Process Safety Management: Some Lessons from Recent Incidents

Presentation to the Introduction to Environmental,

Health & Safety WorkshopCSChE 2008 Conference

Ottawa, ON, October 21, 2008

Graham Creedy, P.Eng, FCIC, FEICSenior Manager, Responsible Care®

Canadian Chemical Producers’ Association(613) 237-6215, gcreedy@ccpa.ca

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Origins of this Workshop

• Why Process Safety Management?

• Knowing (and meeting) the regulations is important; but is not enough – especially in Canada

• Need to Know:– How to spot the hazards– Why and How defences fail– How to communicate

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Personal safety hazards can sometimes be easy to spot; but major hazards are often not obvious

• Keep an open mind about hazards – do not assume that if it is important, someone else would have noted it

• Know the basic hazard identification & risk assessment techniques and when to use them

• If using a contractor for this, know enough to watch for competence

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Why and How Defences Fail

• People often assume systems work as intended, despite warning signs

• Examples of good performance are cited as representing the whole, while poor ones are overlooked or soon forgotten

• Failure modes and effects analysis (FMEA) should include human and organizational aspects as well as equipment, physical and IT systems

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Avonmouth, UK 1996

• Although not recent, it is a classic example of a latent failure

• Hazard of material known, but lack of awareness of potential system failure mode leads to defective procedure design

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Ghent, WV 2007

• Hazards well-known and supposedly covered by equipment and procedure design

• Latent errors in procedure execution allow actual practice to deviate from assumed

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Danvers, MA 2006

• Hazards known, but defences compromised by apparently benign change

• Latent error in procedure design creates vulnerability to likely execution error

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Port Wentworth, GA 2007

• Hazard of material not obvious (despite history)

• Latent error allowed dust to accumulate, creating conditions for subsequent events

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James Reason’s “Cheese Model”

shows how the layers of protection intended to control hazards are not perfect, but are subject to holes that can increase over time if not monitored

carefully. Eventually the holes are such that enough defences fail, leading to a major incident

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The Process Safety Management Guide

• Summarizes CCPS approach in handy, short booklet

• Available as free download from CSChE’s PSM division website, in English and French (or as booklet, for nominal fee)

• Website:http://psm.chemeng.ca

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Self-assessment of Current Status Process 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. We’ll 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 those responsible 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 and

assess 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 the “HISAT” Site Self-Assessment Tool, available on the PSM Division website http://psm.chemeng.ca

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• The US Chemical Safety Board website www.csb.gov has case studies and videos – great for understanding and “Could it happen here?”

• Center for Chemical Process Safety (CCPS) guide– Easy to use– Describes hazard evaluation

procedures– Explains when and how to use them

www.aiche.org/ccps

Understanding and sizing up the hazards

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When communicating, remember the New Product Introduction Curve

• Categories differ by ability and more importantly, motivation• Where is your org, and your boss, on this curve?

Innovators

Early Adopters

Early Majority

Laggards

Late Majority

Per

cent

ad

optio

n

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Dealing with a Safety (or Engineering) Problem• Finding out who you’re dealing with

– Where is the organization on the curve? (generally, and re the specific issue or problem)

– Where are the people you’re dealing with on the curve? (generally, and re the issue or problem)

• Finding out what to do– “Benchmark” – don’t try to reinvent the wheel unless you’re sure there isn’t one

already (or you’ve time and it’s fun to do so)– Find out what others are doing about it– Read the instructions– Identify/define the issue– If it’s likely to be regulated, check with government agencies, trade associations, web,

internet– If not regulated but likely good industry practice, check suppliers, other users of same

material or item, other users of similar items, other industry contacts – but test 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 it’s working

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Questions?