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SAChE® Certificate Program

Level 1, Course 4: An Introduction to Managing Process Safety Hazards

Unit 1 – The Process Safety Management System: An Overview

Narration:

[No narration]


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Getting Started

Narration (female voice):

If this is your first time taking a SAChE course, please take a few minutes to explore the interface.

This slide will explain how to use the controls to navigate through the course. All of the units in

the course use the same interface. This interface has four main features that you should be

aware of:

• Here is the left navigation bar. It contains a list of the slides as well as the narrative

transcript. At any point in the course, if you would like to revisit any content, click the

slide title to jump back.

• You may also use the Previous button on the bottom of the player. To advance forward,

use the Next button.

• The Search feature allows you to search for content using any word in the current unit.

• On the top menu bar you will find the Help, Abbreviations, Glossary, Resources and Exit

options. The resources included in this course include any unit-specific attachment as

well as a printable copy of the unit slides and narrative.


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• Use the Exit tab to leave this unit at any time.

Click the arrows if you want to learn more about the interface features. Click ‘Next’ when you’re

ready to continue.


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Objectives

Narration (male voice):

This is the first of four units in the “An Introduction to Managing Process Safety Hazards” course.

By the end of this unit, titled “The Process Safety Management System: An Overview,” you will

be able to:

• Explain the difference between process safety and personal safety;

• List some of the historical events that led to process safety regulation in the U.S. and

worldwide;

Identify organizations that have developed Process Safety Management (or PSM)

frameworks; and

• Identify the elements of PSM.


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SECTION 1: Why Process Safety Management is Important

Narration:

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Section 1


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Process Safety Management – Defined


The Center for Chemical Process Safety, or CCPS, views process safety management as:

• A disciplined framework for managing the integrity of operating systems and processes

handling hazardous materials by applying good design principles, engineering, and

operating practices.

• The application of management systems to the identification, understanding, and

control of process hazards to prevent process related injuries and incidents.


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Process Safety vs. Personal Safety


Note that there is a distinction between Process Safety and Personal Safety. The Center for

Chemical Process Safety views Chemical Process Safety as:

• The operation of facilities that handle, use, process, or store hazardous materials in a

manner free from episodic or catastrophic incidents;

• A dynamic condition involving technology, materials, people and equipment that

comprise a facility; and

• An ideal condition toward which an operation strives.


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Why Process Safety Management is Important


For many years, companies focused their accident prevention efforts on improving the

technology and human factors. In the mid-1980s, following a series of serious chemical

accidents around the world, companies, industries, and governments began to identify

management systems (or the lack thereof) as the underlying cause for these accidents.


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Why Process Safety Management is Important (continued)


Several disasters have led to significant movement in process safety regulation, including:

• The Flixborough disaster in England (June 1, 1974);

• The Seveso disaster in Italy (July 10, 1976);

• The Union Carbide disaster in Bhopal, India (December 3, 1984);

• The Piper Alpha disaster in the North Sea (July 6, 1988);

• The Texas City disaster (March 23, 2005);

• The T2 Laboratories disaster in Jacksonville, Florida (December 19, 2007); and

• The San Martin PEMEX disaster in Mexico City (December 19, 2010).

Of the incidents listed, Seveso spurred the development of major process safety regulation for

Europe, while Bhopal provided the same impetus for U.S. governance of process safety. We’ll

explore these two disasters in the next two units.


The Chemical Safety Board has produced videos detailing three of these events. Click the video

icons if you would like to watch a video about these events.


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Bhopal (Slide Layer)


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Texas City (Slide Layer)


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T2 Laboratories (Slide Layer)


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SECTION 2: The Seveso Disaster

Narration:

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Section 2


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Seveso: An Overview


On July 10, 1976 a reactor at the company, ICMESA, in Seveso near Milan, Italy experienced a

runaway reaction that resulted in over-pressurization and release of the contents beyond the

plant boundaries.

