My 1st Book ? About Process Safety Enjoy Reading

THINK PROCESS SAFETY
SERIES # 01 OPERATIONAL DISCIPLINE
2021 October
Global EHSS – Process Risk Management
INTERNAL USE
Classification: Internal Use
Think Process Safety Booklet
“This document and any information contained herein are for informational purposes only. It is not intended to and should not be considered a policy nor
a procedure and it is not intended to be a substitute therefore. All Information contained in this document may be changed or updated from time to time.”
Any brands, products or services of other companies referenced in this document are
the trademarks, service marks and/or trade names of their respective holders.
SABIC and brands marked with ™ are trademarks of SABIC or

its subsidiaries or affiliates, unless otherwise noted.
© 2020 SABIC. All Rights Reserved 2

GETTING THE TRUTH OF EHSS
“
Our Safety is our Responsibility …
“
with listening to our people, engaging with them &
empowering them
Ahmed M. Al-Jabr
EVP, Manufacturing
3
© 2020 SABIC. All Rights Reserved.
SABIC GLOBAL EHSS
POLICY COMMITMENT
As part of our commitment to our Security to operate our facilities in a safe, Create and maintain a safe and secure
employees, communities and stable and compliant manner, and to working environment and prevent
environment, we shall ensure implement sound solutions to conserve workplace injuries, illness and violence
compliance with applicable regulations natural resources and minimize adverse by compliance with all applicable EHSS
and pledge to create a mindset within environmental impacts. laws and regulations, SABIC’s EHSS
SABIC to strive to go beyond Management Standards (SHEMs), and
compliance in all our endeavors. In addition, we pledge to maintain other EHSS requirements to which
rigorous and comprehensive security SABIC subscribes.
We are committed to be a world leader and crisis management systems to
in EHSS performance and to strive for effectively respond to crisis and
continuous improvement. emergency events in all areas of our
operations.
We shall implement world-class
processes and best practices for
Process/Occupational Safety, Health,
Industrial Hygiene, Environment and
4
CONTENTS
1 2 3 4 5 6
SABIC CLASS B
INCIDENT CASES
SABIC CLASS A SABIC CLASS C
NON-SABIC INCIDENT CASES INCIDENT CASES
INCIDENT CASES SABIC HIGH
INTRODUCTION POTENTIAL EVENTS
5
“This document and any information contained herein are for informational purposes only. It is not intended to and should not be considered a policy nor a
procedure and it is not intended to be a substitute therefore. All Information contained in this document may be changed or updated from time to time.”
INTRODUCTION
SABIC and brands marked with ™ are trademarks of SABIC Any brands, products or services of other companies referenced in this document are 6
or its subsidiaries or affiliates, unless otherwise noted. the trademarks, service marks and/or trade names of their respective holders.
INTRODUCTION
1 2 3 4 5 6
Lack of OD
Contributes to Many
Incidents
Why this Booklet -
Operational Our Leaders
Discipline Drive Our Culture
Controls To
Keep You Safe You Need To Know
How To Use Your Current Position
This Booklet
SERIES - OPERATIONAL DISCIPLINE 7
HOW TO USE THIS BOOKLET

KEEP THE SUBSTANCES IN THE CONTAINMENT
Welcome to the “Think Process Safety” booklet series. You will quickly recognize this booklet is ‘time-less’. The
incidents may change in time, but the theme is always very
Working with real incidents, both at SABIC and external, we similar.
intend to guide you through common and frequent failures
that have led to, and continue to lead to, many process Use the booklet to start a dialogue with your employees.
safety incidents. This will create mutual understanding. Employees will not
only learn, but also demonstrate that many of the themes
The common theme of the incidents in this first booklet is presented in this booklet are common at your site or
“Operational Discipline”. The majority of process safety affiliate and need to be solved properly.
incidents can be prevented or timely mitigated when
Operational Discipline is implemented properly.
We recommend to use this booklet during training, tool-

box meetings, special sessions to raise awareness,
introduction and improvement sessions on operational “ Responsibility and accountability are
discipline, during presentations etcetera. crucial to drive Operational Discipline ”
SERIES - OPERATIONAL DISCIPLINE INTRODUCTION 8

“FROM LEARNING TO PREVENTION” JOURNEY
ROADMAP
STOP
Process
Dig Deeper Safety
Gain more Events
Talk Under-
standing
Share
Experiences
Focus
“What is
Start my role
Thinking in this ?”
Read “Process
this Safety”
Booklet

CONTROLS TO KEEP YOU SAFE
Incidents do happen, because many hazards Note that “controls” can be of different types and objectives :
out there are waiting for a chance to come • Inherent safe designed plants and well defined ways of doing the work (01)
alive. This booklet illustrates which controls • Mechanical, Instrumental or Human Protection Layers (02, 03, 04), and
or protection layers failed, rather than listing • Response on failing protection layers and other circumstances (05)
specific root causes.
Hazards need to be kept in control. Many

different kinds of controls are available. We 01 02 03 04 05
do distinguish 5 types, which are illustrated
in this Swiss Cheese model. DESIGN AND
WORK PROCESS
MECHANICAL
SAFEGUARDS
INSTRUMENTAL
SAFEGUARDS
PROCEDURE
AND RULES
RESPONSE AND
OTHER FACTORS
When all types of control fail, an incident

occurs. When many controls fail, but one or
two keep standing, we call this a High
Potential Event. Both events require incident
investigation to understand which controls
need to be strengthened.
The Swiss Cheese model demonstrates how

an hazard creeps thru all gaps in the
controls to express itself. Our task is to find Hazard Incident
these gaps and close them.

