PSM Course 2014 Day 4

Process Safety Management
Eindhoven, June 5th, 2014 dr. ir. M.A. Stam

Summary Day 3
• Understand Hazard and Risks

• Process Safety Knowledge
• Hazard Identification and Risk Analysis
• Process Hazard Analysis
• Different Methodologies: e.g. What If, HAZOP, FMEA
• Risk Acceptance Matrix
• Layer of Protection Analysis – SIL levels
• HAZOP Workshop
• Manage Risks
• Standard Operating Procedures
• Safe Working Practices
Outline Course
• Industrial Processes
• Operations Management
• Commitment to Process Safety
• Understand Hazards and Risks
• Manage Risks
• Learn from Experience
Process Safety Management
*) Center For Chemical Process Safety, *) Sepeda, L.A., “Understanding Process Safety Management”, American
“Guidelines for Risk Based Process Safety”, Institute of Chemical Engineering, August 2010
2007
Day 4 (morning)
• Asset Integrity and Reliability 09.00-09.15

• Contractor Management 09.15-09.30
• Training and Performance Assurance 09.30-09.45
• Management of Change 09.45-10.10
• Coffee Break 10.10-10.40
• Workshop: Management of Change 10.40-12.00
• Lunch 12.00-13.00
• Presentations 13.00-13.40
Day 4 (afternoon)
• Operations Readiness 13.40-13.50
• Conduct of Operations 13.50-14.00
• Emergency Management 14.00-14.10
• Incident Investigation 14.10-14.30
• Workshop: Incident Investigation 14.30-15.30
• Measurement and Metrics 16.10-16.20
• Auditing 16.20-16.30
• Management Review/Continuous Improvement 16.30-16.40
• Closure 16.40-17.00
“Praxair, St. Louis (June 26, 2006)”
Video (08:22)
Asset Integrity and Reliability
“Asset Integrity Helps Ensure that Equipment is Properly

Designed, Installed in Accordance with Specifications and
Remains Fit For Use Until It is Retired”
“Design and Maintain Equipment that is Fit for Its Purpose and
Functions When Needed is of Paramount Importance to Process
Industries”
“Asset Integrity Activities Occur at Several Organizational Levels

(e.g. experts, operators)”
*) Center For Chemical Process Safety, “Guidelines for Risk Based Process Safety”, 2007
“Flight AA191, Chicago (May 25, 1979)”
1. Incorrect Maintenance Procedures

2. Save Time and Money
Maintain a Dependable Practice
1. Develop a Written Program Description/Policy

2. Determine the Scope of the Asset Integrity Element
3. Base Design and Maintenance Tasks on Standards
4. Involve Competent Personnel
5. Update Practices based on New Knowledge
6. Integrate the Asset Integrity Element with Other Goals
Identify Equipment and Systems
1. Identify Equipment/Systems for Inclusion in the Asset Integrity

Element
2. Develop an Maintenance Plan
3. Update the Maintenance Plan when Equipment Conditions
Change
Develop/Maintain Knowledge, Skills, …
1. Develop Procedures for Inspection, Test, Repair and Other

Critical Maintenance Activities
2. Train Employees and Contractors
3. Ensure that Inspectors hold Appropriate Certifications
4. Provide the Right Tools
Ensure Continued Fitness for Purpose
1. Conduct Initial Inspections and tests as part of Plant

Commissioning
2. Conduct tests and Inspections during Operations
3. Execute Calibration, Adjustment, Preventive Maintenance and
Repair Activities
4. Plan, Control and Execute Maintenance Activities
5. Ensure the Quality of Repair Parts and Maintenance Materials
6. Ensure that Overhauls, Repairs and Tests do not Undermine
Safety
Address Equipment Failures and Deficiencies
1. Promptly Address Conditions that can lead to Failure

2. Review Test and Inspection Reports
3. Examine Results to Identify Broader Issues
4. Investigate Chronic Failures Using a Structured Methodology
5. Plan Maintenance and Repair Activities
Analyze Data
1. Collect and Analyze Data

2. Adjust Inspection Frequencies and Methods
3. Conduct Additional Inspections or Tests as Needed
4. Plan Replacements or Other Corrective Actions
5. Archive Data
Contractor Management
“A System of Controls to Ensure that Contracted Services Support

both Safe Facility Operations and the Company’s Process Safety
and Personal Safety Performance Goals”
“Outsourcing, Including Design and Construction, Maintenance,

Inspection and Testing and Staff Augmentation”
“The Contractor Management Program is Often managed by the

Procurement Function”
“Piper Alpha (July 6, 1988)”
1. Failure in Following The Safe Working Procedure