Overheating of a small area of the vessel contents near the liquid surface initiated a reaction

which propagated in temperature and rate to at least the 230 degrees Celsius onset

temperature and beyond.


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Seveso: The Reactor


Here is an illustration representing the reactor. The temperature of the contents near the

bottom of the chamber was 158 degrees Celsius. The liquid surface temperature increased by

heat transfer from the upper wall to a critical temperature of 230 degrees Celsius. The upper

wall temperature increased to 300 degrees Celsius because of superheated steam.


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Seveso: Confounding Factors


There were a number of confounding factors:

• Because of local law, the process had to be shut down for the weekend with reactant

inventory remaining in the vessel, an unusual situation.

• The exhaust steam pressurizing the heating coils was left on. Additionally, due to low

weekend load, it was elevated at 300 degrees Celsius, well above its normal 190 degrees

Celsius.

• The reactor had no automatic cooling system; it had to be activated manually and only

weekend maintenance personnel were on hand. Vessel contents reached 450 to 500

degrees Celsius, greatly increasing the formation of dioxin.

• No catch tank was installed for the expelled contents.

• This event, and utility operations, were not known to have been covered in a Process

Hazards Analysis (or PHA).


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Seveso: Disaster Results


Most of the reactor contents, about six metric tons (including at least one kilogram of dioxin),

were discharged to the atmosphere through the vessel’s rupture disc.

The dioxin (an unintended by-product of the extreme reaction temperature) fallout to the

surrounding countryside resulted in 17 square kilometers becoming unlivable, requiring

complete removal of the populace, elimination of the town’s highway exit, and demolition of

the factory.

At least 250 people were diagnosed with chloracne, with many others suffering other, likely

related, health effects.


The accident generated probably more regulatory enactment, primarily the Seveso Directive,

than any other chemical industry incident. Click the book icon if you would like to learn about

the Seveso Directive.


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Seveso: Take-away


Deficiencies in process design, hazard identification, and emergency response were significant

(but not exclusive) contributors to the events that took place.


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SECTION 3: The Bhopal Disaster

Narration:

[No narration]

Section 3


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Bhopal: An Overview


On December 2nd and 3rd, 1984, in Bhopal, central India, a Union Carbide subsidiary plant

experienced a massive sudden release of approximately 25 metric tons of methyl isocyanate

(MIC), which spread beyond the plant boundary.

After extensive investigation, the prevailing conclusion is that water was deliberately introduced

to an MIC storage vessel through an instrument connection. MIC is extremely water reactive,

and a runaway reaction ensued.


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Bhopal: Confounding Factors


As in the Seveso disaster, there were a number of confounding factors that led to the Bhopal

disaster:

• A storage tank was filled beyond recommended capacity.

• The vessel refrigeration system was down for six months to save money; its Freon was

being used elsewhere.

• A relief system caustic scrubber was inactive (said to be down for maintenance).

• The downstream flare for a scrubber was also shut down (said to be awaiting

replacement of corroded pipe work).

• A fixed water curtain used to absorb MIC vapors was insufficient to reach the cloud.

• Supervision was slow to react to initial reports of MIC odor in the area; this was coffee

break time (up to an hour may have been lost here).

• A shanty town had been allowed to form along the plant perimeter over a number of

years.

• And an effective emergency communication/response system was not in place.


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Bhopal: Schematic


This is a schematic of the process system. Click the numbered dots to explore the conditions of

the plant on the day of the incident.

[When [1] is clicked...]

The MIC refrigeration system was out of commission and Tank 610 could not be cooled to slow

down the reaction.


The caustic scrubber was shut down for long delayed maintenance.


Toxic MIC vapor is released from the top of the scrubber vent line at a height of 33 meters.


The flare tower was out of service, awaiting long delayed replacement of corroded piping.


