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Industrial Process Safety
Lessons from major accidents and their application
in traditional workplace safety and health
Graham D. Creedy, P. Eng, FCIC, FEICFormerly Senior Manager, Responsible Care
Canadian Chemical Producers Association
(now Chemistry Industry Association of Canada)
System Safety Society Spring Event
May 26, 2011
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Overview
How I got into this
The evolution of the philosophy of
industrial safety and prevention of majoraccidents
Some key insights and concepts
How these apply to management ofworkplace safety in various sectors and at
different levels of the organization
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Some history
1984 Bhopal accident is wake-up call tochemical 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
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Source: US Bureau of Labor Statistics (www.bls.gov/iif)
0.0 2.0 4.0 6.0 8.0 10.0 12.0
ServicesFinance, insurance & real estate
Wholesale & retail trade
Transportation & public utilit ies
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 industriesConstruction
Mining
Agriculture, forestry & fishing
Safety Performance by Industry SectorInjuries & illnesses per 200,000 hours worked (2002)
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Relative risks of fatal accidents in the work
place of selected occupationsFishers (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)
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CIAC website
www.canadianchemistry.ca
Staff contact: Stephanie Butler
613-237-6215 x 245
Chemistry Industry
Association of Canada
Member Performance
http://www.canadianchemistry.ca/http://www.canadianchemistry.ca/8/13/2019 Creedy - Industrial Process Safety for SSS 110526
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Serious/Disabling/Fatalities
Medical Aid Case
Property Loss/1st Aid
Treatment
Near Misses
Unsafe Behaviors/Conditions
Incident Pyramid:
1
30
10
600
10,000
A proactive approach focuses on thesecategories, but be carefulyou may
miss the really serious ones!
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Terminology
Process hazard
A physical situation with potential to cause
harm to people, property or the environment
Risk (acute)
probability x consequencesof an undesiredevent occurring
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They thought they were safe
Good companies can belulled into a false sense ofsecurity by theirperformance in personalsafety and health
They may not realise howvulnerable they are to amajor accident until ithappens
Subsequent investigationstypically show that therewere multiple causes, andmany of these were knownlong before the event
BP Deepwater Horizon
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Why and how defences fail
People often assume systems work asintended, despite warning signs
Examples of good performance are cited as
representing the whole, while poor ones areoverlooked or soon forgotten
Analysis of failure modes and effects
should include human and organizationalaspects as well as equipment, physical andIT systems
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Process safety management
Recognition of seriousness ofconsequences and mechanisms of
causation lead to focus on the processrather than the individual worker
Many of the key decisions influencingsafety may be beyond the control of theworker or even the sitethey may bemade by people at another site, country
or organization
Causes differ from those for personnelsafety
Need to look at the wholematerials,
equipment and systemsand considerindividuals and procedures as part of thesystem
Management system approach forcontrol
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Scope(elements of process safety management)
1. Accountability
2. Process Knowledge and Documentation
3. Capital Project Review and Design Procedures
4. Process Risk Management
5. Management of Change
6. Process and Equipment Integrity
7. Human Factors
8. Training and Performance
9. Incident Investigation
10. Company Standards, Codes and Regulations11. Audits and Corrective Actions
12. Enhancement of Process Safety Knowledge
CCPS: Guidelines for TechnicalManagement of Chemical Process Safety
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Functions of a management system
Planning Organizing
Leadership
Controlling Implementing
M
easuremen
t
Results
Structure
Direction
CCPS: Guidelines for Technical Management of Chemical Process Safety
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Features and characteristics of a management
system for process safety
PlanningExplicit goals and objectives
Well-defined scopeClear-cut desired outputsConsideration of alternative achievementmechanismsWell-defined inputs and resource
requirementsIdentification of needed tools and training
OrganizingStrong sponsorshipClear lines of authority
Explicit assignments of roles andresponsibilitiesFormal proceduresInternal coordination and communication
ImplementingDetailed work plansSpecific milestones for accomplishmentsInitiating mechanisms
ControllingPerformance standards andmeasurement methodsChecks and balancesPerformance measurement and reporting
Internal reviewsVariance proceduresAudit mechanismsCorrective action mechanismsProcedure renewal and reauthorization
CCPS: Guidelines for TechnicalManagement of Chemical Process Safety
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Examples of PSM management systems concerns at
different organizational levels
CCPS: Guidelines for TechnicalManagement of Chemical Process Safety
Planning
PlanningOrganizing
Planning
Organizing
Organizing
ImplementingImplementing
ControllingControllingControlling
Strategic Managerial Task
Self assessment of Current Status
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Self-assessment of Current StatusProcess 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. Well 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 thoseresponsible 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 andassess 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 theSite Self-
Assessment Tool
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0
20
40
60
80
100
120
140
160
2002
(137 sites)
2003
(141 sites)
2004
(134 sites)
2005
(143 sites)
2006
(139 sites)
2007
(145 sites)
2008
(129 sites)
Excellent
Enhanced
Essential
Almost at Essential
"In Progress"
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
P R l t d I id t M (PRIM) 2007
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Process-Related Incident Measure (PRIM) 2007
Findings: All Elements
PRIM INCIDENT CAUSE ANALYSIS 1998/1999 TO 2007
05
1015
2025303540
1Acco
untability:O
bjectiv
es&G
oals
2Proc
essKnow
ledge
&Docu
m.
