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Industrial Process Safety: Lessons From Major Accidents and Their Application in Traditional Workplace Safety and Health
Industrial Process Safety: Lessons From Major Accidents and Their Application in Traditional Workplace Safety and Health
3
Safety Performance by Industry Sector
Injuries & illnesses per 200,000 hours worked (2002)
Services
Finance, insurance & real estate
Wholesale & retail trade
Transportation & public utilities
Petroleum and coal products
Chemicals and allied products
Printing & publishing
Pulp & paper
Textiles & apparel
Food & food products
Transportation equipment
Electronic and electrical equipment
Industrial machinery & equipment
Primary metal industries
Construction
Mining
Agriculture, forestry & fishing
0.0 2.0 4.0 6.0 8.0 10.0 12.0
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
6
Incident Pyramid:
1 Serious/Disabling/Fatalities
Unsafe Behaviors/Conditions
10,000
• 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
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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 BP Deepwater Horizon
many of these were known
long before the event
9
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
12
Functions of a management system
Planning
Measurement Direction Organizing
Structure
Leadership
Planning
Planning
Organizing
Planning
Organizing
Implementing
Implementing
Organizing
For each survey question, indicate the level of awareness and use at the site by marking the appropriate box, based
on the following:
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.
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.
A page from the
Site Self- Want
Help A
Current Status
B C D
Assessment Tool 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? 16
Use of self-assessment tool for
collective progress reporting and action
160 Excellent
140
120 Enhanced
100
Essential
80
60
Almost at Essential
40
20 "In Progress"
0
2002 2003 2004 2005 2006 2007 2008
(137 sites) (141 sites) (134 sites) (143 sites) (139 sites) (145 sites) (129 sites)
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Process-Related Incident Measure (PRIM) 2007
Findings: All Elements
98/99
PRIM INCIDENT CAUSE ANALYSIS 1998/1999 TO 2007 2000
2001
2002
2003
2004
40
Incidents Analyzed
2005
35 2006
30 2007
25
20
15
10
5
0
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Assessing an organization’s safety effectiveness
20
Excellent guidance
exists – but how is it
being used?
21
The New Product Introduction Curve
adoption
Percent
In E Ea La La
no ar rly gg
va ly te ar
to Ad M M ds
rs o aj aj
pt or or
er ity ity
s
• Can be applied to adoption of new ideas
• Categories differ by ability and more importantly, motivation
22
Accountability
• Management commitment at all levels
23
Management of Change
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
Buncefield, UK
26
Realization of significance of sociocultural factors in
human thought processes and hence in behaviours
27
Human behaviour aspects Familiarity to
engineers
• People, and most organizations, don’t
More
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:
– 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
Reason’s “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
• Hazard of material
not obvious (despite
history)
• Latent error allowed
dust to accumulate,
Scottsbluff, NE 1996
creating conditions
for subsequent
events
• 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
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
x 100
Time
40
Organizational Culture Model
James W. Bayer, Senior VP Mfg, Lyondell Chemical Company
Strong
Tribal Operational
Excellence
People
Chaotic Bureaucratic
• 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
42
• What does an organization’s 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 didn’t 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 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
45
Questions?
46