EXPLAINING THE SWISS CHEESE MODEL
01 02 03 04 05
DESIGN AND MECHANICAL INSTRUMENTAL PROCEDURE RESPONSE AND

WORK PROCESS SAFEGUARDS SAFEGUARDS AND RULES OTHER FACTORS
Trevor Kletz was a pioneer Mechanical Safeguards are Instrumented Safeguards As procedures and rules are The final type of control is any
in Process Safety. He considered very reliable, as are also considered reliable. always human actions, they response to a situation,
learned us to make any there is not an active are considered less reliable including emergency
effort to design plants and component that may fail. Basic Process Control than engineering controls. response or other factors to
work processes as Systems are not a formal stop the incident.
inherently safe as possible. Mechanical and safeguard. Despite, they This booklet focusses on
Instrumented Safeguards are very important, because this type of control, In many cases this is a human
This means such plants and are “engineering controls”, they prevent demands on because it is by far the action (also called
work processes are made in that require proper design, instrumental safeguards largest contributor to ‘administrative control’), but
such a way, that incidents use and maintenance. and overload on panel incidents. can be an engineered control,
are not likely, or if an operators. such as a deluge system.
incident happens, it will not
be so bad.
EXAMPLES: EXAMPLES: EXAMPLES: EXAMPLES: EXAMPLES:

• No large storage of • Bund, dike • Alarms and Interlocks • Work permit • Pre-Incident Planning (PIP)
hazardous chemicals • Shielding, fire wall • Safety Instrumented • Lock-out-Tag-out • Emergency Response
close to a city • Relief system, breather Systems (SIS) • Operating, Planning (ERP)
• Clear and simple work and safety valve, maintenance • Last moment interference
process, with little rupture disk procedures to stop an incident
opportunity for errors • Flame arrestor • Personal Protection
Equipment

WHY THIS BOOKLET - OPERATIONAL DISCIPLINE (OD)
When observing the incidents we experienced

at SABIC, it became clear that more than 80% EHSS IS A CORE VALUE
is directly related to a human activity that without it, we won’t be successful
failed.
You will come across many examples in this

booklet and are bound to quickly recognize
1 2 3
that pattern.
Incidents do not occur very often, and we are

getting used to activities that normally go Know what is the Be willing to Ensure others
well. But, that is no guarantee incidents will right thing to do always do the always do the
right thing right thing
not happen. We do need to keep a chronical
sense of unease and stay alert.
Operational Discipline is an important key to

establish and sustain that focus and improve
the reliability of human activities.
Operational Discipline establishes a consistent culture, that makes sure no human

activity ends up in risk and everyone does each task the right way each time.
LACK OF OD CONTRIBUTES TO MANY INCIDENTS
Insufficient Operational Discipline contributes to many PROFIT

events and incidents each year. Those may be large,
high severity events, smaller events, or even production
losses. Experiencing many smaller events, makes it
likely a larger event is to arrive soon.
2017 2019 2025

Class A, Tier 1 with high severity Production Loss
Class B, Tier 1 with medium severity
Class C, Tier 1 with low severity or Tier 2
• Action done when a procedure is not available COST RISK

Activities are • Procedure not up to date
guided by • Procedure not effectively protecting against risk
procedures, • Procedure not followed
but why do • Procedure not properly managing abnormalities
they fail ? • Activities not supervised
• Procedure not sufficiently being trained 2017 2019 2025 2017 2019 2025
“ Operational Discipline influences all aspects of

business, improving both safety and efficiency”
OUR LEADERS DRIVE OUR CULTURE
EHSS IS NOT OPTIONAL

we all wish to return safely to our Homes
Verify all is playing
out well, visibly
check performance Deeply rooted
in the plant commitment to
keep us all alert
(sense of unease)
02
Leadership plays a crucial role
Authentic
in operational discipline.
01 03
Leaders have to drive us away Visible Engaging
from casual behavior, and
support us in thoughtful and
consistent compliance. 04
Continuously drive
Active
Excellent leaders can be easily Engaging to
recognized, as they are improvement of safely and
ensure all risks
effectively performing all
walking examples of the four are discovered
activities by all
values. and dealt with

