Creedy - Industrial Process Safety for SSS 110526

8/13/2019 Creedy - Industrial Process Safety for SSS 110526

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Industrial Process Safety

Lessons from major accidents and their application

in traditional workplace safety and health

Graham D. Creedy, P. Eng, FCIC, FEICFormerly Senior Manager, Responsible Care

Canadian Chemical Producers Association

(now Chemistry Industry Association of Canada)

[email protected]

System Safety Society Spring Event

May 26, 2011


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2

Overview

How I got into this

The evolution of the philosophy of

industrial safety and prevention of majoraccidents

Some key insights and concepts

How these apply to management ofworkplace safety in various sectors and at

different levels of the organization


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Some history

1984 Bhopal accident is wake-up call tochemical industry

Industry responsibility to understand and

control hazards and risks Responsible Care launched in Canada

Principles, codes, commitment, tools, support,

progress tracking, verification Major Industrial Accidents Council of

Canada 1987-1999


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Source: US Bureau of Labor Statistics (www.bls.gov/iif)

0.0 2.0 4.0 6.0 8.0 10.0 12.0

ServicesFinance, insurance & real estate

Wholesale & retail trade

Transportation & public utilit ies

Petroleum and coal products

Chemicals and allied products

Printing & publishing

Pulp & paper

Textiles & apparel

Food & food products

Transportation equipment

Electronic and electrical equipment

Industrial machinery & equipment

Primary metal industriesConstruction

Mining

Agriculture, forestry & fishing

Safety Performance by Industry SectorInjuries & illnesses per 200,000 hours worked (2002)


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Relative risks of fatal accidents in the work

place of selected occupationsFishers (as an occupation) 35.1

Timber cutters (as an occupation) 29.7

Airplane pilots (as an occupation) 14.9

Garbage collectors 12.9

Roofers 8.4

Taxi drivers 8.2

Farm occupations 6.5

Protective services (fire fighters, police guards, etc.) 2.7

Average job 1.0

Grocery store employees 0.91

Chemical and allied products 0.81

Finance, insurance and real estate 0.23

Sanders, R.E, J. Hazardous Materials 115 (2004) p143, citing Toscano (1997)


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CIAC website

www.canadianchemistry.ca

Staff contact: Stephanie Butler

613-237-6215 x 245

Chemistry Industry

Association of Canada

Member Performance
http://www.canadianchemistry.ca/http://www.canadianchemistry.ca/


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Serious/Disabling/Fatalities

Medical Aid Case

Property Loss/1st Aid

Treatment

Near Misses

Unsafe Behaviors/Conditions

Incident Pyramid:

1

30

10

600

10,000

A proactive approach focuses on thesecategories, but be carefulyou may

miss the really serious ones!


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Terminology

Process hazard

A physical situation with potential to cause

harm to people, property or the environment

Risk (acute)

probability x consequencesof an undesiredevent occurring


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They thought they were safe

Good companies can belulled into a false sense ofsecurity by theirperformance in personalsafety and health

They may not realise howvulnerable they are to amajor accident until ithappens

Subsequent investigationstypically show that therewere multiple causes, andmany of these were knownlong before the event

BP Deepwater Horizon


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Why and how defences fail

People often assume systems work asintended, despite warning signs

Examples of good performance are cited as

representing the whole, while poor ones areoverlooked or soon forgotten

Analysis of failure modes and effects

should include human and organizationalaspects as well as equipment, physical andIT systems


11/4611Flixborough, Bhopal, Pasadena

Process safety management

Recognition of seriousness ofconsequences and mechanisms of

causation lead to focus on the processrather than the individual worker

Many of the key decisions influencingsafety may be beyond the control of theworker or even the sitethey may bemade by people at another site, country

or organization

Causes differ from those for personnelsafety

Need to look at the wholematerials,

equipment and systemsand considerindividuals and procedures as part of thesystem

Management system approach forcontrol


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Scope(elements of process safety management)

