Prevent Major Failures andAccidents with Well-Trainedand Empowered OperatorsMuhammad Idreesa and S. Aslamb

aEngro Chemical Pakistan Ltd., Daharki, PakistanbEngro Chemical Pakistan Ltd., Karachi, Pakistan; ssaslam@engro.com (for correspondence)

Published online 3 December 2009 in Wiley InterScience (www.interscience.wiley.com). DOI 10.1002/prs.10348

This article shares Engro’s experience at its ammo-nia plant involving the prevention of major failuresof the synthesis gas compressor turbine by takingprompt action to shutdown the compressor. Engro’sstrategy of providing operations training to enableand empower its people to make the right decisions atright time is the major learning of this article,whereby a manual shutdown before the automaticinstrumentation trip of the machine was initiated.This article also describes the techniques used by theoperations team to train and empower their people.Despite a plant outage of more than 10 days toreplace the rotor, we believe the manual shutdownaverted a more disastrous situation. Continuing torun the turbine may have resulted in a safety inci-dent or an even longer plant shutdown for significantrepairs. A well-trained and empowered operator isalways helpful by making prompt decisions to shutdown equipment, rather than relying solely on instru-mentation to protect equipment. The following is adiscussion of the training program which enablesand empowers the operator to make correct decisionsand take the correct action at the right time. � 2009American Institute of Chemical Engineers Process SafProg 29: 174–178, 2010

Keywords: operator training, manual shut down,empowered operator, instrumentation saving failure

INTRODUCTIONEngro Chemical Pakistan Limited is the second

largest manufacturer of Urea in Pakistan. The manu-facturing site is located in a small town of Daharki,which is 600 km north of the famous Port City ofKarachi.

Engro has accomplished significant progress notonly in its base urea fertilizer business but also indiversification projects. Other businesses includefoods, energy, automation, international trade, poly-mer, and chemical terminal. As part of its urea expan-sion project, Engro is constructing one of the largestAmmonia-urea plants, which will be the largest pri-vate sector investment ever by a national corporationin Pakistan. By mid-2010, annual urea productioncapacity will increase from 1 million to 2.3 millionmetric tons.

MANUFACTURING SITE HISTORYIn 1993, Engro relocated a 1967 Bechtel designed

ammonia plant and a Toyo total recycle urea plantfrom USA and UK, respectively. This projectincreased Engro’s urea capacity to 600,000 metrictons per year from 275,000 metric tons per year. In1995, the capacity was expanded to 750,000 metrictons per year. In 1998 urea production capacity wasincreased to 850,000 metric tons along with improve-ment in the energy efficiency by 7%.

Since 1998 optimization and other retrofits havefurther increased the urea production capacity toaround 1 million metric tons per year. The ammoniaplant modifications included the following:

• Installation of a prereformer• Installation of a semilean CO2 solution flash ves-sel,

• Installation of a rich CO2 solution flash vessel• Replacement of CO2 absorber and stripper trayswith packing,

• Modification of ammonia converter from S-200to S-300

• Replacement of secondary reformer burner• Installation of natural gas booster compressor� 2009 American Institute of Chemical Engineers

174 June 2010 Process Safety Progress (Vol.29, No.2)

• Enhancement of furnace combustion efficiency

The urea plant modifications included the follow-ing:

• Installation of Advanced process for Cost andEnergy savingTM (ACES)

• Installation of additional CO2 compressor• Installation of additional carbamate solutionpump

All projects were implemented on schedule with-out a single loss work day injury.

Currently the ammonia plant is being operated at154% of the re-rated design capacity

AMMONIA PLANT PROCESS DESCRIPTIONEngro’s Ammonia plant is based on standard natu-

ral gas steam reforming process with Catacarb CO2

removal; standard methanation and high pressureback end operation with hydrogen recovery.

As shown in Figure 1 the synthesis gas compressortrain comprises of three compressors driven by steamturbine (syn turbine). The syn turbine is a singleshaft, complete condensing, and variable speed me-chanical drive unit. The turbine has six stages with aconfiguration of eight rotating wheels. The rotor issupported by two equal capacity tilt pad journal bear-ings and axial position is controlled by tilt pad thrustbearings. There are eight rows of reversing bladesalso known as diaphragms. Labyrinth type seals areinstalled between stages and at the shaft ends to pre-vent steam leakage. The turbine is a General Electric,rating 37,500 HP. The syn turbine is designed for 850psig power steam at 8008F, continuous speed of10,400 rpm and a shaft output of 33,000 HP. Thevibration monitoring system is Bently Nevada 3300.There are two radial probes installed at exhaust endand two at inlet end of the syn turbine. Normal vibra-tion is between 1 and 2 mils. Tripping logic is 2 outof 2 through the emergency shutdown system (ESD).Alarm is at 3.0 mils and trip setpoint is at 5.0 mils.

