Industrial Process Safety

Lessons from major accidents and their application

in traditional workplace safety and health

Graham D. Creedy, P. Eng, FCIC, FEIC

Formerly Senior Manager, Responsible Care
Canadian Chemical Producers Association
(now Chemistry Industry Association of Canada)
gcreedy@canadianchemistry.ca

System Safety Society Spring Event

May 26, 2011

Overview
How I got into this
The evolution of the philosophy of
industrial safety and prevention of major
accidents
Some key insights and concepts
How these apply to management of
workplace safety in various sectors and at
different levels of the organization
2

Some history
1984 Bhopal accident is wake-up call to
chemical 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
3

Safety Performance by Industry

Sector
Injuries & illnesses per 200,000 hours worked (2002)

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

4

Relative risks of fatal accidents in the work

place of selected occupations
Fishers (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)
5

Chemistry Industry
Association of Canada
Member Performance

CIAC website
www.canadianchemistry.ca
Staff contact: Stephanie Butler
613-237-6215 x 245

Incident Pyramid:
1

Serious/ Disabling/ Fatalities

10

Medical Aid Case

30

Property Loss/ 1st Aid

Treatment

600

Near Misses
Unsafe Behaviors/ Conditions

10,000

A proactive approach focuses on

these categories, but be careful
you may miss the really serious
ones!

Terminology
Process hazard
A physical situation with potential to cause
harm to people, property or the environment

Risk (acute)
probability x consequences of an undesired
event occurring

They thought they were safe

Good companies can be
lulled into a false sense of
security by their
performance in personal
safety and health
They may not realise how
vulnerable they are to a
major accident until it
happens
Subsequent investigations
typically show that there
were multiple causes, and
many of these were known
long before the event

BP Deepwater Horizon

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
Analysis of failure modes and effects
should include human and organizational
aspects as well as equipment, physical and
IT systems
10

Process safety management

Recognition of seriousness of consequences

and mechanisms of causation lead to focus
on the process rather than the individual
worker

Many of the key decisions influencing safety

may be beyond the control of the worker or
even the site they may be made by people
at another site, country or organization

Causes differ from those for personnel safety

Need to look at the whole materials,

equipment and systems and consider
individuals and procedures as part of the
system

Management system approach for control

Flixborough, Bhopal, Pasadena

11

Scope
(elements of process safety
management)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

Accountability
Process Knowledge and Documentation
Capital Project Review and Design Procedures
Process Risk Management
Management of Change
Process and Equipment Integrity
Human Factors
Training and Performance
Incident Investigation
Company Standards, Codes and Regulations
Audits and Corrective Actions
Enhancement of Process Safety Knowledge
CCPS: Guidelines for Technical Management of Chemical Process Safety

12

Functions of a management system

Planning

Leadership

Results

Organizing

Structure

Measurement
Controlling

Direction

Implementing

CCPS: Guidelines for Technical Management of Chemical Process Safety

13

Features and characteristics of a management

system for process safety
Planning
Explicit goals and objectives
Well-defined scope
Clear-cut desired outputs
Consideration of alternative achievement
mechanisms
Well-defined inputs and resource
requirements
Identification of needed tools and training

Implementing
Detailed work plans
Specific milestones for accomplishments
Initiating mechanisms

Organizing
Strong sponsorship
Clear lines of authority
Explicit assignments of roles and
responsibilities
Formal procedures
Internal coordination and communication

Controlling
Performance standards and
measurement methods
Checks and balances
Performance measurement and
reporting
Internal reviews
Variance procedures
Audit mechanisms
Corrective action mechanisms
Procedure renewal and reauthorization

CCPS: Guidelines for Technical Management of Chemical Process Safety

14

Strategic

Managerial

Planning
Planning

Task

Planning
Organizing

Organizing
Implementing
Organizing
Controlling

Implementing
Controlling

Controlling

Examples of PSM management systems concerns at

different organizational levels
CCPS: Guidelines for Technical Management of Chemical Process Safety
15

A page from the

Site SelfAssessment Tool

16

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

17

Process-Related Incident Measure (PRIM)

2007 Findings: All Elements

18

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
Resourcing not only for ideal but for anticipated
conditions
Balancing with other priorities

How are exceptions handled?