2. Safe Work Procedure Was Not Properly Trained
3. Inadequate Emergency Response Training
1. Ensure Consistent Implementation

2. Identify when Contactor Management is Needed
4. Ensure that Practices Remain Effective
Conduct Element Work Activities
1. Appropriately Select Contractors

2. Establish Expectations, Roles and Responsibilities for Safety
Program Implementation and Performance
3. Ensure that Contractor Personnel are Properly Trained
4. Fulfill Company Responsibilities with respect to Safety
Performance
Monitor Contractor Management System
1. Audit the Contractor Selection Process

2. Monitor and Evaluate Contractor Safety Performance
Training and Performance Assurance
“Training is Practical Instruction in Job and task Requirements and

Methods”
“A Consistently High Level of Human Performance is a Critical

Aspect of Any Process Safety Program”
“The Output is a Set of Job Performance Standards and a List of

Initial and Ongoing Training Needs for Each Job Position”
“Lyon, France (January 4, 1966)”
1. Lack of Correct Trained Workers

2. Lack of Verification of Performance of Workers
1. Define Roles and Responsibilities

2. Validate Program Effectiveness
3. Control Documents
Identify What Training is Needed
1. Conduct a Job/Task Analysis

2. Determine Minimum Requirements for Job Candidates
3. Determine What Training is Needed
4. Group Training into Logical Programs
5. Manage Changes
Provide Effective Training
1. Develop or Procure Training Materials

2. Consider Timing
3. Interweave Related Topics
4. Ensure that Training is Available
Monitor Worker Performance
1. Qualify Workers Initially

2. Test Workers Periodically
3. Review all Qualification Requirements Periodically
Management of Change
“Ensure that Changes to a Process do not Inadvertently Introduce

New Hazards or Unknowingly Increase Risk of Existing Hazards”
MoC Reviews Should Be Done for Bona Fide Changes and not for
Replacements-In-Kind”
“The Results of The Review Process are Typically Documented”
“Flixborough, England (June 1, 1974)”
1. Installation of Temporary By-Pass

2. Lack of Knowledge Design of Large Pipes
3. “…They Did Not Know What They Did Not Know.”
1. Establish Consistent Implementation

3. Keep MoC Practices Effective
Identify Potential Change Situations
1. Define the Scope of the MoC System

2. Manage All Sources of Change
Evaluate Possible Impacts
1. Provide Appropriate Input Information to Manage Changes

2. Apply Appropriate Technical Rigor for the MoC Review Process
3. Ensure that MoC Reviewers have Appropriate Expertise and Tools
Decide Whether to Allow the Change
1. Authorize Changes
2. Ensure that Change Authorizers Address Important Issues
Complete Follow-up Activities
1. Update Records
2. Communicate Changes to Personnel
3. Enact Risk Control Measures
4. Maintain MoC Records
“Belle, West Virginia (January 22/23, 2010)”
Video (13:55)
Workshop – Management of Change
• “Manage Risks”
• 4 Groups
• 1 Representative, 10 Minutes Presentation
• Company “Propac”
• Develop a MoC-Procedure
• Technical Changes
• Use the Swimlane Template
• Develop List of Aspects
Swim Lane
Workshop – Management of Change
• Develop a MoC-Procedure
• Swimlane for Technical Changes
• List of Aspects
• Roles
• Initiator
• Operations Manager (Project Owner)
• Project Manager (Project Leader)
• Gatekeepers
• List of Aspects (Questions) Y/N
• Process Safety
• Environment
• Working Conditions
• …
Operational Readiness/PSSR
“Ensure that Shut Down Processes are Verified to be in a Safe

Condition for Re-Start”
“The Frequency of Incidents is Higher During Process Transition

Such as Start-Ups”
“Typically, Extensive Checklists, Multi-Stage Verification and

Multiple Functional Sign-Offs are required for Start-Up
Authorization”

2. Determine Types of and Triggers for the Readiness Practices
3. Determine the Scope of Readiness Reviews
5. Ensure that Readiness Practices Remain Effective
Conduct Readiness Reviews as Needed
1. Provide Appropriate Inputs

2. Involve Appropriate Resources and Personnel
3. Apply an Appropriate Work Process
4. Perform Element Work in a Diligent Manner
5. Create Element Work Products
Make Start-up Decisions on Readiness Results
1. Consider Important Issues Affecting the Start-up

2. Communicate Decisions and Actions from the Readiness
Review
Follow Through Decisions/… Readiness Results
1. Enact Risk Control Measures

