Professional Documents
Culture Documents
MARCH 2016
RobertJ.Weber,P.E.
President/CEO
+Houston+Bogota+ Kuwait+Lagos+Singapore
PRESENTATIONOUTLINE
IndustryIncidents&LessonsLearned
IntroductiontoPSMAuditing
PSM CommonDeficienciesfromAuditing
KeySuccessFactors:Whatdoesgoodlooklike?
Conclusion
INDUSTRYINCIDENTS
&
LESSONSLEARNED
INDUSTRYINCIDENTS&LESSONSLEARNED
Itshouldnotbenecessaryfor eachgenerationto
rediscoverprinciplesofprocesssafety whichthegeneration
beforediscovered.Wemustlearnfrom theexperienceof
othersratherthanlearnthehardway.Wemustpassonto
thenextgenerationa recordofwhatwehavelearned.
~JesseC.Ducommun
VicePresident,ManufacturingandadirectorofAmerican
OilCompanyin1961;ProcessSafetyPioneer
FLIXBOROUGH,U.K.(1974)
NyproU.K. Cyclohexane
releasefromtemporary
bypasspipeandsubsequent
explosion
28fatalities,36onsiteinjuries
Offsiteconsequencesresulted
in53reportedinjuries
1,800nearbyhomesdamaged
$425MMUSDpropertyloss
FLIXBOROUGH,U.K.(1974)
CAUSES/LESSONSLEARNED
Lackofplantmodification/changecontrol.
Managementoftemporarychanges.
Managementofchangefororganizationalchange.
Lackofdesigncodesforpipework.
Lackoflanduseplanningandsitingconsiderations
relativetolocationoftheprocessversusplant
buildingsandthelocalcommunity.
SEVESO,ITALY(1976)
ICMESA(IndustrieChimiche
MedaSocietaAzionaria)
Tetrachlorodibenzoparadioxin
(DIOXIN)release,a
poisonousandcarcinogenic
byproductofuncontrolled
exothermicreaction
25kmNorthofMilan
Nofatalities.Morethan600
peopleevacuated;20people
treatedforDioxinpoisoning.
Longtermhealthimpacts.
Ledtodevelopmentofinitial
EUSevesodirective.
MEXICOCITY(1984)
PEMEXLPGTerminal
BLEVE(BoilingLiquidExpansionVaporExplosion)
andfireafterlossofcontainmenttolocalsewer
system
650+fatalities,mostlyoffsite
$20MMUSDpropertydamages
ContributingFactors:
Plantlayout
Active/passivefireprotection
Emergencyisolation
Emergencyresponse/spill
control
BHOPAL,INDIA(1984)
UnionCarbideIndiaLtd.(UCIL) insecticideplant
Methylisocyanaterelease
3,000+fatalities;100,000+injuries
Accidentaresultofpoorsafetymanagementsystems,poorearlywarning
systems,andlackofcommunitypreparedness.
Consideredworldsworstindustrialdisaster
Eventually,resultedindemiseofUnionCarbide,oneoftheworldslargest
integratedchemicalcompanies
PIPERALPHA(1988)
OccidentalPetroleum
Platform NorthSea
167fatalities
$3.4BUSDinsuredloss
ContributingFactors
Firewatersystem
bypassed
Lackofadequate
emergencyevacuation
andegress
PHILLIPSPASADENA(1989)
Vaporcloudexplosion
85,000lbs.flammablegas
release;explosionwithforce
of2.4tonsTNT
23fatalities;130injuries
Propertyloss~$750MMUSD
ContributingFactors
Humanerror(manualvalve
inadvertentlyleftopen)
Facilitysitingandplantlayout
ofprocess,buildings
HISTORYOFPROCESSSAFETY
Process Safety Management was initiated by
U.S. OSHA in 1992 as a way to respond with
government regulations / oversight of industries
using highly hazardous chemicals (HHCs).
Several other countries have followed since.
