Process Safety Management:
Some Lessons from Recent Incidents
Presentation to the
Introduction to Environmental, Health & Safety
Workshop
CSChE 2008 Conference
Ottawa, ON, October 21, 2008
Graham Creedy, P.Eng, FCIC, FEIC
Senior Manager, Responsible Care®
Canadian Chemical Producers’ Association
(613) 237-6215,
[email protected] Origins of this workshop
• Why process safety management?
• Knowing (and meeting) the regulations is
important, but is not enough – especially in
Canada
• Need to know:
– How to spot the hazards
– Why and how defences fail
– How to communicate
2
Personal safety hazards can sometimes be easy
to spot, but major hazards are often not obvious
• Keep an open mind
about hazards – don’t
assume that if it’s
important, someone else
would have noted it
• Know the basic hazard It’s clear this isn’t safe
identification & risk
assessment techniques
and when to use them
• If using a contractor for
this, know enough to
watch for competence
3
But what about this?
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
• Failure modes and effects analysis (FMEA)
should include human and organizational
aspects as well as equipment, physical and
IT systems
4
Avonmouth, UK 1996
• Although not
recent, it is 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 5
Ghent, WV 2007
• Hazards well known
and supposedly
covered by
equipment and
procedure design
• Latent errors in
procedure execution
allow actual practice
to deviate from
assumed
6
Danvers, MA 2006
• Hazards known,
but defences
compromised by
apparently benign
change
• Latent error in
procedure design
creates
vulnerability to
likely execution
error
7
Port Wentworth, GA 2007
• Hazard of material
not obvious (despite
history)
• Latent error allowed
Scottsbluff, NE 1996
dust to accumulate,
creating conditions
for subsequent
events
8
Port Wentworth, GA 2007
The ‘Swiss cheese’ model of
SSAP organisational accidents 2
Some holes due Hazards
To active failures
Other holes due to
latent conditions
Losses
Successive layers of defences
Reason’s “Cheese Model”
James
James Reason - The Management of Safety, Reason,
SSAP presentation
Launch Event 17/02/2004to Eurocontrol 2004 9
The Process Safety Management Guide
• Summarizes CCPS
approach in handy, short
booklet
• Available as free download
from CSChE’s PSM division
website, in English and
French (or as booklet, for
nominal fee)
• Website:
http://psm.chemeng.ca
10
Self-assessment of Current Status
Process 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. We’ll have a team member
A page from the
contact you with advice on how and where to get the information or help.
“HISAT” Site Self- Want
Help A
Current Status
B C D
Assessment Tool, 1. Accountability: Objectives and Goals
available on the PSM (a) Are responsibilities clearly defined and communicated, with those
responsible held accountable?
Division website (b) Is there a system for control of contractor operations?
http://psm.chemeng.ca 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?
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(b) Are corrective actions defined and implementation followed up?
(c) Are the above items formally documented?
Understanding and sizing up the hazards
• The US Chemical Safety Board
website www.csb.gov has case
studies and videos – great for
understanding and “Could it happen
here?”
• Center for Chemical Process Safety
(CCPS) guide
– Easy to use
– Describes hazard evaluation
procedures
– Explains when and how to use them
www.aiche.org/ccps
12
When communicating, remember
the New Product Introduction Curve
adoption
Percent
• Categories differ by ability and more importantly, motivation
• Where is your org, and your boss, on this curve? 13
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
14
Questions?
15