2. Update Process Safety Knowledge and Records
3. Maintain Element Work Records
Operation and Maintenance Supervision
Operations Supervisor
Maintenance Supervisor
Job Job
Procedure First Break
Conduct of Operations
“Conduct op Operations is the Execution of Operational and

Management Tasks in a Deliberate and Structured Manner”
“A Consistently High Level of Human Performance is a Critical

Aspect of Any Process Safety Program”
“A Defined Framework of Controls to Implement a Defense-In-

Depth Strategy to Ensure that Process Operations Remain within
Safe Operating Limits”
“Martinez, California (January 21, 1997)”
1. Temperature Excursion
2. Ignorance of Data Logger Due to Unreliability
3. Communication to Control Room Were Garbled

2. Establish Standards for Performance
Control Operations Activities
1. Follow Written Procedures

2. Follow Safe Work Practices
3. Use Qualified Workers
4. Assign Adequate Resources
5. Formalize Communications Between Workers
6. Formalize Communications Between Shifts
7. Formalize Communications Between Work Groups
8. Adhere to Safe Operating Limits and Limiting Conditions for
Operation
9. Control Access and Occupancy
Emergency Management
“The Consequences of Any Particular Incident can be Significantly

Reduced with Effective Emergency Planning and Response“
“Emergency Planning is Typically Performed by Specialists, both

Within and External to the Facility”
“Effective Emergency Management Should Reduce the Magnitude

of Effects of an Incident, including Any Loss of Good Will with
Stakeholders”
“Texas City, Texas (April 16, 1947)”
1. Mainly Failures in Emergency Response:

• Decision to Use Steam to Displace Oxygen Rather Than Water to Remove Heat
• Failure to Evacuate Bystanders from the Dock Adjacent to the Grandcamp
1. Develop a Written Program

2. Designate an Owner and Define Roles and Responsibilities
3. Define the Scope of the Program
Prepare for Emergencies (1)
1. Identify Accident Scenarios Based on Hazards

2. Assess Credible Accident Scenarios
3. Select Planning Scenarios
4. Plan Defensive Response Actions
5. Plan Offensive Response Actions
6. Develop Written Emergency Response Plans
7. Provide Physical Facilities and Equipment
8. Maintain/Test Facilities and Equipment
Prepare for Emergencies (2)
9. Determine when Unit Operator Response is Appropriate

10. Train ERT Members
11. Plan Communications
12. Inform and Train All Personnel
13. Periodically Review Emergency Response Plans
Test the Adequacy and Preparedness
1. Conduct Emergency Evacuation and Emergency Response Drills

2. Conduct Tabletop Exercises
3. Practice Crisis Communication
4. Critique Exercises, Drills and Actual Responses
5. Conduct Assessments and Audits
6. Address Findings and Recommendations
“US Airways 1549, New York (January 15, 2009)”
Video (02:08)
Incident Investigation
“A Way of Learning from Incidents and Communicating the

Lessons Learned to Both Internal Personnel and Other
Stakeholders”
“Incident Investigations are Conducted Whenever and Wherever

Incidents Occur”
“A Multidisciplinary Team is Appropriate for Investigations with

Greater Consequences and Risks”
“Columbia Space Shuttle (January 16, 2003)”
1. At Least 65 Missions Had Experienced Foam Loss

2. No Root Cause Analysis of Foam Separation
3. Successful Missions: Believe of Shuttle Was Immune
4. Lack of Proper Investigation of Near Miss Incidents
1. Implement the Program Consistently Across the Company

2. Define an Appropriate Scope for the Incident Investigation Element
4. Monitor Incident Investigation Practices for Effectiveness
Identify Potential Incidents for Investigation
1. Monitor All Sources of Potential Incidents

2. Ensure that All Incidents are Reported
3. Initiate Investigations Promptly
Use Appropriate Techniques for Investigation
1. Collect Appropriate Data During the Investigation

2. Interface with the Emergency Management Element
3. Use Effective Data Collection Methods
4. Use Appropriate Techniques for Data Analysis
5. Investigate Causes to an Appropriate Depth
6. Demand Technical Rigor in the Investigation Process
7. Provide Investigation Personnel with Appropriate Expertise and
Tools
8. Develop Effective Recommendations
Document Incident Investigation Results
1. Prepare Incident Investigation Reports

2. Provide Clear Linking between Causes and Recommendations
Follow Through on Results of Investigations
1. Resolve Recommendations
2. Communicate Findings Internally
3. Communicate Findings Externally
4. Maintain Incident Investigation records
Trend Data to Identify Repeat Accidents
1. Log All Reported Incidents

2. Analyze Incident Trends
Root Cause Analysis
• Direct Cause – Unplanned release of energy or hazardous materials
• Indirect Cause – Unsafe acts and/or unsafe conditions
• Root Cause – policies and decisions, personal factors, environmental

factors
TRIPOD Analysis (1)
TRIPOD Analysis (2)
TRIPOD Analysis (Example)
Basic Risk Factors
DE Design
HW Hardware
MM Maintenance Management
HK Housekeeping 30
EE Error Enforcing Conditions 25
PR Procedures 20
15
TR Training 10
CO Communication 5
0
IG Incompatible Goals
OR Organization
DF Defences
Why Investigate?
• Prevent future incidents (leading to accidents).