YOU NEED TO KNOW YOUR CURRENT POSITION
5
Chronic Unease
Optimum sustained Generative
performance, risks
systematic mitigated Optimum
4
Obsessed with statistics
Predictable Proactive
performance and risk
management Predictable
3 Bad news is tolerated

Stable, “baseline” Calculative
performance with risk
mitigated Stable
2
Bad new is hidden
Basics are implemented, Reactive
but still high degree of
risk Vulnerable
Progress can be measured. Regular
reviews help us to improve. Without 1
For any questions contact: Bad news is ignored
Operational Discipline we will never
achieve Operational Excellence. KSA East Coast : Ibrahim Abdullah Al-Jamaan( JamaanIA@SABIC.com ) “Co-Author” Unpredictable Pathological
Europe, Americas, Asia : Marcus ( Marco.van.Pinxteren@SABIC.com ) “Author” performance and high-
KSA West Coast : Abdullah Al-Sulaimani( SulaimaniAa@SABIC.com ) “Reviewer” risk operations
Improvement is expressed in levels At Risk
of maturity. Your Operations are bound to be Disciplined
0

NON-SABIC MAJOR INCIDENTS
16
NON-SABIC MAJOR INCIDENTS
1 2 3 4 5
Maintenance on
Emergency Shutdown
Valves
Interruption of a Batch Housekeeping

for the Weekend
Chemical Storage Plant Start-up
During Shut Down

CHEMICAL STORAGE DURING SHUT DOWN
18
INCIDENT DESCRIPTION
WHEN ACTIVITY RELEASE IMPACT
Turnaround shutdown, 42 tons Methyl-Iso-Cyanate 3,787 formal fatalities

≃00:40 AM keeping chemicals in the (extremely toxic) 558,125 injured
MONDAY Dec 3, 1984 process vessel up to 20,000 informal fatalities
Normal condition During Incident WHAT HAPPENED
Due to maintenance activities, all safety and cooling

Off-gas
√ systems were shut down. Many of them had become
treatment dysfunctional due to overdue maintenance. Employees
that complained about lack of safety were disciplined.
Bhopal City
Tank E420 (68 m3) was filled with 42 tons MIC, while 30
Nitrogen √ Nitrogen Water in tons were the safe limit. Nitrogen blanket pressure on
this tank was lost and attempts to empty the tank with
nitrogen before turnaround failed.
Water leaked into the tank, causing an undetected

√ Cooling
exothermic reaction to start. It developed into a
Cooling runaway reaction, that blew out all contents into the
E420 E420
atmosphere. The toxic gas cloud settled in the area,
42 Tons Reactants Runaway Reaction causing many people to die.
SERIES - OPERATIONAL DISCIPLINE NON-SABIC INCIDENT CASES CHEMICAL STORAGE DURING SHUTDOWN - UNION CARBIDE BHOPAL INDIA CLASS A TIER 1 SEVERITY 81 19
CONTROLS THAT FAILED
01 02 03 04 05

Hazard
TOXIC CHEMICAL 558,125 INJURED

RELEASE DUE TO 20,000 FATALITIES
RUNAWAY REACTION
Refrigeration Gas scrubber No alarm to warn Shutdown Alarm raised

system that had was turned off of self-heating, procedure not after 2 hours
to keep the tank farm alarms followed and
chemical cool Flare was dysfunctional for insufficient Water curtain
was turned off disconnected for over 4 years hazard could not catch
maintenance assessment gas cloud
A LESSON LEARNED – DO’S AND DON’TS
OPERATOR,
LEADERS EHSS SUPERVISOR
TECHNICIAN
Make sure shut- Perform audits on shut- Timely check if Follow shut-down
DO
down procedures down, be involved with appropriate and actual procedure exactly
are reviewed by PHA developing shut-down shut-down procedures
and applied by programs are available
operations
DON’T Assume shut-down Wait for questions Assume shut-down was Improvise or skip
instructions are safely done when the shut-down items
appropriate and process is no longer
followed up operating
“Appropriate shut-down procedures shall be available and applied”
INTERRUPTION OF A BATCH
FOR THE WEEKEND
22
Temporary interruption of a 6 tons dioxins 3,300 animals dead

≃12:37 PM batch process due to a (very toxic chemicals) 447 people with skin injuries
SATURDAY Jul 10, 1976 weekend shutdown Abortion of 26 pregnancies
A batch reaction process was temporarily interrupted

due to a regular weekend shutdown
Due to lack of demand, the stand-by steam boiler

produced much hotter steam, which initiated a
runaway reaction
Toxics settled
BATCH BATCH This caused a blow-out of 6 tons dioxine (a very toxic
over 18 km2
REACTOR REACTOR chemical), that dispersed over 18 km2 area
Runaway
Reaction
Steam As a result 3,300 animals died, 447 people had skin
Heating injuries, but the most impact was 26 pregnant women
had to abort because of the high risk of life-long
deformities if these children were born
Steam hotter due to
weekend shut down
SERIES - OPERATIONAL DISCIPLINE NON-SABIC INCIDENT CASES INTERRUPTION OF A BATCH FOR THE WEEKEND - HOFMANN LA ROCHE SEVESO ITALY CLASS A TIER 1 SEVERITY 81 23
01 02 03 04 05

