Industrial Process

Safety
ECH5504
Lessons from Major Accidents & Their Application
in Traditional Workplace Safety & Health

Assoc. Prof. Dr. Mohd Halim Shah B. Ismail

Why Safety?

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 Why Safety?
• Why is safety
important?
• Why bother with it?
• Isn’t it just another
government or
company program?

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 A Good Health & Safety
Program Can Reduce Injuries...

In the U.S. an injury occurs

about every 8.3 seconds

Source: NSC 2004

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 More About The Injuries
4,365,200 injuries resulted in:
– lost work time
– medical treatment (other than 1st aid)
– loss of awareness
– restriction of work or motion or
– transfer to another job

Source: BLS 2004

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 More About The Injuries
More than 2.2 million injuries were serious
enough to require recuperation away from work
or to restrict duties at work or both

Source: BLS 2004

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 More About The Injuries

Nationwide, injury rates

generally are higher for
companies with 50-249
workers than for smaller
or larger companies

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 Overview

• How I got into this?

• The evolution of the philosophy of
industrial safety and prevention of major
accidents
• Some key understandings and concepts
• How these apply to management of
workplace safety in various sectors and at
different levels of the organization
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 Risk of Death
[per person per year]

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 The Rising Case for Change

 1984– Bhopal, India – Toxic Material

Released
– 2,500 immediate
fatalities; HAZARD:
20,000+ total Highly Toxic
– Many other Methyl Isocyanate
offsite injuries

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 The Rising Case for Change

• 1984 – Mexico City, Mexico –

Explosion
– 300 fatalities
(mostly offsite) HAZARD:
– $20M damages Flammable LPG
In Tank

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 The Rising Case for Change

• 1988 – Norco, LA – Explosion

– 7 onsite fatalities, 42 injured
– $400M+ damages

HAZARD:
Flammable
Hydrocarbon Vapors

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 The Rising Case for Change
• 1989 – Pasadena, TX – Explosion
and Fire
– 23 fatalities, 130 injured; damage $800M+

HAZARD:
Flammable
Ethylene/isobutane
Vapors In A 10” Line

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What Can Go Wrong? Where Do We Start?

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The Process for Managing Risk

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Hazard Scenario

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Hazard Scenario – Osaka Milk Factory
(June, 2000)

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Hazard Scenario (Accident Scenario)

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Four Layers in The “Safety Hierarchy”

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Protection Layers

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What is the Basis or Goal for
Engineering Design?

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Why Should We Study Past Accidents in
Technological Systems?

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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)
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Incident Pyramid:
1
Serious/Disabling/Fatalities

10 Medical Aid Case

30 Property Loss/1st Aid

Treatment

600
Near Misses

10,000
Unsafe Behaviors/
Conditions

A “proactive” approach focuses on these categories, but

be careful – you 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 consequences of an undesired
event occurring

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 They Thought They Were Safe
• “Good” companies can be
comforted into a false
sense of security by their
performance in personal
safety and health
• They may not realize how
weak they are to a major
accident until it happens
• Subsequent investigations
typically show that there
were multiple causes, and
many of these were known BP Deepwater Horizon
long before the event

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 Why & How Defenses Fail
• People often assume systems work as
intended, even with 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

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Process Safety Management (PSM)
• Recognition of seriousness of
consequences and mechanisms of
causation lead to focus on the process
rather than the individual worker

• Many of the key decisions influencing

safety may be beyond the control of
the worker or even the site – they may
be made by people at another site,
country or organization

• Causes differ from those for personnel

safety

• Need to look at the whole – materials,

equipment and systems – and
consider individuals and procedures
as part of the system

• Management system approach for

control
Flixborough, Bhopal, Pasadena
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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 Regulations
11. Audits and Corrective Actions
12. Enhancement of Process Safety Knowledge

CCPS: Guidelines for Technical Management of Chemical Process Safety

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Functions of A Management System