INCIDENTAt the start of the morning shift on 3rd of August

2007, the synthesis compressor driver turbine exhaust

end radial vibration increased to the alarm level andcontinued to fluctuate. At the same time, abnormalsound from the turbine was heard from the field. Thecompressor was immediately tripped from the controlroom.

The exhaust end bearing was found to be dam-aged, and repair was completed in situ. On restart,the machine showed abnormal behavior during rampup by vibration monitoring and sound. The machinewas once again shutdown, and the subsequentinspection found the first and fifth wheels damaged.The incident had the potential of a major failurewhich may have resulted in a safety incident or anunusual longer outage.

Inspection FindingsFollowing were the findings of the inspection:

1. Rub marks were found on the exhaust end bear-ing. Wear and tear was observed on the rotor anddiaphragms in the form of a missing shroud pieceof first wheel, and diaphragm indentations andthinning.

2. The fifth stage (wheel) rivet head from one of thebuckets was found chipped off, and damage inthe form of small dents was found on the wheels.

3. Similarly the broken shroud of first wheel causedconsequential damage on second and third stagediaphragm and at the second wheel blades in theform of dents.

4. Oxidation/corrosion marks were also found onsecond wheel.

5. Thinning of second, third, and fourth stage dia-phragms was found.

As a result, a rotor replacement was carried out inpresence of OEM’s (GE) service specialist from 6th to16th of August, 2007.

Preventing CatastropheDespite a plant outage of more than 10 days to

replace the rotor, we believe the manual shutdownaverted a more disastrous situation. Continuing to runthe turbine may have resulted in a safety incident oran even longer plant shutdown for significant repairs.

Figure 1. Layout of syngas compressor train. [Color figure can be viewed in the online issue, which is availableat www.interscience.wiley.com.]

Process Safety Progress (Vol.29, No.2) Published on behalf of the AIChE DOI 10.1002/prs June 2010 175

A well trained and empowered operators team isalways helpful by making prompt decision to shutdown equipment, rather than relying solely on instru-mentation to protect equipment. The following is adiscussion of the training system which enables andempowers the operator to make correct decisionsand take the correct action at the right time.

PEOPLE DEVELOPMENT PROGRAMThis program ensures that the entire operating staff

possesses and maintains necessary skills and knowl-edge to execute job functions in a manner consistentwith the safe and reliable operations of our site. Theobjective of the program is to develop and maintaina highly professional, skilled, empowered, and moti-vated team to achieve the organizational objectives ofsafety, environment, quality, production, and costeffectiveness.

OrganizationIn the production department the people develop-

ment program is conducted by a committee. The Pro-duction Manager heads the committee and all Pro-duction Unit Managers are the members (AmmoniaUnit Manager, Urea Unit Manager, Utilities Unit Man-ager, and Bagging Unit Manager). This committeeholds bimonthly meetings to review the programimplementation status, evaluate the effectiveness ofprogram, and propose changes for further improve-ment.

Unit Managers are further responsible for the de-velopment of their unit’s annual training plans. Theseplans are based upon the people development pro-gram. The annual training plans are reviewed by thecommittee before implementation at the start of year.

Unit Managers are responsible for the implementa-tion and leadership of the annual plans. They do sothrough the shift supervisors and shift coordinators.

Training Program LayoutThe program includes (a) position specific training,

(b) shift supervisor and coordinator training, (c) oper-ator training, (d) emergency response team training,and (e) plant emergency training.

Position Specific TrainingPosition specific training is the training that is spe-

cific for a role or job. The objective of this training isto impart the necessary knowledge and skills to anindividual to ensure the minimum desired compe-tence level for a specific job or position is achieved.The program covers training for the following posi-tions:

1. Shift Coordinator2. Shift Engineer/Supervisor3. Field Operator and Boardmen (DCS)4. Fresh Operators and Engineer

This category of training ensures that the variousprofessionals are properly trained through a struc-tured training program. The training elements utilizedfor specific position training include on the job train-

ing, cross training, job qualification program (JQP),professional skill development courses (PSDC), andfinally formal skill certification by respective unitmanager of the unit.