Hazard
TOXIC RELEASE DUE
TO A RUNAWAY
REACTION
MAJOR IMPACT
No measures Safety valve, but No temperature No procedure No emergency ON HEALTH &
taken to make no secondary control or high describing response, as ENVIRONMENT
the batch containment for temperature temporary none were aware
reaction inherent released toxic switch shutdown of toxic release
safe chemicals
OPERATOR,
TECHNICIAN
Make sure there are Perform audits on Before starting an Only Start any activity
DO
clear instructions for hazards that may activity, make sure after having the
temporary shut down occur when activities there are clear required Procedure/
get interrupted instructions in case Instruction for any
of interruption Interruption
DON’T Assume temporary Assume hazards are Assume any task will Assume all Hazards
situations have been well known be finished without disappeared after
covered in the PHA interruption Plant Shut-down
“Dealing with Interruptions is a major part of our works”
MAINTENANCE ON
EMERGENCY SHUT DOWN VALVES
26
Routine Maintenance on 39 ton ethylene through 23 Fatalities

≃13:05 PM Emergency Shutdown Valves an open valve, ignited 314 Injuries
MONDAY Oct 23, 1989 after 2 minutes Explosion 3.5 on Richter scale
WHAT HAPPENED
Normal condition During Incident
During previous maintenance, isolation valves were

Air Air closed and their compressed air controls wrongly
Connections Connections connected. So they would close when required open and
vice versa.
Open Close Close Open
Note this is an undetected failure. Nobody is aware the
Hydrocarbon
emergency isolation valves do not work properly.
released to
atmosphere
When (much later) during normal operation, an
REACTOR REACTOR emergency shut down was triggered, 39 tons ethylene
were released from the (wrongly) opened valve.
The gas cloud ignited (probably at a furnace). An iso-

butane tank exploded 15 minutes later followed by 4 other
large explosions.
SERIES - OPERATIONAL DISCIPLINE NON-SABIC INCIDENT CASES MAINTENANCE ON ESD VALVES - PHILLIPS 66 HOUSTON US CLASS A TIER 1 SEVERITY 84 27
01 02 03 04 05

Hazard
ETHYLENE RELEASE TO
ATMOSPHERE THROUGH
FAILURE TO OPEN VALVE
23 FATALITIES
Emergency None Shutdown Maintenance Shutdown failed, 314 INJURED
Isolation Valve valves, but they Procedure failed because of a
design that can failed to deliver safe common cause
be wrongly Gas detectors, installation with the failed
connected but they were procedure
too late
OPERATOR,
TECHNICIAN
Make sure operations Check if maintenance on Independently check Perform maintenance

DO
checks whether EHSS Critical Equipment the delivered on EHSS Critical
maintenance jobs are is done via EHSS Critical maintenance work Equipment only
correctly delivered Maintenance Procedures based on EHSS
Critical Procedure
DON’T Allow them to decide Allow alternative paths Assume technicians Rely on experience
themselves never make mistakes only
“Acceptance of Maintenance Works is a critical Task”
HOUSEKEEPING
30
Normal Operation
19:00 PM Sugar Dust exploded 14 Fatalities
36 injuries
THURSDAY Feb 7, 2008 Refinery had to be demolished
WHAT HAPPENED
Normal condition During Incident
An 8 stores high building was used as sugar refinery, with
Belt transports Dust depositions all over the plant 112 people working. Sugar dust had settled over period of
sugar powder whirled up and caused devastating time. The sugar industry was aware of dust explosion risk
secondary explosions from 1926 onwards and managers had raised concerns in
1960s already.
New enclosure
collects dust Sugar is a hydrocarbon that can easily burn. Fine sugar
dust is explosive, as it easily gets dispersed into the air to
form an explosive cloud.
Plugging
prevents dust The refinery had been running for 28 years, before an
Primary Explosion removal explosion occurred in the bagging facility. Heated
bearings ignited the collected sugar dust. The initial
explosion swirled up dust throughout the plant, causing
Overheated bearings devastating secondary explosions. The impact was
registered 3.5 on the Richter Earthquake Scale.
SERIES - OPERATIONAL DISCIPLINE NON-SABIC INCIDENT CASES CLEAN HOUSEKEEPING - GEORGIA SUGAR REFINERY TEXAS US CLASS A TIER 1 SEVERITY 54 31
01 02 03 04 05