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The poorly designed water curtain only reached a maximum height of 15 meters. This height

was insufficient to mitigate the toxic MIC cloud at 33 meters.


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Bhopal: Disaster Results


This became the worst disaster in the history of the chemical industry.

• Between 2500 and 5000 people were killed.

• Up to 200,000 were injured.

• Litigation and medical complications are ongoing to this day.

• The tragedy gave rise to most of the significant Process Safety Management (or PSM)

regulation and industry practices we know today.


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Bhopal: Approximate Profile of MIC Release


This chart illustrates the cloud footprint of the MIC release during the Bhopal disaster.


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Bhopal: Approximate Profile of MIC Release (continued)


This chart illustrates the cloud height of the MIC release during the Bhopal disaster.


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Bhopal: Take-away


In most of Bhopal’s causal factors, you can see glaring deficiencies in the major PSM elements of

hazard analysis, mechanical integrity, operating procedures, and management of change. Yet,

this was not considered to be a problematic facility at the time. They were looking at different

things.


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Some Questions Arising from the Bhopal Disaster


Here are some examples of questions arising from the Bhopal disaster:

• Would the operators have made the decisions to disconnect the flare, scrubber and

refrigeration systems on their own?

• If the relief and other protective systems were not designed to handle a runaway, why

not? Was that judged to be highly unlikely? What analysis of this was documented?

• If a risk analysis would have been done, even quantitatively assessing protective system

liability, would it have considered the possibility of all these protective systems being

shut down?

• A valve on the vessel had to be opened to allow water in. Can we really estimate the

probability that a person will make a conscious decision to open it (or not close it)?


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Many Incident Examples


As you progress through the program, you’ll explore many case studies of incidents. In these

examples, there will always be some technical cause or initiating event. In many cases, these

happened at large companies.

Do you think they didn’t have the technical expertise to avoid these mishaps? Of course not!


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SECTION 4: Organizations Involved in Process Safety

Narration:

[No narration]

Section 4


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The Process Safety Management System


Because of these disasters, various regulations and codes of practice were developed along with

a system of process safety management in order to prevent or minimize these events in the

future.

Various countries have their own form of process safety regulation, but there are more

similarities than differences.


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U.S. Regulations and Organizations


In the U.S., federal government rules are published in the Federal Register (FR) and the Code of

Federal Regulations (CFR). Rules and regulations come from governmental agencies, such as the:

• Occupational Safety and Health Administration (OSHA);

• National Institute for Occupational Safety and Health (NIOSH);

• Environmental Protection Agency (EPA);

• Department of Transportation (DOT); and

• The Mine Safety and Health Administration (MSHA).

There are also non-governmental organizations that issue industry guidance, including the:

• American Institute of Chemical Engineers (AIChE);

• American Petroleum Institute (API);

• ASTM (formerly American Society for Testing and Materials); and

• The National Fire Protection Association (NFPA).


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You can visit the website of any of these agencies and organizations by clicking the respective

logo.


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U.S. Regulations and Organizations (continued)


The regulations that govern U.S. based process safety management are OSHA’s PSM regulation

found in 29 CFR 1910.119 and the EPA’s Risk Management Plan regulation found in the Clean Air

Act, Section 112(r). These regulations are implemented in the form of required “management

elements.”


Click the documents if you would like to examine these regulations.


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Process Safety Management Elements


Management elements of process safety include:

• Accountability;

• Process Knowledge and Documentation;

• Risk Assessment and Hazard Analysis;

• Training;

• Operating Procedures;

• Mechanical Integrity;

• Management of Change;

• Incident Investigation; and

• Audits.

The Center for Chemical Process Safety includes detailed information on these management

elements:


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• Enhancement of Process Safety Knowledge;

• Capital Project Review; and

• Human Factors.

OSHA has detailed rules and guidance on the following management elements:

• Employee Participation;

• Emergency Planning and Response;

• Pre-Start-up Safety Review;

• Contractors; and

• Hot Work.