1. Accountability

2. Process Knowledge and Documentation

3. Capital Project Review and Design Procedures

4. Process Risk Management

5. Management of Change

6. Process and Equipment Integrity

7. Human Factors

8. Training and Performance

9. Incident Investigation

10. Company Standards, Codes and Regulations11. Audits and Corrective Actions

12. Enhancement of Process Safety Knowledge

CCPS: Guidelines for TechnicalManagement of Chemical Process Safety


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Functions of a management system

Planning Organizing

Leadership

Controlling Implementing

M

easuremen

t

Results

Structure

Direction

CCPS: Guidelines for Technical Management of Chemical Process Safety


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Features and characteristics of a management

system for process safety

PlanningExplicit goals and objectives

Well-defined scopeClear-cut desired outputsConsideration of alternative achievementmechanismsWell-defined inputs and resource

requirementsIdentification of needed tools and training

OrganizingStrong sponsorshipClear lines of authority

Explicit assignments of roles andresponsibilitiesFormal proceduresInternal coordination and communication

ImplementingDetailed work plansSpecific milestones for accomplishmentsInitiating mechanisms

ControllingPerformance standards andmeasurement methodsChecks and balancesPerformance measurement and reporting

Internal reviewsVariance proceduresAudit mechanismsCorrective action mechanismsProcedure renewal and reauthorization



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Examples of PSM management systems concerns at

different organizational levels


Planning

PlanningOrganizing

Planning

Organizing

Organizing

ImplementingImplementing

ControllingControllingControlling

Strategic Managerial Task

Self assessment of Current Status


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Self-assessment of Current StatusProcess Safety Management

Requirements to Achieve the ESSENTIAL Level

For each survey question, indicate the level of awareness and use at the site by marking the appropriate box, based

on the following:

A Widespread and comprehensive use wherever significant hazard potential exists.

B Moderate use, but coverage is uneven from unit to unit or not comprehensive in view of potential

hazards.

C Appropriate personnel are aware of this item and its application, but little or no actual use.

D Little awareness or use of this item.

Mark the box labeled "Help" if this is an item where you are in urgent need of guidance. Well have a team member

contact you with advice on how and where to get the information or help.

Want Current Status

Help A B C D

1. Accountability: Objectives and Goals

(a) Are responsibilities clearly defined and communicated, with thoseresponsible held accountable?

(b) Is there a system for control of contractor operations? 2. Process Knowledge and Documentation

(a) Are the safety, health and environmental hazards of materials on site

clearly defined?

(b) Is there current comprehensive documentation covering the process

operating basis, including both normal and abnormal conditions?

3. Process Safety Review Procedures for Capital Projects

(a) Are all project proposals for new or modified facilities subjected to

documented hazard reviews before approval to proceed?

(b) Are systems established to ensure that the facility is built as designed? (c) Is there an effective link between design modifications and operating

procedures?

4. Process Risk Management

(a) Is there a system, conducted by competent personnel, to identify andassess the process hazards from materials present at this site?

(b) Are corrective actions defined and implementation followed up? (c) Are the above items formally documented?

A page from theSite Self-

Assessment Tool


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0

20

40

60

80

100

120

140

160

2002

(137 sites)

2003

(141 sites)

2004

(134 sites)

2005

(143 sites)

2006

(139 sites)

2007

(145 sites)

2008

(129 sites)

Excellent

Enhanced

Essential

Almost at Essential

"In Progress"

Use of self-assessment tool for

collective progress reporting and action

As of August 29, 2008 compared with past five years

(some site changes)

Target for meeting Essential level: June 30, 2003

P R l t d I id t M (PRIM) 2007


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Process-Related Incident Measure (PRIM) 2007

Findings: All Elements

PRIM INCIDENT CAUSE ANALYSIS 1998/1999 TO 2007

05

1015

2025303540

1Acco

untability:O

bjectiv

es&G

oals

2Proc

essKnow

ledge

&Docu

m.

3Capital

ProjectR

eview

&De

sign

4Proc

essRisk

Manag

ement

5Manage

mento

fChan

ge

6Proc

ess&Eq

uipme

ntInte

grity

7Hu

manF

actors

8Trainin

g&Pe

rforma

nce

9Incident

Investiga

tion

10Co

mpany

Standards

/Code

s/Re

gs.