Hazard
ACCUMULATED SUGAR 14 FATALITIES
DUST CREATING AN 36 INJURIES
EXPLOSIVE DUST CLOUD
Many complaints Changes to the Ignition sources A procedure for Employees were
about the transport belt should have timely removing not trained for
malfunctioning enabled dust been dust emergency
transport belt accumulation systematically (housekeeping)
were ignored removed (Atex) should have A firewall helped
been in place to save lives
OPERATOR,
TECHNICIAN
Make sure known Actively challenge Make sure known Act according to
DO
hazards are properly identification and mitigation hazards are procedures and speak
mitigated of hazards. Act upon signals mitigated properly up when machines do
and accidents happening at malfunction or you are
equivalent industries. Speak up if not so not trained for hazards
DON’T Assume nothing will Take lack of legislation and Stop asking Assume everything is
happen, because at lack of government questions when organized properly
this plant, there was inspections on specific previous questions
no explosion for 28 hazards as a signal that were not acted upon
years everything is ok
“Procedures for mitigating known hazards shall be in place and acted upon”
PLANT START-UP
34
13:13 PM Plant Start-Up 196 m3 heated liquid raffinate 15 Fatalities

180 Injuries
WEDNESDAY Mar 23, 2005 Severe Damage on Refinery
WHAT HAPPENED
Overfilling
Splitter Tower
During the start-up of the refinery, the raffinate splitter
Relief valves send raffinate to tower was filled up to 99%, put on manual level control
blow-down drum Blow-down drum blows out and heated. Shift handover during this startup failed to
rafinate vapour cloud properly transfer information regarding levels in both
splitter and storage.
As the level transmitter gave non-consistent signals

above 100% level, it suggested low level when the
splitter tower was overfilling. Independent check via
sight glass was not possible, because it was opaque.
The splitter tower spilled over liquid raffinate via the

relief valves towards the blow-down drum. The drum
got overfilled and released liquid to the sewer and blew
Level transmitter Overflow in sewer caused liquid out over the top, causing a huge vapour cloud
wrongly shows low level widespread vapour cloud explosion.
SERIES - OPERATIONAL DISCIPLINE NON-SABIC INCIDENT CASES PLANT START-UP - BP REFINERY TEXAS CITY US CLASS A TIER 1 SEVERITY 84 35
01 02 03 04 05

Hazard
RELEASE OF RAFFINATES 14 FATALITIES &
DUE TO OVERFILLING 36 INJURIES
No Facility Siting, The sight glass Level transmitter Start-Up Many injured
therefore was opaque indicated low procedure called were in nearby
contractor level while for 50% filling, contractor
buildings were Liquid release overfilled but practice was cabins
too close to the due to overfilling No level switch to manually fill
plant blow-down drum implemented up to 99%
OPERATOR,
TECHNICIAN
Actively challenge start- Perform audits on Make sure issues with When a start-up
DO
up and shut-down procedures to make sure the way procedures procedure is not
programs, and other they are workable and solve describe the work workable, do not
potential hazardous any issues that are shall be done, are improvise, but
activities that are only identified by operations addressed and speak up !
done once in a while solved
DON’T Just hope nothing will Wait for operations to ask Assume the Improvise to get
happen, because start- procedures are ok things done and
ups and shut-downs are Ignore issues with because the ignore errors in the
only done very few times procedures operators have found procedure because
a way to deal with it it is only a once in a
six years thing
“Start-up procedures shall be realistic”
SABIC CLASS A INCIDENT CASES
38
SABIC CLASS A INCIDENTS
1 2 3 4
Trouble Shooting during Removing an EHSS Critical

Plant Start-Up Safeguard for maintenance
Alarm During Normal Preparation for

Operation Start-up

TROUBLE SHOOTING DURING START-UP
40
INCIDENT IMPRESSION
SERIES - OPERATIONAL DISCIPLINE SABIC CLASS A INCIDENT CASES TROUBLESHOOTING DURING START-UP - SABIC CLASS A TIER 1 SEVERITY 12 41
17:39 PM Troubleshooting during Plant

Start-Up
Cryogenic liquid & Perlite Explosion
7 injured (hospital admissions)
a MONDAY in 2007
A carbon dioxide and hydrocarbons breakthrough

occurred at a plant start-up.
During troubleshooting, two explosions were heard in the

plant. The liquid gas columns were then found ruptured.
Debris of the explosion damaged the cold box and

COLD COLD released its perlite thermal insulation, causing poor
BOX BOX visibility. Seven contractors complained of asphyxiation.
01 02 03 04 05