ProcessSafetyManagement
DEFINITION
A management system design to
PREVENT
the Release of
OR
MINIMIZE
the Consequences of Release
of
Highly Hazardous Chemicals (HHCs)
ProcessSafetyManagement
ELEMENTS
Process Safety
Information
Process Hazard
Analysis
Trade
Secrets
Operating
Procedures
Employee
Participation
Training
PROCESS SAFETY
MANAGEMENT
Compliance
Audits
Emergency
Planning and
Response
Contractors
Pre-Startup
Safety Review
Incident
Investigation
Mechanical
Integrity
Management
of Change
Hot Work
Permit
HISTORYOFPROCESSSAFETY
PERFORMANCE-based regulation, Not
Prescriptive
Regulation sets forth minimum requirements for
compliance (based on 14 Elements)
Regulation specifies WHAT TO DO, Not HOW
TO IT
HISTORYOFPROCESSSAFETY
IS IT WORKING?
BPTEXASCITY(2005)
Vaporcloudexplosion
15fatalities;170
injuries
BothBPandU.S.
ChemicalSafety&
HazardInvestigation
Board(CSB)identified
numeroustechnicaland
organizationalfailingsat
therefineryandwithin
BPcorporate
WESTFERTILIZER(2013)
Retailfertilizeroperationinrural
Texas
Ammoniumnitrateexplosion
15fatalities;160+injuries
Manyfatalitieswereemergency
responders.
Morethan150nearbybuildingsand
homesdamagedordestroyeddue
toblast
USGSrecordedexplosionasa2.1
magnitude
HISTORYOFPROCESSSAFETY
U.S.regulationshaveNOT changedsincetheir
promulgation,but.
OSHAPetroleumRefineryProcessSafetyManagementNational
EmphasisProgram(NEP)Directive 2007
OSHAPSMCoveredChemicalFacilitiesNationalEmphasis
Program(NEP)Directive 2011
ExecutiveOrder13650(August2013)
PendingchangesbyOSHAandEPAtoPSMandRMPregulations
toexpandcoverage,respectively
Morechemicalscovered,morefacilitiescovered,lowerthreshold
quantities
PSM AUDITING
OVERVIEW
10
COMPLIANCEAUDIT
OSHA29CFR1910.119(o)
Performauditatleasteverythree(3)years.
Conductedbyatleastonepersonknowledgeablein
theprocess.
AReportofthefindingsshallbedeveloped.
Theemployershalldocumentaresponsetoeachof
thefindings.
Theemployershalldocumentcorrectiveactionsto
eachofthefindings.
Employershallretainthetwo(2)mostrecent
complianceauditreports.
Audit
PreAudit
Activities
Assemble
Audit
Team
COMPLIANCEAUDIT
Post
Audit
Activities
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COMPLIANCEAUDIT WHY?
Excellenttooltoassessyour
organizationsProcessSafety
effectiveness writtenprogramand
implementation
Assesscompliance;benchmark
performancewithindustry
Identifyandmitigateearlywarning
signsbeforeapotentialincident
IntegraltoPLAN DO CHECK ACT
cycleofcontinuousimprovement
Meticulousverificationrequiredto
preserveLicensetoOperate,whichis
aprivilege,notaright
PSM AUDITING
COMMON DEFICIENCIES
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CommonDeficiencies
BASIS
350+audits/assessmentsperformed
2005 2015
Large,majorOPCOstosmaller,nichespecialty
chemicalcompaniesandindustries
Varietyofindustries:
Oil&Gas
PetroleumRefining
GasProcessing
Petrochemicals
Chemicals
Pharmaceuticals
NH3
CommonDeficiencies
EMPLOYEEINVOLVEMENT
Lackofwellarticulatedmanagementexpectations
anddefinedgoals;leadingtoweakemployeemorale
anddecreasedemployeeparticipation.
EmployeesdonotknowhowtoaccessPHAsand
otherPSMinformation.
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CommonDeficiencies
EMPLOYEEINVOLVEMENT
EXAMPLESOFGOODEMPLOYEEPARTICIPATION:
Assignment of PSM Champions (by Element, by Unit, etc.)
Plant safety steering committee
Toolbox safety meetings
Employee participation in PHAs, PSM audits, incident investigations,
development of SOPs, etc.