Shift Supervisor and Coordinator TrainingA fresh engineer receives one year training at ei-

ther the ammonia or urea units, which mainlyincludes plant safety management, plant configura-tion, and overall site knowledge, line tracing andstudy of P & IDs, study of operating manuals alongwith plant startup and shutdown and emergency han-dling procedures, job-specific procedures, safety criti-cal systems and procedures, and material balances,and study of APIs.

After extensive evaluation by all unit managersand production manager they are given an independ-ent shift supervisor position. The engineer spendsaround 5 years in one plant (either ammonia or urea)and then is moved to the next plant for further train-ing. See Figure 2.

The program is managed as follows:

1. Reassignment is initiated by production managerand unit managers based on the individual’s devel-opment plan.

Figure 2. Shift coordinator development flowchart.

176 June 2010 Published on behalf of the AIChE DOI 10.1002/prs Process Safety Progress (Vol.29, No.2)

2. The training plan is customized for the respectiveunit to which the individual has been assigned. Theplan specifies the training period, usually 3–6 months depending upon availability and the indi-vidual’s experience and potential. The plan alsodefines the timing of reviews with the managers.

3. Progress reviews are carried out by the shift coor-dinator and unit manager jointly according to apredetermined frequency as defined in the trainingplan.

4. Final assessment is conducted by a panel compris-ing of production manager and unit managers.The individual is given an independent shift ifdeclared satisfactory by the panel.

5. After being responsible for an independent shift,the incumbent performs his duties for a minimumof 6 months as independent shift supervisor.

6. Final assessment is conducted by the same panel.If the individual’s performance is declared satisfac-tory by the panel, the individual is assigned as anindependent shift coordinator. The shift coordina-tor is fully authorized to make decisions and takeaction to shut down the plant—fully or partially—or to reduce to low load operation in case of plantupset. He is fully empowered and can do so with-out consulting any manager.

A new shift coordinator is given most skilled team(experienced supervisors and boardmen), for the ini-tial 6 months, which builds confidence in the individ-ual for his new responsibility.

Operator TrainingThe following describes the training process for an

operator (see Figure 3) that has been newly hired, orreassigned to a new post or unit:

1. Operator is assigned to the post with an experi-enced operator of that post. Shift supervisor/shiftcoordinator keep track of the training activities.

2. The operator is issued the training plan and jobknowledge/skill requirements of the respectivepost by the shift supervisor.

3. Usually a training period is between 3 and 6months depending upon the operators learningability. Random verbal reviews and practical dem-onstration tests in the field are conducted by theshift supervisor/shift coordinator. He is alsorequired to present major emergency scenarios tothe shift personnel, where he is asked questions tocheck his preparation in the presence of shift co-ordinator.

4. The operator is also involved in the operationalactivities at the post, initially in the presence of anexperienced operator and then he is given thetemporary charge of that post to carry out all theactivities by himself, while the permanent incum-bent remains as his back-up.

5. The operator is also required to pass written testsof that post under Job Qualification Program(JQP). A test is divided into at least two blockseach containing three written tests and 1 practicaldemonstration test.

6. Written tests are conducted by the training section.The shift supervisor examines the test papers andconducts the practical demonstration test within 1week. He is also responsible to discuss the paperswith the operator and inform him of the results.The operator must receive a score of at least 90%to pass the written test papers and 100% to passthe practical demonstration.

7. If the operator fails in whole or in part, he isasked to redo the failed part of the skill block aftera minimum of 1 month of preparation and study.

8. If the candidate has passed, he receives a 6%upward salary adjustment per block after approvalby the unit manager i.e. financial incentive forimproving his knowledge.

9. Near the end of allotted period a final verbalreview is conducted by Shift supervisor and Shiftcoordinator. If the knowledge about the processand operations of the post is found satisfactory,the operator is moved to a second shift for furtherevaluation, otherwise he is given 2 weeks time towork on his weak areas and then re-evaluated.

Figure 3. Operator training flowchart.

Process Safety Progress (Vol.29, No.2) Published on behalf of the AIChE DOI 10.1002/prs June 2010 177

The second shift supervisor/coordinator checksthe skill and knowledge of the individual for thatpost based on a comprehensive skill question-naire document and assigns score (1 or 0) againsteach question in the document. The question-naire also includes a practical knowledge test,which is conducted in the field by the shiftsupervisor/coordinator. This process takes 3 to 4weeks, till the whole questionnaire is completed.If the operator’s performance is found to be satisfactory against the skill questionnaire, theoperator is forwarded to unit manager for thefinal evaluation otherwise the operator is sentback to the first shift for further training onhighlighted areas by the second shift.