Hazard
HYDROCARBON
EXPLOSION &
RELEASE DURING
7 HOSPITAL ADMISSIONS
PLANT START UP
Design error None Interlock No troubleshoot Immediate

caused too high hydrocarbon procedure, Shutdown and
CO2 level analyzer SOP not strictly Evacuation
continuously overridden followed,
(put in No training on
calibration mode) hazards
.
OPERATOR,
TECHNICIAN
In case of problems, Develop troubleshooting In case of troubleshooting, Ask for training and
DO
ask how they have instructions for common make sure employees know procedure for
solved it and make sure problems. Be available for what they are doing troubleshooting. If not
troubleshooting call-out in case of available, ask for help.
instructions were problems.
applied.
Be relieved the problem Assume production will Allow trial and error in the Improvise and override
DON’T
has been solved and solve the issue, because hope to get rid of the interlocks to solve the
move on they have done that problem problem and get the
multiple times plant running
“No troubleshooting without specific troubleshooting instructions”
ALARM DURING NORMAL OPERATION
45
INCIDENT IMPRESSION
SERIES - OPERATIONAL DISCIPLINE SABIC CLASS A INCIDENT CASES ALARM DURING NORMAL OPERATION - SABIC CLASS A TIER 1 SEVERITY 3 46
Alarm during normal

07:45 AM operation of a
Volatile hydrocarbons Fire
US$ 4 million asset damage
a THURSDAY in 2013 hydrocarbon heater
An operator noticed smoke and fire from an hydrocarbon

Stack Stack
heater. Tubes of the re-boiler were ruptured due too high
heater temperature. The fire brigade could not prevent
collapse of the heater stack.
Alarm Alarm
The high temperature alarm was not noticed, because the

High High alarm sound was muted on the DCS panel. Active alarms
Temperature were not logged.
HEATER HEATER
The heater control valve acted sluggish, but that was not
reported. Supervision was inadequate, operators were
not sufficiently trained and the design was depending
only on human safeguards, while an interlock should have
been installed.
01 02 03 04 05

Hazard
TUBE-RUPTURE IN FIRE &
AN HYDROCARBON ASSET DAMAGE
HEATER DUE TO
HIGH TEMPERATURE
DCS sluggish Temperature No interlock No action on Fire Brigade
valve operation exceeded the installed DCS alarm could only save
was not Maximum because PHA because it was the remaining of
reported for Allowable failed to insist muted and not the plant
repair Design Limit of logged
the heater
OPERATOR,
TECHNICIAN
Enforce the Perform audits on Actively check follow Act upon alarms.
DO
deployment of alarm alarms and actively up of alarms. Make
management system manage alarm floods sure issues get Report control issues
to ensure operators solved. and alarm floods to
Talk with DCS
are in control. prevent repetition.
operators about
alarm floods.
DON’T Assume all is well Assume all is well Silence alarms during
Assume errors are
because no issues because no alarm can alarm flood. Keep
made outside only,
are raised. be heard in the silence on issues
not in the control
control room. because they never
room, nor in a PHA.
get solved anyway.
“Act upon alarms. Raise control and alarm issues for repair”
REMOVING AN EHSS CRITICAL

SAFEGUARD FOR MAINTENANCE
50
INCIDENT IMPRESSION
SERIES - OPERATIONAL DISCIPLINE SABIC CLASS A INCIDENT CASES REMOVING EHSS CRITICAL SAFEGUARD FOR MAINTENANCE – SABIC CLASS A TIER 1 SEVERITY 3 51
Removing an EHSS Critical Smoke as a result of No injury

≃17:57 PM Safeguard for maintenance Hydrocarbon Fire US$ 8 million Asset Damage
a SATURDAY in 2016
Fire Hatch The fire hatch of a waste oil tank (EHSS Critical Safeguard)
Air was removed for maintenance, leaving the flange
Fire Hatch temporary covered with a loose piece of plastic.
removed
HC Flow
The nitrogen addition to the tank was closed, the flange
Dip Tube not properly blinded.
Nitrogen After some time, fire was observed from the open flange
Flammable followed by an explosion inside the tank followed by a fire
mixture
ball resulting in major damage to the tank.
The open flange allowed air to enter the tank, forming a

Static charge
flammable mixture. It is believed to be ignited by
Hydrocarbons
electrostatic discharge to the dip pipe.
01 02 03 04 05

Hazard
FLAMMABLE MIXTURE INTERNAL EXPLOSION
IN TANK DUE TO AIR & FIRE
ENTRANCE DURING
MAINTENANCE
Not designed to Open connection Low Level No operation Emergency
remove fire to air after interlock procedure for Response could
hatch for removing fire bypassed and the tank, no protect the Plant
maintenance hatch, not identified as maintenance but this Tank
during operation Nitrogen flow EHSS critical procedure for had already
closed removing hatch exploded
OPERATOR,
TECHNICIAN
Set clear expectations Check the availability of Personally convince Speak up when no
DO
for use of procedures. maintenance maintenance that EHSS procedures are available
Go out into the field procedures and how critical safeguards is
and check personally. they are applied prepared correctly Do not start maintenance
without maintenance
procedure
DON’T Manage from office by Allow deviations to Assume preparations Improvise, based on
replying to incidents normalize are ok when nobody experience only
only speaks up
“No Maintenance without Maintenance Procedure”
PREPARATION FOR START-UP
55
PREPARATION FOR STARTUP
SERIES - OPERATIONAL DISCIPLINE SABIC CLASS A INCIDENT CASES PREPARATION FOR STARTUP - SABIC CLASS A TIER 1 SEVERITY 10 56
Preparation for Start-up Explosion impact, smoke, 3 injuries (1 hospitalized)