Planning
Measurement Direction Organizing

Structure
Leadership

Controlling Results Implementing

CCPS: Guidelines for Technical Management of Chemical Process Safety

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 Features & Characteristics of A Management
System for Process Safety
Planning Organizing
Explicit goals and objectives Strong sponsorship
Well-defined scope Clear lines of authority
Clear-cut desired outputs Explicit assignments of roles and
Consideration of alternative achievement responsibilities
mechanisms Formal procedures
Well-defined inputs and resource Internal coordination and communication
requirements
Identification of needed tools and training
Implementing Controlling
Detailed work plans Performance standards and
Specific milestones for accomplishments measurement methods
Initiating mechanisms Checks and balances
Performance measurement and reporting
Internal reviews
Variance procedures
Audit mechanisms
Corrective action mechanisms
Procedure renewal and reauthorization

CCPS: Guidelines for Technical Management of Chemical Process Safety

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Assessing an Organization’s 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
• Resourcing – not only for ideal but for expected conditions
• Balancing with other priorities

• How are exceptions handled?

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 Consider Targets in Groups
• Those who:
– Don’t care
– Don’t know (and perhaps don’t know that they
don’t know)
– Did know, but may have forgotten or could
have gaps in application (and perhaps don’t
realize it)

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Excellent guidance
exists – but how is it
being used?

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Accountability
• Management commitment at all levels

• Status of process safety compared to other

organizational objectives such as output, quality and
cost

• 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 & 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

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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 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
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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 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

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The ‘Swiss cheese’ model of
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 Reason, presentation to Eurocontrol 2004
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 Active & Latent Failures

• Active
– Immediately adverse effect
– Similar to “unsafe act”
– Active failures encompass the unsafe acts that can be directly
linked to an accident, such as (in the case of aircraft accidents) a
navigation error

• Latent
– Effect may not be noticeable for some time, if at all
– Latent failures include contributing factors that may lie inactive
for days, weeks, or months until they contribute to the accident

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 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

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 Another

Danvers, MA, Nov 2006

Solvent explosion at printing ink factory

• Hazards known, but defences

compromised by apparently kindly
change
• Latent error in procedure design
creates vulnerability to likely
execution error
US Chemical Safety Board
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 In General, Safety Gets Better As Society Learns More

Standard
of Safety

Time
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 But The Rate Of Improvement Is Not Steady

Standard
of Safety

x 10

Time
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 In Fact, The Curve Can Be One Of Periodic Rapid Gains
Followed By Gradual But Increasing Declines

Note how the rate

of decay can be
Standard expected to
increase due to
of Safety normalization of
deviation

x 100

Time
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Safety Engineering -
Some Terms to Know

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Hazard Identification
1. Check Lists

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Hazard Identification
2. Relative Ranking

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 Hazard Identification
2. Relative Ranking: Dow Index

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 Hazard Identification
2. Relative Ranking: Dow Index

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 Hazard Identification
2. Relative Ranking: Dow Index

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 Hazard Identification
2. Relative Ranking: Dow Index

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 Hazard Identification
2. Relative Ranking: Dow Index

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 Hazard Identification
3. Hazard & Operability: HAZOP

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 Hazard Identification
3. Hazard & Operability: HAZOP

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 Hazard Identification
3. Hazard & Operability: HAZOP

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 Hazard Identification
3. Hazard & Operability: HAZOP

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 Hazard Identification
3. Hazard & Operability: HAZOP

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 Hazard Identification
3. Hazard & Operability: HAZOP
Class Example: Fired Heater

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 Hazard Identification
3. Hazard & Operability: HAZOP

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 Hazard Identification
3. Hazard & Operability: HAZOP

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 Hazard Identification
3. Hazard & Operability: HAZOP

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 Hazard Identification
3. Hazard & Operability: HAZOP

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 Hazard Identification
3. Hazard & Operability: HAZOP

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 Hazard Identification
3. Hazard & Operability: HAZOP

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 Hazard Identification
3. Hazard & Operability: HAZOP

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 Hazard Identification
3. Hazard & Operability: HAZOP

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Questions?

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