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www.csb.gov
1
EvolvingSafetyThoughts
MaryBethMulcahy,PhDChemicalIncidentInves0gator
U.S.ChemicalSafety&HazardInves>ga>onBoard
SafetybyDesignApril2016
ChemicalSafetyBoard(CSB)• Independent Federal Agency
• Non-regulatory
Mission
To prevent chemical accidents
• Conduc=ng root cause inves=ga=ons
• Repor=ng findings publicly
• Making recommenda=ons to organiza=ons and agencies that can affect change • Companies • Government Agencies (local, state and federal) • Standard seJng, i.e. American Petroleum Ins=tute (API)
TTU…
BarriersPreventorMiFgateMajorAccidents
Technical/Physical(equipment&
engineeredcontrols)
OrganizaFonal(policies&procedures)
OperaFonal(humanacFon)
ManagementFailures
SafetyCulture
APIRecommendedPrac>ce,754,1sted.,ProcessSafetyPerformanceIndicatorsfortheRefiningandPetrochemicalIndustries,April2010,pp8
ProcessSafetyIndicatorPyramid
MeasuringSafetyCulture
Accident
PoorCommitment GoodCommitment
GoodSafetyPoliciesandProcedures
PoorPoliciesandProcedures
SafetyCulture
GoodCommitment
GoodSafetyPoliciesandProcedures
SafetyCulture
Accident
TheHeartofSafetyCuture?
LossofControl
TheHeartofSafetyCulture
Top Event LossofControl
Hazard/TopEvent
Hazard • Health Hazard
(carcinogen, toxin, etc.)
• Physical Hazard (flammable, explosive, etc.)
Whendoyouhavetochangeyourresponse? • Threshold amount
• Loss of containment
• Loss of u=li=es
Barriers
MajorAccident
Top Event LossofControl
Barriers
Alarms
PreventaFveMaintenance
Back-upSystems
PPE
EvacuaFon
AutomaFcShutdownSystem
PreventaFve MiFgaFve
MajorAccident
Top Event LossofControl
ManagementSystems
PreventaFveBarriers
MiFgaFveBarriers
• Hazard Iden=fica=on
• Procedures
• Incident Inves=ga=ons
• Indicators
Top Event LossofControl
TTUExample
LossofControl
BacktoCulture…