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PSM Activities Have Stagnated


After an initial surge of activity, process safety management activities appear to have stagnated

within many organizations. Incident investigations continue to identify inadequate management

system performance as a key contributor to the incident. And audits reveal a history of repeat

findings indicating chronic problems whose symptoms are fixed again and again without

effectively addressing the technical and cultural root causes.

Left unchecked, such issues can do more than cause stagnation; they can leave organizations

susceptible to losing their focus on process safety, resulting in a serious decline in process safety

performance or a loss of emphasis on achieving process safety excellence.


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Risk Based Process Safety (RBPS)


This is one of the reasons the Center for Chemical Process Safety (CCPS) created the next

generation process safety management framework - Risk Based Process Safety (RBPS), which is

addressed in the Introduction to Process Safety course.

Note in the “Commit to Process Safety” foundational block that the names of the pillar elements

suggest activities which reflect an organization’s appreciation for the importance and value of

process safety management.

Likewise, take a look at the names of the elements in the “Manage Risk” block – “Manage

Change,” “Operating Procedures,” “Training,” “Safe work practices,” and so on – all suggest

activities aimed at maintaining a safe operating facility.


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RBPS Resources


Resources for information on RBPS include the:

• Center for Chemical Process Safety;

• Chemical Safety Board; and

• AIChE Academy.

We’ll explore these resources on the slides that follow.


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Center for Chemical Process Safety (CCPS)


The Center for Chemical Process Safety was founded by AIChE in response to the Bhopal disaster.

The organization has approximately 200 member companies.

The mission of CCPS is to advance state-of the-art process safety technology and management

practices. The organization generates guidelines, research, major symposia, college curricula

and course such as this one.

While CCPS is not a lobbying group, it has had a tempering effect on legislation through

collaboration with the U.S. Chemical Safety Board, OSHA, EPA and HSE in the United Kingdom.

CCPS is a source of benchmarking and contacts.


Click the book icon if you would like to visit the CCPS website.


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CCPS Members


Click the CCPS logo if you would like to review a list of CCPS corporate members.


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Chemical Safety Board (CSB)


The Chemical Safety Board (or CSB) is an independent federal agency headquartered in

Washington, D.C. The agency is charged with investigating industrial chemical accidents;

however, it does not issue fines or citations.

CSB does the following:

• Makes recommendations to plants, regulatory agencies, industry organizations, and

labor groups;

• Conducts investigations of more general chemical accident hazards; and

• Produces reports, news releases and extremely valuable incident summaries and

training videos.


Click the book icon if you would like to visit the CSB website.


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American Institute of Chemical Engineering (AIChE)


AIChE provides a series of courses (eLearning and face to face) as well as a library of videos on

RBPS, including “20 Elements of Risk Based Process Safety.”


Click either computer to open the respective web page.


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Why Have Process Safety?


The most common motivators for process safety as promoted by CCPS include:

• It is the right thing to do – it’s the ethical way to operate;

• It may be required by law;

• It displays your company’s high level of corporate and social responsibility;

• It helps your company manage risk and prevent major losses; and

• Other factors, including monetary savings, community goodwill, creation of sustaining

company value, and business flexibility.


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Significant Issue for Process Safety Management


Many small and even medium sized businesses slip through the net, and they can have serious

accidents. They can benefit from PSM, but how to implement it practically remains elusive.


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Unit 1 Summary


We’ve reached the end of the first unit in the “An Introduction to Managing Process Safety

Hazards” course. Having completed this first unit on the “Process Safety Management System:

An Overview,” you should now be able to:

• Explain the difference between process safety and personal safety.

• List some of the historical events that led to process safety regulation in the U.S. and

worldwide;

• Identify organizations that have developed PSM frameworks; and

• Identify the elements of PSM.

In the next two units, we’ll select two elements, Process Safety Culture, and Management of

Change, to see what they mean in practice.