Reducing Major Accident Potential:

- Lessons From The Refining

Industries

Graham Bennett
Downstream Director

DNV Energy
Objectives of this presentation
„ To review process safety related accidents that have
occurred within the recent history of the refining industry, and
share the experiences
„ To examine lessons to be learned
„ To challenge some existing paradigms
„ To identify opportunities for the future
Process Safety Challenges
Seveso (?†/?) 1976 P36 (10†/2) 2001
Flixborough (28†/36) 1974

Humber Oil Refinery (0†/0) 2001

Grangemouth (0†/0) 2000

Norco, Louisiana (4†/42) 1988

1984 Bhopal (20,000†/50,000)

Pasadena, Texas (23†/232) 1989

1998 Longford (2† / numerous)

Henderson, Nevada (2†/350) 1988

Toulouse (29†/650) 2001
Buncefield, UK (0†/40) 2005
Piper Alpha (167†/?) 1988
Alon (0 †/0) 2008
Skikda (27†/56) 2004 Texas City (15†/170) 2005
Texaco Pembroke - July 1994

ƒ Inadequate maintenance of plant & instrumentation

ƒ Control valve closed when monitoring system indicated it was open
ƒ Poor management of change
ƒ Control room graphics did not provide sufficient process overview
ƒ Poor alarm management
ƒ Attempting to keep the unit running when it should have been shutdown
ƒ Incorrect assumptions on corrosion allowances
ƒ Failure to incorporate lessons learned from previous incidents
BP Grangemouth - June 2000

ƒ Inadequate Maintenance of pipework integrity

ƒ Not following risk assessment procedures for start-up
ƒ Poor organisational structure
ƒ Poor alarm management
ƒ A safety report that did not reflect operating realities
ƒ Plant unreliability not adequately assessed - short term focus problem
ƒ Not learning from previous similar incidents
ƒ Not acting on previous reports
ConocoPhillips Humber - April 2001

„ Poor management of pipework inspection

„ Poor management of change
„ Poor corrosion management
„ Communication failings
„ Insufficient attention paid to process safety
„ Emergency response improvements necessary
„ Gaps in safety management system coverage
„ Failure to act on previous incidents/reports
But major accidents are rare events?
„ In January 2005, as part of an internal R&D project, DNV developed a
new internal database system to record major incidents and accidents in
the refining & petrochemical industry.
„ Since its inception, the database has recorded over 1800 incidents,
which have been classified as follows

Incident Type Number Consequence Number

Loss of containment 745 Loss of life 163

Fire 538 Injury 276

Explosion 369 Site Evacuation 114

Environmental release 44 Regulatory Fines 674

Production Downtime 219
How are things in Europe?
 Trends in occupational safety
5

4
Incidents per 200,000 work hours

API
Bayer
BP
3 Chevron Texaco
Concawe
ConocoPhillips
2 Dow
DuPont
ExxonMobil
OMV
1
Shell
Trend Line

0
93

95

97

99

01

03

05
19

19

19

19

20

20

20
 Trends in refinery material damage costs
Incident costs - $ per 1000bbls refinery capacity corrected to 2000 prices
30.00

25.00
Damage $/1000 bbl refinery production at 2000 prices

Raw data
20.00

5-year average

15.00 Linear (5-year

average)

10.00

5.00

0.00
64

66

68

70

72

74

76

78

80

82

84

86

88

90

92

94

96

98

00
19

19

19

19

19

19

19

19

19

19

19

19

19

19

19

19

19

19

20
Occupational incidents improve
faster than major accidents

The hope . . . . . . The reality ?

1 major injury 1

10 minor injury 8
0.5

5 30 property damage 20
15

300
600 no visible loss 300

The Hope The Idea The Reality

If we address the There is a fixed ratio If we address the
smaller events, the big of accident smaller events, we
ones will also improve severities improve smaller
events
Process Safety Incident Ratio Pyramid

Fatality 1

Injury 2

Production Downtime 1.5

Explosions 2.5

Fires 3.5

Loss of Containment 5

PS Incidents 11

Process Defects?
DNV Experience Globally
„ DNV has observed and participated in many regulatory and engineering
approaches aimed at reducing major accident risks
„ What we have seen in the downstream process industry
- Process industry in EU
- Very good personnel safety improvements
- Some basic process safety initiatives now implemented, but the trend in
major accidents is steady (from EU MAR dataset)
- But - worst process accident in 20+ years at Toulouse in 2001, other
serious accidents at Buncefield, Humber, and Grangemouth
- Process industry in USA
- Very good personnel safety improvements
- Some basic process safety now implemented via OSHA 1910, but no
trend showing decline in major accidents (EPA RMP dataset)
- But - worst accident in 16 years at Texas City
- In 2007 CCPS commits to a major series of initiatives on PSM
Major Accident Trends: Offshore North Sea
„ Two major accidents in 1980’s
- Alexander Kjelland 1980 (123 dead) and Piper Alpha 1988 (167 dead)

„ Since then
- No major accidents, intensive safety case program in UK sector
- This shows significant reduction in major leaks – precursor to serious accidents

• This graph from the UK HSE

shows that major leaks have
decreased consistently, by
over 70 % in the last 9 years
• A recent DNV review of
international offshore leak
frequencies for QRA purposes
shows leak frequencies have
reduced by 71-84% since
1995
What are the key lessons?
¾ The Baker and CSB reports into the Texas City event implied that
improvements in SMS and culture alone might be sufficient means to
manage major accident risks
¾ Our experience suggests that a more integrated approach to HSE and
Asset Management is needed in order to achieve the necessary process
safety improvements.
¾ Management systems that are designed primarily for occupational safety
issues rarely perform well in managing major accident hazard potential. A
detailed risk-based process safety management program is a necessary
foundation to prevent major accidents
¾ New initiatives to define critical barriers, establish performance
standards, and manage these throughout the plant lifetime, are required
¾ Greater use of leading rather than lagging indicators of major accident
potential needs to be made.
Key Lessons
¾ Major accident hazard industries must ensure that lessons learned both internally
and externally are incorporated into their management systems
¾ Disruptions in utility systems on major hazard potential sites can have significant
implications for process safety and should not be underestimated.
¾ Greater organisational “connectivity” is needed for major hazard issues and asset
management
¾ Greater care needs to be taken to manage the risk portfolio (projects plus normal
operations)
¾ Transferring functions to contractors does not transfer the risk responsibility.
Maintain close control of contractor activities.
¾ Always adhere to inherent safety principles, don’t place too much reliance on
instrumented safety systems, alarms etc to solve problems if they can be avoided
in the basic process design.
¾ Maintain improved awareness of process safety competency issues
¾ Recognise that short term business KPI’s can negatively impact PSM
performance
Remember!
“Companies with the best
performance in major
accident risk management
do not necessarily have
better systems than those
with poorer performance,
they are just much more
diligent in doing what they
say they do”