• Identify and eliminate hazards.
• Expose deficiencies in process and/or equipment.
• Reduce injury and worker compensation costs.
• Maintain worker morale.
• Meet regulatory requirements that you investigate serious accidents.
How to Investigate?
• Develop a plan
• Assemble an investigation kit
• Investigate all incidents and accidents immediately
• Collect facts
• Interview witnesses
• Write a report
Develop a Plan
• Develop your action plan ahead of time.

• Your plan might include
• Who to notify in the workplace?
• How to notify outside agencies?
• Who will conduct the internal investigation?
• What level of training is needed?

• Who receives report?
• Who decides what corrections will be taken and when?
• Who writes report and performs follow up?
Actions At The Accident Scene
• Check for danger

• Help the injured
• Secure the scene
• Identify and separate witnesses
• Gather the facts
Fact Finding
• Witnesses and physical evidence

• Employees/other witnesses
• Position of tools and equipment
• Equipment operation logs, charts, records
• Equipment identification numbers
• Take notes on environmental conditions, air quality
• Take samples
• Note housekeeping and general working environment
• Note floor or working surface condition
• Take many pictures
• Draw the scene
Interview Witness
• Interview promptly after the incident

• Choose a private place to talk
• Keep conversations informal
• Talk to witnesses as equals
• Ask open ended questions
• Listen. Don’t blame, just get facts
• Ask some questions you know the answers to
Write A Report (1)
• An accurate narrative of “what happened”

• Clear description of unsafe act or condition
• Recommended immediate corrective action
• Recommended long-term corrective action
• Recommended follow up to assure fix is in place
• Recommended review to assure correction is effective
Write A Report (2)
• When and where did the accident happen?

• What was the sequence of events?
• Who was involved?
• What injuries occurred or what equipment was damaged?
• How were the employees injured?
Measurement and Metrics
“Establish Performance and efficiency Indicators to Monitor the

Effectiveness of the RBPS Management System”
“Facilities Should Monitor the Real-Time Performance of

Management Activities Rather Than Wait for Accidents”
“The Ultimate Product is Using Metrics to Identify Evolving

Weaknesses and Make Adjustments to RBPS”
“Mars Climate Orbiter (September 23, 1999)”
1. 10x More Propulsion Actions Required

2. Software Module Coded in Wrong Measurement Units
3. No Investigation of Deviations in Trajectory
4. Underlying Causes Were Not Investigated/Understood/Corrected
1. Establish Consistent Implementation

2. Determine Triggers for Metrics Collection and Reporting
3. Ensure that the Scope of the Metrics is Appropriate
5. Keep Metrics Practices Effective
Conduct Metrics Acquisition
1. Implement Appropriate Element Metrics

2. Collect en Refresh Metrics
3. Summarize and Communicate Metrics in a Useful Format
Use of Metrics to make Corrective Actions
1. Use the Metrics Element to Improve RBPS elements
Auditing
“An Audit is a Systematic, Independent Review to Verify

Conformance with Prescribed Standards of Care”
“Ensure That All RBPS Elements Are In Place and Functioning to

Protect Against Process Safety risks.
“Audit Results Should Be Trended Over Time to Determine

Improvements and Program Adjustments”
“Longford, Victoria, Australia (October 14, 1998)”
1. Good PSM System (Audit 6 Months Prior to Disaster)

2. Royal Commission Found Significant Deficiencies:
• Risk Identification, Analysis and Management
• Training
• Operating Procedures
• Documentation
• Communications

3. Identify when Audits are Needed
Conduct Element Work Activities
1. Prepare for the Audit

2. Determine the Audit Scope and Schedule
3. Assemble the Team
4. Assign Responsibilities
5. Gather Advanced Information
6. Plan Onsite Activities
7. Conduct the Audit
8. Document the Audit
9. Address Audit Findings and Recommendations
Use Audit to Enhance RBPS Effectiveness
1. Monitor RBPS Maturation over Time for Each facility