3Capital
ProjectR
eview
&De
sign
4Proc
essRisk
Manag
ement
5Manage
mento
fChan
ge
6Proc
ess&Eq
uipme
ntInte
grity
7Hu
manF
actors
8Trainin
g&Pe
rforma
nce
9Incident
Investiga
tion
10Co
mpany
Standards
/Code
s/Re
gs.
11Au
dits&Corre
ctiveA
ctions
12En
hancem
entProcessS
afetyK
nowled
ge
PSM Element Possibly Involved
Incidents
Analyzed
98/9920002001
200220032004200520062007
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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
Resourcingnot only for ideal but for anticipatedconditions
Balancing with other priorities
How are exceptions handled?
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Consider targets in groups
Those who:
Dont care
Dont know (and perhaps dont know that theydont know)
Did know, but may have forgotten or could
have gaps in application (and perhaps dont
realize it)
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Excellent guidance
existsbut how is it
being used?
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The New Product Introduction Curve
Can be applied to adoption of new ideas
Categories differ by ability and more importantly, motivation
P
ercent
a
doption
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Accountability
Management commitment at all levels
Status of process safety compared to otherorganizational objectives such as output, quality andcost
Objectives must be supported by appropriate resources
Be accessible for guidance, communicate and lead
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Management of Change
Change of process technology
Change of facility
Organizational changes
Variance procedures Permanent changes
Temporary changes
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Process and Equipment Integrity
Design to handle allanticipated 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 especial ly careful of automatic safeguards
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Consider operator asfallible humanperforming tasks inbackground
Design for errortolerance, not justprevention
detection correction
Buncefield, UK
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Realization of significance of sociocultural factors in
human thought processes and hence in behaviours
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Human behaviour aspects
People, and most organizations, dont
intend to get hurt (have accidents) To understand why they do leads useventually into understanding humanbehaviour, both at the individual andorganizational 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
Familiarity to
engineers
More
Less
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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 sensethey 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
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Reasons Cheese Model
James Reason, presentation to Eurocontrol 2004
2
SSThe Swiss cheese model of
organisational accidents
Some holes due
To active failures
Other holes due to
latent conditions
Successive layers of defences
Hazards
Losses
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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
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A Classic Example of a Latent
Failure
Hazard of material
known, but lack of
awareness of potential
system failure modeleads to defective
procedure design
through management
decision
Epichlorhydrin fire,
Avonmouth, UK
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Danvers, MA, Nov 2006
Solvent explosion at printing ink factory
US Chemical Safety Board
And another
Hazards known, but defencescompromised by apparently benignchange
Latent error in procedure designcreates vulnerability to likely
execution error
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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
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Lessons from other fields
Aerospace andnuclearshow how significanthuman and organizational aspects can be evenwhere the obvious signs of failure are technicalin nature
Financeshows: 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
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The relevance of organizational factors has also been
graphically and tragically revealed in the inquiry reports of recentUK transportation and offshore oil disasters.
Prior to ..., senior managers in all the organizationspropounded the pre-eminence of safety. They believed in theefficacy of the regulatory system, in the adequacy of their existing
programs, and in their confidence of the skills and motivation oftheir staff.
The inquiry reports reveal that their belief in safety was amirage, their systems inadequate, and operator errors andviolations commonplace.
The inquiry reports stated that ultimate responsibility laywith complacent directors and managers who had failed to ensurethat their good intentions were translated into a practical andmonitored reality. Moreover, the weaknesses so starkly revealedwere not matters of substantial concern to the regulatory
authorities before the accidents. HSC, 1993
Relevance of organizational factors
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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 mostimportant 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.
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Standard
of Safety
Time
In general, safety gets better as society learns more
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Standard
of Safety
Time
But the rate of improvement is not steady
x 10
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Standard
of Safety
Time
In fact, the curve can be one of periodic rapid gains
followed by gradual but increasing declines
x 100
Note how the rate
of decay can be
expected to
increase due to
normalization ofdeviance
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People
Systems
Tribal
Chaotic
Operational
Excellence
Bureaucratic
Strong
Weak Strong
Organizational Culture ModelJames W. Bayer, Senior VP Mfg, Lyondell Chemical Company
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Demographic effects Less staff
Experienced cohort leaving or left
Skills transfer senior > (middle)> junior
Replacements understand the way something isdone, but not why it is done that way, the potentialconsequences of doing it differently and how to detectand recover from undesired actions
We are starting to see lowered standards ofdesign and supervision that fifteen years agowould have been unthinkable in the chemicalindustry (Challenger, 2004)
Preservationor lossof corporate memory
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Knowledge
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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 areother 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 asintended
Did analysis consider why execution not as intended?
Was corrective action appropriate and balanced?
Was review of system execution limited or broad in scope?
D li ith S f t ( E i i ) P bl
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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 orproblem)
Where are the people youre dealing with on the curve? (generally, and re the issueor problem)
Finding out what to do
Benchmark dont try to reinvent the wheel unless youre sure there isnt onealready (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 ofsame material or item, other users of similar items, other industry contactsbuttest 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
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Questions?