19

Consider targets in groups

Those who:
Dont care
Dont know (and perhaps dont know that they
dont know)
Did know, but may have forgotten or could
have gaps in application (and perhaps dont
realize it)

20

Excellent guidance
exists but how is it
being used?

21

Percent
adoption

The New Product Introduction Curve

Ea
In
E
no ar
rly
va ly
M
to Ad
aj
rs o
or
pt
ity
er
s

La
te

aj
or
it

La
gg
ar

ds

Can be applied to adoption of new ideas

Categories differ by ability and more importantly, motivation
22

Accountability
Management commitment at all levels
Status of process safety compared to other
organizational objectives such as output, quality and
cost
Objectives must be supported by appropriate resources
Be accessible for guidance, communicate and lead

23

Management of Change

Change of process technology

Change of facility
Organizational changes
Variance procedures
Permanent changes
Temporary changes

24

Process and Equipment Integrity

Design to handle all anticipated 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 especially careful of automatic safeguards
25

 Consider operator as
fallible human
performing tasks in
background
Design for error
tolerance, not just
prevention
detection
correction

Buncefield, UK

26

Realization of significance of sociocultural factors in

human thought processes and hence in behaviours

27

Human behaviour aspects

People, and most organizations, dont
intend to get hurt (have accidents)
To understand why they do leads us
eventually into understanding human
behaviour, both at the individual and
organizational level, and involves:

Familiarity to
engineers
More

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

Less
28

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 sense they 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
29

Reasons Cheese Model

James Reason, presentation to Eurocontrol 2004

30

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

31

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
through management
decision
Epichlorhydrin fire,
Avonmouth, UK
32

And another

Danvers, MA, Nov 2006

Solvent explosion at printing ink factory

Hazards known, but defences

compromised by apparently benign
change
Latent error in procedure design
creates vulnerability to likely
execution error

US Chemical Safety Board

33

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

34

Lessons from other fields

Aerospace and nuclear show how significant
human and organizational aspects can be even
where the obvious signs of failure are technical
in nature
Finance shows:
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
35

Relevance of organizational factors

The relevance of organizational factors has also been
graphically and tragically revealed in the inquiry reports of recent
UK transportation and offshore oil disasters.
Prior to ..., senior managers in all the organizations
propounded the pre-eminence of safety. They believed in the
efficacy of the regulatory system, in the adequacy of their
existing programs, and in their confidence of the skills and
motivation of their staff.
The inquiry reports reveal that their belief in safety was a
mirage, their systems inadequate, and operator errors and
violations commonplace.
The inquiry reports stated that ultimate responsibility lay
with complacent directors and managers who had failed to ensure
that their good intentions were translated into a practical and
monitored reality. Moreover, the weaknesses so starkly revealed
were not matters of substantial concern to the regulatory
HSC, 1993
authorities before the accidents.

36

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 most
important 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.
37

In general, safety gets better as society learns more

Standard
of Safety

Time
38

But the rate of improvement is not steady

Standard
of Safety

x 10

Time
39

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

followed by gradual but increasing declines

Note how the rate

of decay can be
expected to
increase due to
normalization of
deviance

Standard
of Safety

x 100

Time
40

Organizational Culture Model

James W. Bayer, Senior VP Mfg, Lyondell Chemical Company

Strong
Tribal

Operational
Excellence

Chaotic

Bureaucratic

People

Weak

Systems

Strong
41

Preservation or loss of corporate memory

Demographic effects

Less staff
Experienced cohort leaving or left
Skills transfer senior > (middle) > junior
Replacements understand the way something is done,
but not why it is done that way, the potential
consequences of doing it differently and how to detect
and recover from undesired actions

We are starting to see lowered standards of

design and supervision that fifteen years ago
would have been unthinkable in the chemical
industry (Challenger, 2004)
42

 What does an organizations investigation

of its failures reveal about its:
Culture
Management system?

43

 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 are
other 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 as
intended
Did analysis consider why execution not as intended?
Was corrective action appropriate and balanced?
Was review of system execution limited or broad in scope?

44

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

Finding out what to do

Benchmark dont try to reinvent the wheel unless youre sure there isnt one already
(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 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 its working

45

Questions?

46