In doing so, he stumbled and fell, landing heavily on the
Supervisor should ensure floor resulting in a fracture injury on his left leg.
the hazards of working
What went well?
at height have been
communicated properly to • The injured person (IP) was taken to the Ruwais hospital
the workers and mitigated by ambulance.
prior to the execution of the • Incident investigation was conducted immediately.

task.
It is always necessary • The worker made a shortcut by jumping out from the
to have a toolbox talk trailer.
about the work activity, to • Lack of supervision and safety direction from supervisor.
conduct discussion on the Actions to prevent re-occurrence
risks and hazards of the
job which could cause an • To conduct tool box talk to the workers about the hazards
accident and explain how of shortcuts and the proper use of access ladder or
platform while going down the top of the trailer truck.
they can be prevented
• To conduct refresher training for the supervisors on
by applicable accident preparing safe work plans and task risk assessments.
prevention measures.
44
Never take shortcuts. It can cause injury.
2014
28
OCTOber Finger injury
Not applicable

A trainee incurred an injury on his right hand fingers when they
Trainees should undertake were caught in between the belt and pulley of the demo non-
all activities based on energized centrifugal fan in the training class room. He took
instructions and supervision the belt out from a nearby cabinet without any instruction or
from their instructors. authorization from his instructor, installed it over the pulley and
tried to rotate the pulley manually.
Trainees should always be What went well?
supervised and monitored
while undertaking work • The injured person was immediately taken to the hospital.
activities.
Immediate notification of • Injured person did not perceive the risk.
emergencies to Fire Control • The IP undertook an activity that he is not authorized or
Room (Tel. Nos. -72555/ instructed to do.
72999) is essential.
• HSE to undertake more Observation Tours in the new
Training Centre building.
• HSE to conduct awareness session for Instructors,
Supervisors, Team Leaders and Managers of Technical
Training Centre on HSE reporting procedure (HSE-PR-003).
• Conduct work related risk assessment involving Technical
Training Centre (TTC) instructors and HSE for all work
activities and equipment at work place.
• On-site workplace risk assessment to be part of the
induction for the new trainees.
• Get professional behavioral consultant to help in changing
behavior of young trainees/interns.
• Review HSE trainings to make them more interactive.
46
Undertake activities based on Supervisor instruction only
2014
29
OCTOber BURN INJURY
Personnel
protective
equipment

An operator incurred a burn injury on his left hand when molten
Whenever in doubt, stop polymer splashed as he was pushing the trolley containing the
the job and ask for help. molten polymer during the extruder start-up activity.
Use the prescribed Personal What went well?

Protective Equipment (PPE)
• The affected hand was immediately washed with water.
for the activity. • The operator was shifted immediately to the hospital.
Always follow the Standard Why did it happen? Cause(s)

Operating Procedures
• Polymer splashed on the hand and safety gloves used
(SOP) for the activity. were not prescribed for the activity.
• Extruder start-up Standard Operating Procedure (SOP)
Immediate notification of related to PPE was not followed.
emergencies to Fire Control
Room (Tel. Nos.- 72555 / Actions to prevent re-occurrence
72999) is mandatory. • Safety gloves awareness bulletin was published to raise
awareness to workers on the proper gloves to wear.
• Conduct awareness session to department staff
concerned on the safety gloves and its importance in their
routine activities.
• Modify the existing trolley for better hand protection
during extruder start up activity.
• Re-emphasise to strictly follow Standard Operating
Procedure (SOP).
48
Use the heat resistant gloves for handling hot materials
2014
9
november
Thumb injury
Personnel
protective
equipment

A laboratory technician sustained a cut on his left thumb while
PPE should be worn properly preparing a polymer sample specimen on the Microtome
when handling and working cutting machine. The sampling operation had already been
around sharp objects. completed and he had removed his safety gloves when he
met with the accident.
Always follow standard
What went well?
operating procedure (SOP)
when operating cutting • First aid was applied with antiseptic solution and band
equipment. aids strips.
• Injured person was sent to hospital for further medical
treatment.

• The injured person’s left thumb accidentally touched the
blade cutter of the machine.
• The knife guard was opened unintentionally.
• Working glove was not worn.
• The design of the Knife guard was inadequate as it moves
easily.