11Au

dits&Corre

ctiveA

ctions

12En

hancem

entProcessS

afetyK

nowled

ge

PSM Element Possibly Involved

Incidents

Analyzed

98/9920002001

200220032004200520062007


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Assessing an organizations safety effectiveness

What is the safety policy and culture (written,unwritten)?

How are the following handled? Establishing what has to be done

Benchmarking

Communicating

Assigning accountabilities

Ensuring that it gets done

Monitoring and corrective action

Evidence (documentation) and audit process

Resourcingnot only for ideal but for anticipatedconditions

Balancing with other priorities

How are exceptions handled?


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Consider targets in groups

Those who:

Dont care

Dont know (and perhaps dont know that theydont know)

Did know, but may have forgotten or could

have gaps in application (and perhaps dont

realize it)


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Excellent guidance

existsbut how is it

being used?


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The New Product Introduction Curve

Can be applied to adoption of new ideas

Categories differ by ability and more importantly, motivation

P

ercent

a

doption


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Accountability

Management commitment at all levels

Status of process safety compared to otherorganizational objectives such as output, quality andcost

Objectives must be supported by appropriate resources

Be accessible for guidance, communicate and lead


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Management of Change

Change of process technology

Change of facility

Organizational changes

Variance procedures Permanent changes

Temporary changes


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Process and Equipment Integrity

Design to handle allanticipated conditions, not just ideal

or typical ones

Make sure what you get is what you designed

(construction, installation)

Test to make sure the design is indeed valid

Make sure it stays that way

Preventative maintenance

Ongoing maintenance Review

Be especial ly careful of automatic safeguards


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Consider operator asfallible humanperforming tasks inbackground

Design for errortolerance, not justprevention

detection correction

Buncefield, UK


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Realization of significance of sociocultural factors in

human thought processes and hence in behaviours


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Human behaviour aspects

People, and most organizations, dont

intend to get hurt (have accidents) To understand why they do leads useventually into understanding humanbehaviour, both at the individual andorganizational level, and involves:

Physical interface Ergonomics

Psychological interface

Perception, decision-making, control actions

Human thought processes

Basis for reaching decisions Ideal versus actual behaviour

Social psychology

Relationships with others

Organizational behaviour

Familiarity to

engineers

More

Less


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Human behaviour modes

Instead of looking at the ways in which people can fail, look at how they

function normally:

Skill-based

Rapid responses to internal states with only occasional attention to

external info to check that events are going according to plan

Often starts out as rule-based Rule-based

IF, THEN

Rules need not make sensethey only need to work, and one has

to know the conditions under which a particular rule applies

Knowledge-based Used when no rules apply but some appropriate action must be

found

Slowest, but most flexible


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Reasons Cheese Model

James Reason, presentation to Eurocontrol 2004

2

SSThe Swiss cheese model of

organisational accidents

Some holes due

To active failures

Other holes due to

latent conditions

Successive layers of defences

Hazards

Losses


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Active and latent failures

Active

Immediately adverse effect

Similar to unsafe act

Latent

Effect may not be noticeable for some time, if at all

Similar to resident pathogen. Unforeseen trigger conditions

could activate the pathogens and defences could be undermined

or unexpectedly outflanked


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A Classic Example of a Latent

Failure

Hazard of material

known, but lack of

awareness of potential

system failure modeleads to defective

procedure design

through management

decision

Epichlorhydrin fire,

Avonmouth, UK


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Danvers, MA, Nov 2006

Solvent explosion at printing ink factory

US Chemical Safety Board

And another

Hazards known, but defencescompromised by apparently benignchange

Latent error in procedure designcreates vulnerability to likely

execution error


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And another

Hazard of material

not obvious (despite

history)

Latent error allowed

dust to accumulate,creating conditions

for subsequent

events

Scottsbluff, NE 1996

Port Wentworth, GA 2007


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Lessons from other fields

Aerospace andnuclearshow how significanthuman and organizational aspects can be evenwhere the obvious signs of failure are technicalin nature

Financeshows: Relevance of such factors without technical

distractions

How fast a system can deteriorate once controls are

relaxed How wrong risk assessments can influence bad policy

decisions


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The relevance of organizational factors has also been

graphically and tragically revealed in the inquiry reports of recentUK transportation and offshore oil disasters.