10. Unit manager holds the panel review, which alsoincludes one to two shift coordinators and certi-fies the operator if he finds his skill leveladequate enough to work independently.

Emergency Handling TrainingThis training consists of team and position related

skills. The purpose is to ensure efficient functioning ofindividual shift groups during emergencies. It servesas a two-way communication forum to jointly discussthe plant emergencies and safe handling strategies.

There are mainly two types of training sessionswithin this program as follows:

1. Plant emergency training (on duty)2. Classroom training (off duty)

These sessions help the transfer of knowledge tothe group as well as in developing supervisory andtechnical skills of the individuals.

Plant emergency training. The purpose of plantemergency training is to develop the skills requiredfor a high quality and swift emergency response. Thediscussions are conducted during the shift. All of theshift operators and boardmen participate in this emer-gency discussion or simulation exercise. Complianceto the discussion and simulation is recorded in theshift coordinators log sheet. All of the plant emergen-cies, listed on the training matrix are discussed withall shift operators at least once during the year.

Classroom training session. The purpose of thesetraining sessions is to develop the team to carry outcorrect emergency response activities. All shifts arespared for 1 full day on a bimonthly basis for thesesessions.

Class room training helps to eliminate misunder-standing, clarifies and builds concepts for correctlymanaging an emergency. The training sessions arecomprised of the following three parts:

1. Discussion on specific emergency handling,including explanations on all relevant process andequipment details and the reasoning of particularaction steps (i.e. the why’s & how’s).

2. Discussion on safety hazards, safety precautions andPPE (personal protective equipment) to be used forboth special procedures and routine procedures.

3. Red tag drills after the session i.e. practical demon-stration of emergency handling by shift group inrespective field.

These sessions are conducted and facilitated bythe Shift Supervisor and Shift coordinator.

1. Standard presentations have been developed andplaced in unit library which are used during train-ing sessions. Information from feedback is addedto the training materials and presentations on acontinuous basis.

2. Pre- and posttests are conducted in every sessionto enhance effectiveness of the sessions andresults are documented.

3. Red tag drills (field simulation and practical dem-onstration) are carried out after the session.

CONCLUSIONSThe effectiveness and functioning of the program

is measured by the safety statistics and plant perform-ance. To ensure that the program imparts the trainingneeds of individuals and team, evaluation is con-ducted on an individual basis. The evaluations helpdetermine individual and team training requirements.The evaluations also help to continuously improvethe development program by highlighting deficien-cies in the current training program.

‘‘Our goal is safe operation’’; we believe thatthrough a well-managed People Development Pro-gram we can have ‘‘better trained and empoweredoperating personnel’’ who can definitely contribute to‘‘improve plant safety, reliability, and ultimately profit-ability.’’

More details of the accident that supported theteachings of this article are found in a previous pub-lished article [1]. Since training is especially importanttopic, anyone interested should review additional PSParticles on this topic [2–5].

LITERATURE CITED1. M. Idrees and S. Salman bin Aslam, ‘‘Saving major

failure—Well-trained & empowered operators candeliver more than machines,’’ 53rd AmmoniaSafety Symposium of AIChE, held in Sept 2008 inSan Antonio, Texas. Saf Ammonia Plants RelatFacil Symp Proc 49 (2008), 355–362.

2. P. Myers, B. Watson, and M. Watson, ‘‘Effectivetraining programs using instructional systemsdesign and e-learning,’’ Process Saf Prog 27 (2008),131–138.

3. J. Sharkey, R. Cutro, W. Fraser, and G. Wildman,Process safety testing program for reducing risksassociated with large scale chemical manufacturingoperations, Plant Oper Prog 11 (1992), 238–246.

4. S. Mani, S.K. Shoor, and H. Pedersen, Experiencewith a simulator for training ammonia plant opera-tors, Plant Oper Prog 9 (1990), 6–10.

5. N. Latino, Training technology through interactionmanagement, Plant Oper Prog 8 (1989), 82–83.

178 June 2010 Published on behalf of the AIChE DOI 10.1002/prs Process Safety Progress (Vol.29, No.2)