Regular communication of action items from PHAs, audits, incidents to
affected employees
Employee feedback; suggestion for improvement boxes
Management consultation with operators on the frequency and content
of training
Regularly-planned emergency action plan drills and exercises with
follow-up and response critique
Behavioral-based safety programs (BBS)
HSSE
Engineering &Construction
PSMSupervisor
Operators
Maintenance
AllEmployees
Contractors
Applicability (a)
EmployeeParticipation (c)
ProcessSafetyInformation (d)
R/A
ProcessHazardsAnalysis (e)
Role
PSMActivity
Operations
COO
RACIMATRIX
Training (g)
Contractors (h)
R/A
HotWorkPermit (k)
ManagementofChange (l)
TradeSecrets (p)
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CommonDeficiencies
PROCESSSAFETYINFORMATION
Hazardouseffectsofinadvertentmixingofdifferent
chemicalsthatcouldforeseeablyoccurnotaddressed
LackofcompleteElectricalAreaClassification
documentationandfieldsurvey
Designbasisinformationforemergencyrelief/PSVand
flaresystemsincomplete(e.g.,PIRP520/520RVsizing
contingencyanalysis)
CommonDeficiencies
PROCESSSAFETYINFORMATION
Designbasisinformationforsafeguards,which
preventormitigateapotentialrelease,incomplete
(e.g.,firewatersystems).
Materialsofconstructioninformationnotonfilefor
allequipmentinthecoveredprocess.
LackofreferencePlantdesigncodesandstandards
identified(RAGAGEP).
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CommonDeficiencies
PROCESSSAFETYINFORMATION
MOSTFREQUENTLYREFERENCEDRAGAGEPsINRECENT
OSHAINSPECTIONS
API520:Sizing,Selection&InstallationofPressure
RelievingDevicesinRefineries
API521:PressureRelievingandDepressuringSystems
APIRP752:ManagementofHazardsAssociatedwith
LocationofProcessPlantPermanentBuildings
APIRP753:ManagementofHazardsAssociatedwith
LocationofProcessPlantPortableBuildings
CommonDeficiencies
PROCESSSAFETYINFORMATION
MOSTFREQUENTLYREFERENCEDRAGAGEPsINRECENT
OSHAINSPECTIONS
API510:PressureVesselInspectionCode Inservice
Inspection,Rating,RepairandAlteration
API570:PipingInspectionCode Inservice
Inspection,Rating,RepairandAlterationofPiping
API574:InspectionPracticesforPipingSystem
Components
ANSI/ISAS84.01:FunctionalSafety Safety
InstrumentedSystemsfortheProcessIndustrySector
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CommonDeficiencies
PROCESSHAZARDSANALYSIS
PHAfailstocomprehensivelyidentifyallhazardsof
theprocessbecause:
Selectionofthewrongmethodologybasedoncomplexity
oftheprocess
IncompletesetofGuidewords+Parameters(Deviations)
utilized
FailuretoreviewStartup/Shutdownissues,Abnormal
Operations
CommonDeficiencies
PROCESSHAZARDSANALYSIS
Safeguardsnotindependentoftheinitiatingevent/
cause.FailuretoperformLayerofProtectionAnalysis
(LOPA)toassesseffectivenessofsafeguards.
Consequencesnotbasedonfailureofengineering
controls,buttakingintoaccountsafeguards.Failure
toassessconsequencestoultimatelossevent
assumingsafeguardsarenonexistentorineffectiveas
designed.
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CommonDeficiencies
PROCESSHAZARDSANALYSIS
FailuretoaddressFACILITYSITINGissues.
FailuretoaddressHUMANFACTORSissues.
CommonDeficiencies
PROCESSHAZARDSANALYSIS
FailuretoaddressFACILITYSITINGissues.
FailuretoaddressHUMANFACTORSissues.
USE INDUSTRY-STANDARD CHECKLISTS!!!
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CommonDeficiencies
PROCESSHAZARDSANALYSIS
Previousincidents,includingnearmisses,not
consideredbythePHAteam.
OverduePHArecommendationswithnomanaged
scheduleforresolution,completion.
IncompletecompilationofProcessSafetyInformation
priortoperformingthePHA.
CommonDeficiencies
OPERATINGPROCEDURES
SOPsnotwrittenforALLphasesofoperation(esp.,
nonroutineoperations,e.g.,purging,cleaning,
sampling,emergencyoperations,etc.)
Safeoperatinglimitsandconsequencesofdeviation
fromtheselimitsnotwelldefined.Stepsto
correct/avoiddeviationsnotdocumented.
NowrittenproceduresforShiftChange/Handover
operations.
Proceduresnotreviewedoftenenoughforaccuracy;
lackofannualcertification.