≃13:15 PM heat, hydrocarbons Waste Heat Boiler Exploded
WEDNESDAY 1998
Normal situation During Incident WHAT HAPPENED

Medium Pressure High Pressure
Compressor Hydrocarbons Hydrocarbons
During startup preparations of 5 batch-wise operated
Air Air reactors, a trip of the hydrocarbon compressor required it
had to be taken on manual. This resulted in a reactor with
much higher hydrocarbon pressure than normal.
Reactor
This was followed by an error with the manual operated
Closed Open valves, causing hydrocarbons to flow from that reactor via
a vacuum system to another reactor, mix up with air and
Ejector then flow to the waste heat boiler, which exploded with
Flammable
debris 100 meters away.
Runaway
Mixture
Reaction
The hot explosive mixture (520ºC) was above the ‘formal’
Auto Ignition Temperature (460ºC). At this temperature,
you do not need a spark to ignite. Like in a diesel engine,
Boiler it will go spontaneously. At large volumes the AIT will be
much lower. In this case the AIT was about 320ºC.
01 02 03 04 05

Hazard
EXPLOSION OF WASTE EXPLOSION
HEAT BOILER DUE TO DAMAGE
WRONG COMPRESSOR 3 TECHNICIANS
PRESSURE OR INJURED
REGENERATION VALVE Insufficient PHA .None High Pressure Procedure was Many
SETTINGS studies. Switch Evacuator not clear unnecessary
Learnings from by-passed. people in control
previous No other switch History of not room
incident not to stop HC flow following
implemented. to heater procedures
OPERATOR,
TECHNICIAN
Personally convince Verify and support, so Ensure conditions to Follow Procedures and
DO
that learnings from transient operations are perform critical activities report deficiencies
incidents are properly and timely are supportive
implemented prepared Never make overrides
Personally check all without permission
overrides
DON’T Make startup more Hesitate to ask Allow anyone to disturb Override interlock
important than questions about non those working on critical without formal written
ensuring safety standard operations to activities permission
identify hidden hazards
Do not check overrides Take process on manual
without procedure
“Critical activities require supportive conditions”
SABIC CLASS B INCIDENT CASES
60
SABIC CLASS B INCIDENTS
1 2 3 4 5 6
Prepare a Pipeline for

Maintenance
Steam Cleaning of a Acid Overflow
Process Drum from a Tank
De-Choking a Pneumatic leg Trouble Shooting

with Nitrogen (2 incidents)
Exchanging a Filter
(2 incidents)
EXCHANGING A FILTER 1
62
INCIDENT IMPRESSION
SERIES - OPERATIONAL DISCIPLINE SABIC CLASS B INCIDENTS EXCHANGING A FILTER 1 - SABIC CLASS B TIER 1 SEVERITY 6 63
Opening a filter vessel drain 6000 kg hot quench oil 1 injured (hospital admission)
≃21:00 PM line, to exchange a filter during spray release
a TUESDAY in 2017 normal operation
Normal situation During Incident WHAT HAPPENED
A process technician went to open a filter vessel drain

line, which was isolated with LOTO, to exchange a filter.
However, he broke the joint of the wrong (live) filter, and

being in the line of fire, he got sprayed.
Wrong
Filter
The filters did not have a local level or temperature
indicator and the drain lines were relatively cold. So the
technician had no independent indication he was working
on the wrong filter.
Quench oil solidifies in cold drain lines. So when

unbolting the blind, initially there was no flow and the
technician kept on unbolting until suddenly the oil blew
out.
01 02 03 04 05

Hazard
HOT CORROSIVE CHEMICAL TECHNICIAN
SPRAY FROM FILTER DRAIN, HOSPITALIZED
HITTING TECHNICIAN
No formal No physical No local Procedure does No clear

system to indication : filter instruments that not specify requirements for
allocate work, drain lines are indicate independent adequate PPE,
technician was cold, causing temperature or identification of therefore
not experienced quench oil to be level isolation insufficient
viscous initially protection
OPERATOR,
TECHNICIAN
High risk activities require Actively review and support Make sure hazards are well Follow procedures.
DO
additional attention. The high-risk activities to understood and proper Understand potential
safety of such activities understand the work hold points are available to hazards of your activity
highly depend on human process and the quality of independently check if it is and ask questions if not
acts and need support. controls to stop any hazard. safe to proceed. 100% sure.
DON’T Think that getting these Wait for any issue to require Expect people to know it all Try to prove you know
activities right is the task assistance. and that procedures are how to do it, or be afraid
only of those writing and perfect. to ask for help.
executing procedures.
“High-risk activities require multiple and independent confirmation”
EXCHANGING A FILTER 2
67
INCIDENT IMPRESSION
Opening a filter house top lid, 160 kg hot pressurized 3 operators injured
≃09:49 AM to exchange a filter corrosive chemical (≃ 70°C) (hospital admissions)
a SUNDAY in 2016
A trainee operator under the supervision of two

experienced operators unbolted the filter house top lid to
Wrong exchange the filter.
Filter
He opened the wrong filter, that was still in operational

mode and had neither LOTO applied nor was it flush
cleaned.
All three operators got splashed with hot corrosive

chemical, causing mainly thermal and some chemical
burns (respectively 60%, 25% and 10% of body burned).
01 02 03 04 05