2. Share Best Practices
Process Safety Management Audit (1)
*) Moore et al., “Enterprise PSM Development, Implementation and Auditing”, 9th Global Congress on Process Safety, San Antonio, 2013
1
Num Question
1 20-C-1. Has the employer investigated each incident
w hich resulted in, or could reasonably have resulted in
a catastrophic release of highly hazardous chemical in
the w orkplace?
2 20-C-2. Have incident investigations been initiated as

promptly as possible, but not later than 48 hours
follow ing the incident?
3 20-C-3. Have incident investigation teams been

established and consisted of at least one person
know ledgeable in the process involved, including a
contract employee if the incident involved w ork of the
contractor, and other persons w ith appropriate
know ledge and experience to thoroughly investigate
and analyze the incident?
*) Kahn et al., “Identifying Root Causes in Auditing”, 9th Global Congress on Process Safety, San Antonio, 2013
Management Review, Continuous Improvement
“The Routine Evaluation of Management System Performance”
“Effective Performance is A Critical Aspect of Any Process Safety

Program”
“Management Review Should Be Monitored Over Time, and

More Frequent Reviews Should Be Scheduled if Persistent
Problems are Evident”
“Delaware (July 17, 2001)”
1. Corrosivity and Flammability Hazards Were Not Identified

2. Ignorance of Repeated Requests for Inspection
3. Hot Work Permit Failed

2. Establish Standards for Performance
Conduct Review Activities
1. Prepare for the Review

2. Determine the Review Scope
3. Schedule the Review
4. Gather Information
5. Prepare a Presentation
6. Conduct the Review
7. Document the Review
8. Address Review Findings and Recommendations
Monitor Organizational Performance
1. Strive to Continuously Improve

2. Conduct Field Inspections
“Moerdijk, NL (January 5, 2011)”
Video (08:37)

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Process Safety Management

Eindhoven, June 5th, 2014 dr. ir. M.A. Stam

• Understand Hazard and Risks

• Asset Integrity and Reliability 09.00-09.15

“Asset Integrity Helps Ensure that Equipment is Properly

“Asset Integrity Activities Occur at Several Organizational Levels

1. Incorrect Maintenance Procedures

1. Develop a Written Program Description/Policy

1. Identify Equipment/Systems for Inclusion in the Asset Integrity

1. Develop Procedures for Inspection, Test, Repair and Other

1. Conduct Initial Inspections and tests as part of Plant

1. Promptly Address Conditions that can lead to Failure

1. Collect and Analyze Data

“A System of Controls to Ensure that Contracted Services Support

“Outsourcing, Including Design and Construction, Maintenance,

“The Contractor Management Program is Often managed by the

1. Failure in Following The Safe Working Procedure

1. Ensure Consistent Implementation

1. Appropriately Select Contractors

1. Audit the Contractor Selection Process

“Training is Practical Instruction in Job and task Requirements and

“A Consistently High Level of Human Performance is a Critical

“The Output is a Set of Job Performance Standards and a List of

1. Lack of Correct Trained Workers

1. Define Roles and Responsibilities

1. Conduct a Job/Task Analysis

1. Develop or Procure Training Materials

1. Qualify Workers Initially

“Ensure that Changes to a Process do not Inadvertently Introduce

“The Results of The Review Process are Typically Documented”

1. Installation of Temporary By-Pass

1. Establish Consistent Implementation

1. Define the Scope of the MoC System

1. Provide Appropriate Input Information to Manage Changes

“Ensure that Shut Down Processes are Verified to be in a Safe

“The Frequency of Incidents is Higher During Process Transition

“Typically, Extensive Checklists, Multi-Stage Verification and

1. Ensure Consistent Implementation

1. Provide Appropriate Inputs

1. Consider Important Issues Affecting the Start-up

1. Enact Risk Control Measures

“Conduct op Operations is the Execution of Operational and

“A Consistently High Level of Human Performance is a Critical

“A Defined Framework of Controls to Implement a Defense-In-

1. Define Roles and Responsibilities

1. Follow Written Procedures

“The Consequences of Any Particular Incident can be Significantly

“Emergency Planning is Typically Performed by Specialists, both

“Effective Emergency Management Should Reduce the Magnitude

1. Mainly Failures in Emergency Response:

1. Develop a Written Program

1. Identify Accident Scenarios Based on Hazards

9. Determine when Unit Operator Response is Appropriate

1. Conduct Emergency Evacuation and Emergency Response Drills

“A Way of Learning from Incidents and Communicating the

“Incident Investigations are Conducted Whenever and Wherever

“A Multidisciplinary Team is Appropriate for Investigations with

1. At Least 65 Missions Had Experienced Foam Loss