icheme presentation slpsig 2012 learning fr past incidents

7/30/2019 IChemE Presentation SLPSIG 2012 Learning Fr Past Incidents

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ERMDelivering sustainable solutions in a more competitive world

Safety & Loss Prevention

Special Interest Group Launch

Learning from Past Accidents

Presented by

Dr. Christina PhangEnvironmental Resources Management

The worlds leading sustainability consultancy


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ERMSlide 2

Presentation Outline

Some lessons from past accidents

Three Causes of major accidents

Four Practical Initiatives


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ERMSlide 3

Past Major Disaster

Piper Alpha (1986)

Esso Longford (1998)

Texas City (2005)


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ERMSlide 4

Piper Alpha - Lessons

Engineering Integrity Platform not designed to withstand

prolonged fire

Operator Performance

Insufficient training to ensureeffective operation of the PTWsystem

Contractors lack offshoreexperience

Working Environment

Inadequate flow of labour

Inadequate working programme

Pressure to maintain production atwhatever cost

Communication & Information

Lack of feed forward and feedbackcommunication

Inadequate display and access ofinformation

Inadequate emergency controlcentre

Emergency procedures manualinadequate

Procedures & Practices

Maintenance procedures wereinadequate

Emergency Procedures were

inadequate


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ERMSlide 5

Piper Alpha - Lessons Management Control

Inadequate performancemeasurements

Failure to manage change as rigprocesses were extended

Inadequate co-ordination anddefinition of responsibilities

Unclear assignment of safetyresponsibilities

Poor emergency planning

Site & Plant Facil ities

Operating outside the designenvelope

Lack of isolation of gas pipelinesfrom other rigs

Organization & Management

Inadequate methods for setting

work priorities Lack of commitment to safe working

environment

Inadequate PTW system and firesafety

Poor organization betweenoperations and maintenance

Inadequate shift changeoverprocedures

Inspectors and auditors failed toidentify hazards

System Climate

Company subjected to productionpressures

Risks from other rigs not realized


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ERMSlide 6

Esso Longford, 1998

Brittle fracture of vessel

2 fatalities 8 injuries

25 tonnes released causing an explosion followed byJet fi re which burned for 2 days

Loss of gas supply to Victoria for 2 weeks withsubstantial disruption to the local economy


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ERMSlide 7

Learning from Esso Longford

No Process Hazard Analysis completed (egHAZOP)

No assessment of Major Accident Hazards

Ineffective management procedures

Staff competency

Reliance on lost time injury data in major hazard industries is

itself a major hazard - Hopkins


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ERMSlide 8

BP Texas City, 2005

Vapour Cloud Explosion

15 People killed 180 Injuries

Isomeriser Tower overfilled

Blowdown vessel and associatedstack overfilled

Liquid hydrocarbon released andformed flammable vapour cloud


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ERMSlide 9

Key findings

Cost cutting and production pressure impaired safetyperformance

No responsibility for assessing & verifying MAH prevention

Reliance on low personal injury rate as safety indicator

Mechanical integrity programme - equipment was run-to-failureLack of reporting and learning culture

Safety campaigns were aimed at personal safety

Deep seated problems identified but management action was

too little too late


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ERMSlide 10

Baker Panel Recommendations

Effective leadership from senior management

Implement an integrated and comprehensiveProcess Safety Management (PSM) system

Ensure employees and contractors haveappropriate process safety knowledge

Develop positive process safety culture

Implement leading and lagging indicators

Implement an effective audit process


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ERMSlide 11

What Can We Learn from Past Incidents?

Challenges in having design, technical andoperations integrity

What safety barriers/ controls/ mitigationmeasures were missing or failed?

Information sharing new hazards,understanding of risk levels, etc.

Identification ofPerformance Indicators

that might have given an indication that an

major accident/ incident was imminent


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ERMSlide 12

Three Causes of Accidents(There are only three!!)

Poor design and Poor Equipment

Poor procedures or people not following procedures

Incompetent and ill-disciplined people


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ERMSlide 13

Problem 1:

If everything is important then nothing isimportant.


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ERMSlide 14

Typical decline in process safety

Time

SafetyPe

rformance

Learning

Phase

Ageing p lant

Loss of memory

Creeping Change


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ERMSlide 15

Where do I start?


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ERMSlide 16

Solution 1:

Understand what is Critical


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ERMSlide 17

Bow Tie Analysis


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ERMSlide 18

Define Performance

System definition and role

Function

Reliability and availability

Survivability


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ERMSlide 19

What can Bow Ties do for me?

Overview: understand the major accident events:causes, consequences, hazards and safetybarriers

Focus: what is CRITICAL

Understand Communicate Act


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ERMSlide 20

Problem 2:

Poor or Non-existent Procedures


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ERMSlide 21

Solution 2:

Statement of Operational Boundaries(SOOB)


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ERMSlide 22

Follow Critical Rules - SOOB


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ERMSlide 23

Scope of a SOOB

Barrier-defeating factors

Concurrent operations (aka SIMOPs)Non-routine operations

Abnormal process conditions

Equipment that is not fit -for-purpose

Systems unavailable due to maintenance or damagePoor environmental conditions

Key personnel unavailable


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ERMSlide 24

Problem 3:

People cause accidents most of the time


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ERMSlide 25

Incompetent ill-disciplined people


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ERMSlide 26

Solution 3:

Employ competent and disciplined people


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ERMSlide 27

All Outcomes Arise from Behaviors

Behaviour = Thought + Action Management whether they know it or not

creates an env ironment that y ields a

body of operator behaviours

The front line behaviours which arise willyield good and bad HSE (and operational)

outcomes

Acceptable / Unacceptable impacts

Compliance / Non-compliance

Controlled Risks / Accidents

There is no improvement in performance

without a change in behaviour


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ERMSlide 28

Improve Safety Culture

Make sure: the way we do

things around here,

is the safe way


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ERMSlide 29

Problem 4:

Inability to respond to a major accident


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ERMSlide 30

Solution 4:

Be prepared for the worst case scenarios


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ERMSlide 31

Understanding Accident Scenarios


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ERMSlide 32

Be Detailed & Verify

Plan

Equipment

Consumables

Command and control

InterfacesTraining, drills, combined exercises


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ERMSlide 33

Four Initiatives tied to Accidents Prevention

Use the BTD to show how they fit

What is critical applies to all green boxes

Manual of permitted operations poor procedures and peoplenot following procedures - Prevention

Hire competent disciplined people covers both sides of BTD

Prepare for worst case scenario RHS of BTD

icheme presentation slpsig 2012 learning fr past incidents

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