Prior to ..., senior managers in all the organizationspropounded the pre-eminence of safety. They believed in theefficacy of the regulatory system, in the adequacy of their existing

programs, and in their confidence of the skills and motivation oftheir staff.

The inquiry reports reveal that their belief in safety was amirage, their systems inadequate, and operator errors andviolations commonplace.

The inquiry reports stated that ultimate responsibility laywith complacent directors and managers who had failed to ensurethat their good intentions were translated into a practical andmonitored reality. Moreover, the weaknesses so starkly revealedwere not matters of substantial concern to the regulatory

authorities before the accidents. HSC, 1993

Relevance of organizational factors


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Factors that can influence

likelihood of failure

Organizational culture

the way we do things around here when no-one is

looking

increasingly being recognized as one of the mostimportant factors in major accidents

perceived balance between output, cost and safety is

heavily dependent on this culture, and influences

whether personnel work in a certain way because

they believe the company and their co-workers feel it

is the right way to do things, or whether they are

simply going through the motions.


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Standard

of Safety

Time

In general, safety gets better as society learns more


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Standard

of Safety

Time

But the rate of improvement is not steady

x 10


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Standard

of Safety

Time

In fact, the curve can be one of periodic rapid gains

followed by gradual but increasing declines

x 100

Note how the rate

of decay can be

expected to

increase due to

normalization ofdeviance


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People

Systems

Tribal

Chaotic

Operational

Excellence

Bureaucratic

Strong

Weak Strong

Organizational Culture ModelJames W. Bayer, Senior VP Mfg, Lyondell Chemical Company


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Demographic effects Less staff

Experienced cohort leaving or left

Skills transfer senior > (middle)> junior

Replacements understand the way something isdone, but not why it is done that way, the potentialconsequences of doing it differently and how to detectand recover from undesired actions

We are starting to see lowered standards ofdesign and supervision that fifteen years agowould have been unthinkable in the chemicalindustry (Challenger, 2004)

Preservationor lossof corporate memory


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Knowledge


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Knowledge Never realized problem could occur (benchmarking error)

was it treated as a unique deficiency?

was there a broader review of the benchmarking process to find if there areother areas where knowledge could be deficient?

Policy Thought situation would be acceptable but didnt realize full implications

until it happened Does it appear to be acceptable now?

Was review of policy and accountability limited or broad in scope?

System design Even if everything had been done as intended, problem would still have

occurred How comprehensive was analysis of system deficiencies and practicality of

solutions?

How effective is action plan and follow through?

Was review of system design limited or broad in scope? System execution (management system error)

Problem occurred because someone or something did not perform asintended

Did analysis consider why execution not as intended?

Was corrective action appropriate and balanced?

Was review of system execution limited or broad in scope?

D li ith S f t ( E i i ) P bl


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Dealing with a Safety (or Engineering) Problem

Finding out who youre dealing with

Where is the organization on the curve? (generally, and re the specific issue orproblem)

Where are the people youre dealing with on the curve? (generally, and re the issueor problem)

Finding out what to do

Benchmark dont try to reinvent the wheel unless youre sure there isnt onealready (or youve time and its fun to do so)

Find out what others are doing about it

Read the instructions Identify/define the issue

If its likely to be regulated, check with government agencies, trade associations,web, internet

If not regulated but likely good industry practice, check suppliers, other users ofsame material or item, other users of similar items, other industry contactsbuttest the info!!!(cross-check, ask if it makes sense)

Check standard reference works, (Lees, CCPS, etc)

Doing it

Try to think of all situations that are likely to occur (process, eqpt, people)

KISS, keep it user-friendly, show basis for decisions if practical to do so

Follow up afterwards to see how its working


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Questions?

Documents

Creedy - Industrial Process Safety for SSS 110526