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CommonDeficiencies
SAFEWORKPRACTICES
Nodocumented
Equipmentspecific
proceduresforLOTO,
ConfinedSpace.
Lackofperiodictraining
forLOTO,ConfinedSpace
CommonDeficiencies
TRAINING
Missingrecordsofinitial
trainingforqualified
operators.
Refreshertrainingnot
conductedatleastevery
three(3)years.
Lackofverificationof
personnel
comprehensionof
trainingprogram.
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CommonDeficiencies
TRAINING
Nowrittenproofthatoperatorsconsultedon
frequencyorcontentofrefreshertraining.
Refreshertrainingtoomuchfocusedonnormal
operations.
CommonDeficiencies
CONTRACTORS
Lackofduediligencequalification,certification
recordsforcontractoremployeeswhoperform
specializedskillorcraftwork,e.g.,
Craneandriggingwork
Forkliftdriving,mobilelifts/JLGs
Certifiedwelding
Instrumentcalibration
Other
Lackofperiodicsurveillanceofcontractorspost
selection;contractorsonlydisciplinedwhen
somethinggoeswrong
21
CommonDeficiencies
PRESTARTUPSAFETYREVIEW
PSSRnotperformedanddocumentedfornewplant
facilitiesorprocessmodificationspriorto
introductionofhighlyhazardouschemicals
PSSRnotperformedanddocumentedforeach
MOC
Weak,shortformPSSRchecklistusedformajor
changes
CommonDeficiencies
MECHANICALINTEGRITY
FIXITWHENITBREAKSmentality
Failuretoidentifycriticalequipmentrelativeto
thePSMcoveredprocess
Lackofwrittendeficiencymanagementprogramfor
nonconformancesidentifiedduringinspectionand
testingactivities
Overdueinspections
FailuretoidentifyandimplementRAGAGEPfor
inspectionsandtests
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CommonDeficiencies
MECHANICALINTEGRITY
FailuretoreviewPHAandincludeallsafeguards
inMechanicalIntegrityprogram.
Focusonstationaryequipment;lessemphasison
RotatingEquipmentandInstrumentation&
Controls.
Lackoffitnessforservicedocumentationfor
processequipment.
MOCprocessnotusedforchangestoinspection
frequency.
CommonDeficiencies
HOTWORK
Hot work permit does not clearly identify object
on which hot work being performed.
Pre-job Hot Work Checklist not completed.
Missing signature authorizations on hot work
permit form.
No documentation of fire watch
training/qualifications.
Hot work training not performed annually.
Permit-required hot work areas inconsistent
with definition of electrically classified area.
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CommonDeficiencies
MANAGEMENTOFCHANGE
MOC process not applied for:
Installation of temporary equipment
Decommissioning or taking equipment out-ofservice
Changes to alarm setpoints
Procedural-only changes (e.g., conversion from
paper-based to electronic systems)
Changes in shift work; workforce reductions
CommonDeficiencies
MANAGEMENTOFCHANGE
MOC process not institutionalized may be
strong in Operations; but weaker by
Maintenance.
PSI, SOPs, M.I. not updated when affected by
the MOC.
MOC forms completed and signed off before
PSSR completed.
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CommonDeficiencies
INCIDENTINVESTIGATION
Near misses not documented;
possibly due to:
Level1
Incidentsof
greater
consequence
Level2
Incidentsoflesser
consequence
Level3
Challengestosafetysystem
Level4
OperatingDiscipline&ManagementSystem
PerformanceIndicators.
(NotreportedyetinRCI)
CommonDeficiencies
INCIDENTINVESTIGATION
Incident investigations not commenced within
48 hours of the incident.
Incident investigation team composition does
not include a contractor employee for incidents
involving the work of a contractor.
Failure to identify root causes leading to
repeat of incidents.
Failure to communicate the findings and action
items resulting from incident investigations.
25
CommonDeficiencies
EMERGENCYPREPAREDNESS&RESPONSE
Emergency action plan not up-to-date.
Emergency evacuation maps with routes and safe
distances not posted.
No written process for testing and servicing plant
alarms; no documentation that alarm testing was
completed
Lack of documented drills and exercises
Lack of coordination of EAP with local community,
responders.
CommonDeficiencies
COMPLIANCEAUDITS
Compliance audits performed; but not certified
in writing.