• To add extra safety precaution by covering the blade
assembly with PE molded plastic.
• To increase safety awareness on hazardous operating
procedure.
• To provide refresher training on operating procedure.
• To share the lesson learned across the organization.
50
Use hand gloves while working with sharp objects
Install blade guard when cutting machine is not in use

2014
12 Underground cooling
november
water pipeline failure
Not applicable

An underground cooling water pipeline failure occurred in the
Avoid working on live OCU plant causing a significant soil erosion in the area and
system. If in doubt, it damaged the concrete pavement.
is better to postpone
the activity to the next What went well?
Turnaround.
• Operation prompt action to close the cooling water supply
valve to stop the leak immediately and prevent further
Always take into account damages.
the water pressure surge • Closing the manual isolation valve of cooling water return
and water hammering when line to prevent interruption on cooling water flow to PO
plants.
closing and opening supply
valves of cooling water Why did it happen? Cause(s)
system.
• The closing and opening of the cooling water supply valve
Learning from previous was done in a fast pace causing the water pressure to
surge in the piping system.
incidents should be • There was water hammering and pressure surge in the
taken into account when cooling water header to OCU causing the failure of the
evaluating any jobs that pipe at its weakest point.
might impact the cooling • The risk assessment failed to consider the impact of water
water system. pressure surge and water hammering in the pipeline due
to inadvertent fast closing and opening of the supply valve.

• A modification project is planned and will be executed
during the next Turnaround.
52
2014
Late Response to 17
emergency gas alarm november
Not applicable

An emergency gas alarm activated in Technical Building which
Always follow the
resulted the evacuation of all occupants of the building. A call
was made to Fire Control to report the gas alarm however, Notification Guideline
they did not proceed to the site but instead requested FGT for Fire Control Room on
crew to check the situation. A second call was again made to emergency response.
Fire Control which caused them to respond and proceed to
the site.
What went well?

• The building was evacuated by all occupants.
• The alarm was a false alarm.
• Problem was rectified at the site by FGT crew.

• Emergency gas alarm notification did not showed up in
Fire Control panel.
• Fire & Rescue Supervisor assessed the situation as Un-
Classified event (event#18) which does not require a
response from Fire Team and instead requested FGT crew
to go to the site.

• To conduct refresher training to Fire & Rescue Shift
Supervisor on Notification Guideline for Fire Control
Room.
53
2014
8
december
Fall from height
Working
at height

While attempting to retrieve a dropped tool, a contractor
Never use scaffolding with technician climbed off a red tag scaffolding platform onto a
Red Tag since it is not plywood ceiling which was unable to sustain his weight
certified safe for use. resulting in the injured person (IP) falling approximately 5
meters below a wooden platform.
100% tying-off the full body
What went well?
harness during working at
height is mandatory. • First aid treatment was immediately given to the IP.
• Emergency response team promptly brought the IP to
Use tool pouch or belt while hospital for further treatment.
• Incident investigation began immediately.
working at height to prevent
any tool from falling. Why did it happen? Cause(s)
Never climb over or extend • Tool pouch or belt was not provided as per site procedure
the body over the handrails. for working at height.
• Full body harness was not secured as procedure 100%
tie-off.
• Unsafe acts were committed by the IP since he used a
scaffolding with a red tag and climbed over the hand rail
without hooking-up his safety harness.

• Toolbox talk was conducted for all workers about
the hazards and risks of working at height and the
corresponding control measures to prevent accident.
• Re-inspected all the hard barriers or edge protection of
scaffolds and platforms to ensure it meets the standard
requirements.
• Provision of tool pouch and tool lanyard has been
implemented for working at height.
54
Use safe working platform for working at height activities
Only use green tagged scaffolding platform

2014
9
december
Finger Injury
Personnel
protective
equipment

A PP-3 operator sustained first degree burn injury at the back
Always wear the prescribed of his left hand fingers when he accidentally touched the hot
heat resistant gloves when polymer at the edge of trolley while checking the die plate of
handling or working with the extruder.
hot polymers.
What went well?
Don’t take risk. Always • First Aid was given immediately by flushing water for 15
wear the proper PPE for the minutes and applying burn gel.
job. • Incident investigation conducted immediately.
Stay away from trolley with

hot polymer. • Lack of awareness about the hazards and risks of handling
hot polymer.
• Non-wearing of prescribed heat resistant gloves.
• The trolley design allows molten polymer to splash over
the edge and outer surface of the trolley.

• Toolbox meeting was conducted within the Shift Groups
including the IP to discuss the incident and the PPE
bulletin issued by HSE.
• To modify the trolleys to prevent splash over.
• To include in the HSE Induction, the hazard of hot polymer
and use of heat resistant gloves.
• To post warning signs such as “Hot Surface” and “Use
Heat Resistant Gloves” at the entrance of the Extrusion
Buildings.
56
2014
Finger injury 15
december
Not applicable

One of the laboratory technicians got a cut on his left finger
Always concentrate while
resulting in a first aid injury while preparing sample specimen
using a scissor. working with sharp cutting
tools.
What went well?
• First Aid was applied with antiseptic solution and band aid
strips.

