Professional Documents
Culture Documents
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The worlds leading sustainability Delivering sustainable solutions in a more consultancy competitive world
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Presentation Outline
Some lessons from past accidents Three Causes of major accidents Four Practical Initiatives
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Operator Performance
Insufficient training to ensure effective operation of the PTW system Contractors lack offshore experience
Working Environment
Inadequate flow of labour Inadequate working programme Pressure to maintain production at whatever cost
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Brittle fracture of vessel 2 fatalities 8 injuries 25 tonnes released causing an explosion followed by
Jet fire which burned for 2 days
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Vapour Cloud Explosion 15 People killed 180 Injuries Isomeriser Tower overfilled Blowdown vessel and associated stack overfilled formed flammable vapour cloud
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Key findings
Cost cutting and production pressure impaired safety
performance
No responsibility for assessing & verifying MAH prevention Reliance on low personal injury rate as safety indicator Mechanical integrity programme - equipment was run-to-failure Lack of reporting and learning culture Safety campaigns were aimed at personal safety Deep seated problems identified but management action was too little too late
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Develop positive process safety culture Implement leading and lagging indicators Implement an effective audit process
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Problem 1:
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Learning Phase
Time
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Where do I start?
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Solution 1:
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Define Performance
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Problem 2:
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Solution 2:
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Scope of a SOOB
Barrier-defeating factors
Concurrent operations (aka SIMOPs) Non-routine operations Abnormal process conditions Equipment that is not fit-for-purpose Systems unavailable due to maintenance or damage Poor environmental conditions Key personnel unavailable
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Problem 3:
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Solution 3:
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Make sure: the way we do things around here, is the safe way
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Problem 4:
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Solution 4:
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Hire competent disciplined people covers both sides of BTD Prepare for worst case scenario RHS of BTD
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