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Let’s Be Frank: Unintended Consequences

By Inspector Frank. October 31, 2024
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In 1958, Mao Zedong decreed that Chinese citizens should destroy the sparrow because the birds were eating much-needed grain crops. Until then, China was known by its citizens as a country where hunger was a constant companion.

This decree against sparrows was part of the Four Evils campaign, which targeted the elimination of four pests: sparrows, rats, flies, and mosquitos. The extermination of sparrows was explicitly called the Smash Sparrows campaign.

This turned into what was effectively a mass extermination project, with large swaths of the population mobilized to take on the sparrow threat. Citizens were explicitly ordered to make loud noises at nesting locations to disrupt sleep patterns and to stop them from being able to land in typical nesting areas while simultaneously being encouraged to do things to impede reproduction and outright kill the birds.

Dutifully, the Chinese people took up the challenge, shooting birds, breaking up nests, smashing eggs, and beating drums to scare the animals and prevent them from landing in nests and resting. After two years, hundreds of millions of birds were dead and the sparrow approached extinction across China.

But destroying these sparrows resulted in one of the most devastating famines in recent history, killing somewhere between 15 and 40 million Chinese citizens in the Great Famine that lasted from 1959 to 1961 (the exact number of deaths remains subject to debate).

Why? Because it turned out that sparrows didn’t just eat grains. They also ate insects, including locusts, which have a voracious appetite for crops. With its major predator effectively side-lined, the locust roamed rampant across China and massive crop destruction resulted.

Leading up to this, the Chinese Communist Party (CCP) touted its reforms and programs as scientifically driven. This demonstrated that the science was far from thorough. Arguably, this very much sounds like a knee-jerk reaction to an identified existing threat.

In 1961, they stopped all these programs once it became apparent that the campaign had led to ecological imbalances and was contributing to widespread famine, worse than what it was originally trying to combat.

However, to be fair to the CCP, targeting rats and mosquitos for destruction proved to have significantly driven down disease rates in China.

Other than being an interesting story in fairly recent history, I wanted to bring this up to discuss a topic I have mentioned before: unintended consequences, especially those that come from poorly thought-out or unscientific plans.

I would like to say we (integrity and reliability personnel of petrochemical and associated industries), as a whole, are making decisions scientifically and technologically driven, so things like the Chinese sparrow program would never happen to us. But that just isn’t true. In fact, I can give you many examples. If you think of your career or the companies you have worked for, you can also see some.

I have already talked about this in some past articles. A big one is the unintended consequences of laying out programs in certain ways, and with that, the metrics we establish and measure (see the article “Let's Be Frank: How Do We Measure Up?” June 2021). This can be taken as another example of poorly thought-out execution of technical principles.

This time I want to talk specifically about technical decisions made without considering the consequences. “But we have management of change (MOC),” you say. Sure. Is it actually effective? Do you have the famous (or infamous) rider on your MOC program or procedure that says it can be done retroactively to keep production going?

If so, then you better have some kind of a stop-gap process. Otherwise, I would argue that the MOC process already has a major gap that can lead to problems. One of the significant failings of the Flixborough disaster (see “Let’s be Frank: The Start of Process Safety Management: The Flixborough Disaster – June 1, 1974,” February 2022) was a complete lack of an MOC process, or even a gut check by competent, experienced personnel, while they were planning to get the plant running quickly while bypassing a removed reactor.

Still unconvinced that any kind of a workaround for an MOC process without other fail safes is good? Here is an example: Let’s theoretically say there was a hydrotreater unit that was designed to clean up a distillate cut, where the reactor effluent line was carrying hydrogen sulfide and ammonium bisulfite (the products of removing sulfur and mercaptans in the reactors from the distillate stream being fed into the reactors). So, the system pumps hydrogen and distillate into the reactors, hot enough to be in a gaseous state over a catalyst to pull out the sulfur and mercaptans. At some point, you will be cooling it back into a liquid state to separate these impurities. For this unit type, the dew point was supposed to occur in some air exchangers (fin fans). These fin fans were alloyed up to handle a more corrosive dew point on the off chance some water made it into the reactors with the distillate feed. There were also heat exchangers (shell and tube) further upstream of the air exchangers where some of the waste heat from the reactor’s effluent was used to help preheat the reactor feed.

When this type of hydrotreater was first designed in the 1950s, the thought was that there would be no water in the distillate at this stage of the processing. Therefore, the original designers weren’t worried about reactor effluent corrosion at or after the dew point. With no water, hydrogen sulfide and ammonium bisulfate become almost a non-effect for corrosion of steel. There was a water injection point, but it was there to desalt the fin fans when the differential pressure got too high across them. Additionally, the fin fans were alloyed for increased corrosion resistance.