Audits incomplete.
Audit action items not tracked or completed in
a timely manner.
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CommonDeficiencies
OSHAREFINERYNEP
ENFORCEMENTSTATISTICS
20072011
Mechanical Integrity
202
189
188
Operating Procedures
184
Management of Change
92
Incident Investigation
71
Compliance Audits
47
Contractors
33
Training
29
855
79%
CommonDeficiencies
OSHAREFINERYNEP
ENFORCEMENTSTATISTICS
20072011
Emergency Planning and Response
17
Employee Participation
15
13
Trade Secrets
1088
27
CommonDeficiencies
CHEMICALNEPPSM
ENFORCEMENTSTATISTICS
20112015
Mechanical Integrity
156
140
Operating Procedures
114
106
Management of Change
44
Compliance Audits
35
Training
21
Incident Investigation
19
Employee Participation
16
516
76%
CommonDeficiencies
CHEMICALNEPPSM
ENFORCEMENTSTATISTICS
20112015
Contractors
14
Trade Secrets
678
28
PSM
KEYSUCCESSFACTORS
1.
2.
3.
4.
PROCESSSAFETYLEADERSHIP
The executive leadership must provide and
demonstrate effective leadership and establish
clear process safety goals and objectives.
Management and leadership must clearly
demonstrate their commitment to process
safety by articulating a consistent message on
the importance of process safety.
Policies and actions should match that
message.
29
PROCESSSAFETYCOMPETENCY
Company must establish and implement a
system to ensure that its executive
management, its line management, and all
employees including managers,
supervisors, workers, and contractors
possess the appropriate level of process
safety knowledge and expertise to prevent
and mitigate accidents.
Avoid falling subject to the Peter Principle.
[Dr. Laurence J. Peter, 1968.]
30
PROCESSSAFETYCULTURE
Company must involve employees at all levels
in order to develop a sustainable, positive,
trusting, and open process safety culture.
Company must promote a culture of individual
ownership of the Process Safety program.
Process Safety should be EVERYONEs
responsibility; not just the responsibility of the
Process Safety Manager or HSE Department.
CLEARLYDEFINEDEXPECTATIONS
&ACCOUNTABILITY
Company must clearly define expectations and
strengthen personnel accountability for process
safety.
At all levels of the organization the executive
leadership, management, supervisors, line
employees, contractors, etc.
31
LEADING&LAGGINGINDICATORS
Company should develop and implement an
integrated set of Key Performance Indicators
(KPIs), including leading and lagging metrics for
more effectively monitoring the performance of
the process safety management system.
KPIs should be realistic and measurable.
KPIs should also be regularly monitored and
periodically updated to reflect industry changes,
best practices, and lessons learned around the
world.
AUDIT&CONTINOUS
IMPROVEMENT
Company must establish and implement an
efficient and effective system to periodically
audit and continuously improve process safety
performance relative to regulatory requirement
and international peers.
Plan-Do-Check-Act
Documentation Documentation Documentation
32
COMMUNITYOUTREACH
Company should out and work closely with
local community leaders to promote its
Process Safety image.
Will lead to increased reputation and goodwill,
improved safety and quality performance of
workers and suppliers.
More adequate preparedness and response
in case of a catastrophic emergency,
Part of corporate social responsibility.
PATHFORWARD
REALIZE THE BENEFITS: SEVEN (7) KEY STEPS
1. Assign personnel who will be accountable.
2. Adopt a personalized Company philosophy of
process safety.
3. Learn more about process safety.
4. Take advantage of strong synergy process safety
has with your other business drivers.
5. Set achievable process safety goals.
6. Track your performance.
7. Revisit your process safety program / continuous
improvement.
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GRACIAS!
Houston
Bogota
Singapore
WWW.PSRG.COM
PSRG OVERVIEW
Established, 1997 (Houston)
Member: ARPEL, CCPS
More than 80 professionals worldwide
averaging 28+ years experience
Diverse industry experience on
1,000+ projects with more than 750
customers in 76 countries
Hands-on plant operations
experience
Single source, one stop shop for
comprehensive PSM/RMP, and HSSE
consulting and training services
Tailored solutions to meet and exceed
customer expectations
Highly qualified resources enable
customers to receive value that far
exceeds cost of our services
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