• Lack of concentration while cutting.

• Discuss the incident in the toolbox talk emphasizing the
need to take more safety precaution when working with
sharp edged tools.
• Discuss the use of appropriate gloves while cutting
samples with laboratory technicians.
• Ensure the use of correct equipment.
57
Hand Gloves in Borouge
Heat Resistant Gloves, Heat Resistant Gloves,

Leather Gloves (SAP
500 C (SAP No. : 250 C (SAP No. :
No. : 544863)
544849) 547457)
Heat Resistant Heat Resistant

Cut Resistant Gloves
Welding Gloves (SAP Welding Gloves (SAP
(SAP No. : 555463)
No. : 506768, 506767) No. : 505689)
Cut Resistant Gloves Impact Resistant Cryogenic Gloves – 50

(SAP No. : 555461, Gloves (SAP No. : C (SAP No. : 544857,
544852, 544854) 555047) 544855, 544856)
Chemical Gloves Chemical Gloves Aluminized Gloves

(SAP No. : 544851) (SAP No. : 544850) (SAP No. : 523527)
“Average people learn from their
mistake, smart people learn from
others mistake”
Brandon Mull
Borouge Tower | Shaikh Khalifa Energy Complex | Abu Dhabi | UAE
Tel: +971 2 6070300 | Fax: +971 2 6070999 | P O Box 6925 | email: info@borouge.com
1 George Street#18-01 | Singapore 049145 | Singapore

Tel: +65 6275 4100 | Fax: +65 6377 1233 | email: info@borouge.com

Borouge 2014 Lessons Learnt Booklet

Uploaded by

Copyright:

Available Formats

Borouge 2014 Lessons Learnt Booklet

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Borouge 2014 Lessons Learnt Booklet

Uploaded by

Copyright:

Available Formats

Learning from Incidents

Jan – Dec 2014

“The real mistake is the one from

Borouge Sustainability Policy 04

Message from CEOs 06

Message from VP, CHSE 07

HSE Performance 2014 08

Overview of 2014 Incidents 13

We are one family, building upon our multicultural diversity.

We thrive on creativity and innovation.

We understand our stakeholders and deliver what is expected of us.

People: Social Responsibility

Planet: Environmental Stewardship

Profit: Economic Growth

Abdulaziz Alhajri Wim Roles

Abdulaziz Alhajri Wim Roles

LTI: 2, RWC: 1 Flaring: 276 KT

FI: 1 PD: 46 VI: 12

NM:125 UA: 140 UC: 907

Management of Change: 91% 90%

HSE Audits undertaken as per plan: 100% 80%

SOT Conducted: 4270 60%

ETP Performance: 64 ppm Target

HSE Incident HSE Incident

Hydrocarbon 44 Land Transportation 39%

Loss of Primary Containment Golden Safety Rules

TRI Freq.: 0.23

HSE Committee Meeting: 203 190

Borouge Golden Safety Rules Implementation: 100% 90%

Site Observation Tours Conducted: 2,428 1,565

Employees accepted the invitation: 1,626 Target

Total Man-hours PTE : 4.34 Million

Ruwais Distribution Center 118 35%

Land Transportation 47%

Golden Safety Rules

APPLICABLE GOLDEN SAFETY RULE

Key learnings Incident summary

Survey your work area to identify hazards

APPLICABLE GOLDEN SAFETY RULE

Key learnings Incident summary

 Ensure that effective What went well?

Actions to prevent re-occurrence

Ensure the door of the fume hood is always closed

APPLICABLE GOLDEN SAFETY RULE

Key learnings Incident summary

 Avoiding forklift transfer

Actions to prevent re-occurrence

Do not take shortcuts. Use Ensure work area

Conduct toolbox talk before

APPLICABLE GOLDEN SAFETY RULE

Key learnings Incident summary

 Toolbox talk on previous

Actions to prevent re-occurrence

Inspect tools regularly and do not use damaged tools

Use ladder or platform for accessing out of reach location

APPLICABLE GOLDEN SAFETY RULE

Key learnings Incident summary

Ensure proper cable

APPLICABLE GOLDEN SAFETY RULE

Key learnings Incident summary

Ensure that effective What went well?

Avoiding forklift transfer

Toolbox talk on previous

Remove and dispose

Use the prescribed Personal What went well?

Always follow the Standard Why did it happen? Cause(s)

Stay away from trolley with