In the late 1950s and into the 1960s, many failures started occurring in these hydrotreater reactor effluent lines due to highly aggressive corrosion. It turns out that small amounts of water did make it into the unit with the distillate feedstock. The design holder started changing their design with this new information and finally realized water injection was needed for corrosion control. If you have a little water, you will form high concentrations of polythionic acids (high H2S, highly acidic) and dissolved ammonium bisulfite (again, at high concentrations), which become extremely aggressive in the corrosion of steel. In this situation, if you have any water present at all, then you want lots of it to dilute these corrosive impurities at dew point. This is now a common form of corrosion control in many types of hydrotreaters.

This changed the design philosophy on using the water injection point from “only there to desalt the fin fans” to “critical to keeping corrosion rates low.” Unfortunately, while all companies “got the memo” at the time, some never updated operations manuals to reflect the new criticality of the water injection points. Some companies also did not notice a significant issue or suffer from a failure, though, because the original design criteria still had the fin fans alloyed up to austenitic stainless steel to deal with the potential to have H2S and ammonium bisulfite dissolved in water.

Now, let’s say you added some more shell and tube exchangers to take more heat from the reactor effluent to put into the reactor feed. Because of this change (pulling out more heat sooner), the dew point got moved up out of the fin fans and into the line upstream, which is plain carbon steel, not the austenitic alloy that is very resistant to erosion/corrosion that is in the fin fan tubes. If you adjusted your water injection to be for corrosion control, this would be less of a big deal; however, if you did not, you have now set up a ticking time bomb.

The failure on this line was pretty spectacular (hot distillate and hydrogen going to the atmosphere) and it all points back to a bunch of decisions not being made scientifically. The big one was that when the extra exchangers were added in the mid-2000s, no one did a complete corrosion study, and the original design thought process that this was a “dry” or water-free unit was still thought to be true, even though by this stage all the literature, design manuals, and even training done in schools said otherwise. Because of this, the water injection was still only used as needed to desalt the fin fans. So, there was a misunderstanding about how the science behind the unit operated. Combined with a poor MOC process where no one involved really knew what the potential risks were for the unit.

The other issue this leads to is a false sense of security that your MOC process is effective and can contribute to a “normalization of deviation” (see the article “Let’s Be Frank: Stop Normalizing Deviance,” August 2021). This can blind the plant management to some real potential issues while thinking they are maintaining control over the safe operation of the plant. If the MOC process does not work well, but you have not had an incident for a while, then you have faith that the poor system is actually acceptable rather than auditing, assessing, and shoring up the deficiencies.

The other issue that combines with having poor programs is not caring (see the latest article, “Let’s Be Frank: Employee Loyalty Versus Employer Loyalty,” August 2024). If you are part of the integrity department and you see gaps in a system that is supposed to ensure integrity, I would ask you to bring it up. We seem to be going back into a heavy cycle of CYA (cover your ass) where people would rather not do anything than get noticed for rocking the boat: “MOC doesn’t work? MOC is part of the Process Safety Group, not Integrity’s problem.” “That’s a bad plan to recover plant throughput, not our problem; Operations runs the plant.”

This attitude is contagious, especially from the top down, and usually comes about when companies are considering or actively downsizing and/or cutting costs. It is one of the most caustic personnel environments I have seen and can be a huge contributing factor to having integrity and reliability departments running on fear rather than soundly applied technical and scientific principles.

I remember taking Sunday school as a child and the discussions we would have on sins of omission versus the sins of commission. A sin of commission is doing something proactive that you know is wrong. For example, if we want to save money, let’s cut thickness monitoring locations (TMLs) from the program to meet the corporate budgetary targets without any formalized review process. Whereas, a sin of omission is not doing something you know is right. We should do an MOC on changing the unit throughputs, and we will get the process supervisor to sign off that it is not required. A better example might be, “I know that management just made a bad decision, but I am not going to say a thing.” These “sins” can result in decisions specifically avoiding sound technical assessment and/or judgments.

Just like killing all the sparrows because they are eating some of your grain crops.

Regardless, to ensure effective process safety management, a facility needs to ensure that its decisions do not have unintended consequences and that programs function for effect based on sound science, not for show.

In trying to solve your particular famine, don’t make it worse by accidentally making decisions based on bad science, having no effective review process, or by inactivity.


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