Hazard
HOT CORROSIVE CHEMICAL OPERATORS

SPRAY FROM FILTER HOUSE, HOSPITALIZED
HITTING EMPLOYEES
An inherent safe Unbolting was Trainee looked Procedure not SOP required
process would not started away at the wrong resilient to PPE, but filter
not require from the trainee, pressure gauge prevent opening exchange was
frequent filter so the leak blew wrong filter, perceived low
exchange straight in his No temperature Supervisors too risk, so not all
face indicators far away to see PPE was used
OPERATOR,
TECHNICIAN
Make plant visits and Human beings can and Make sure people are If you have never done a
DO
ask questions. For any will make errors. experienced to do the job before, ask for
high risk situation, Guarantee high risk job, or are properly assistance. If you are
make sure potential situations are resilient guided by an not feeling secure to do
human failures are against human error. experienced employee. a job, speak up.
managed properly.
DON’T Assume the Assume 4 eyes always Assume if another Try to impress your
organization is able to will stop the hazard. operator guides the boss and assume you
organize to always do employee, all mistakes know how to do . Or be
the things right. can be prevented. afraid to admit you do
not exactly know how to
do the job.
“It takes time before new employees consistently work safely”
DE-CHOKING A PNEUMATIC LEG

WITH NITROGEN
72
INCIDENT IMPRESSION
SERIES - OPERATIONAL DISCIPLINE SABIC CLASS B INCIDENTS DECHOKING A PNEUMATIC LEG - SABIC CLASS B TIER 1 SEVERITY 3 73
De-choking process line with Hot hazardous substance 1 Hospital Admission

≃20:40 PM nitrogen liquid (≃ 150°C) released 1 Medical Treatment
a SATURDAY in 2019 from vessel cover

Choked Choked
Nitrogen Line Line
Nitrogen
CLOSED
OPEN
The pneumatic vapor line on top of the Vessel got
blocked with product.
This solid product is dispersed in the vessel liquid.
By applying nitrogen pressure, operators (routinely) try to

de-choke.
However, this time the plug was too rigid, causing

increase of vessel pressure, resulting in blowing contents
out from the vessel cover.
Both operators got splashed with the hot liquid.
01 02 03 04 05

Hazard
HOT LIQUID (150℃)

RELEASED FROM VESSEL OPERATOR
COVER, HITTING A PERSON HOSPITALIZED
Design issues, Vessel covers Vessel level No procedure or No proper PPE

leading to were not locked interlock was set instruction how were required
frequent choking or bolted at 98% without to safely de-
of the pneumatic because of MOC, causing choke
line frequent de- frequent
choking plugging
OPERATOR,
TECHNICIAN
Make regular plant Do regular reviews to Ensure nobody goes Demand a valid and
DO
effective visits to ensure all are to work without written instruction
ensure activities are working according to written and valid that clearly explains
done conform proper effective procedures instructions the activity and its
instructions with two- hazards
way dialogue
DON’T Think process safety Only rely on the Assume you know
Try to manage safety is only about PHA expertise and how to do it because
from office only by and LOPA experience of incidents only
using metrics and operators and happen to other
giving instructions technicians people
“No activity without a valid procedure”
STEAM CLEANING OF A PROCESS DRUM
77
Steam cleaning of a process Sudden splash of steam 3 injuries

≃20:35 PM drum at an elevated floor condensate with coke traces (1 lost workday,
a SATURDAY in 2019 2 medical treatments)
During boil out cleaning activities of a cracking unit, the

drain line got blocked.
To solve this issue, an operator and two technicians

DRUM DRUM connected a steam hose to the high pressure nozzle of
the level transmitter, which also got blocked. Therefore, a
steam connection was made to the low pressure nozzle
to continue draining.
7 METERS
7 METERS
When they opened the steam flow, a sudden splash of
steam condensate with coke traces. It splashed from the
top vapor outlet nozzle.
In panic, they quickly descended the seven meter high

monkey ladder to evacuate, but slipped and fell down.
SERIES - OPERATIONAL DISCIPLINE SABIC CLASS B INCIDENTS STEAM CLEANING OF A PROCESS DRUM - SABIC CLASS B TIER 1 SEVERITY 3 78
01 02 03 04 05

Hazard
HOT HAZARDOUS
SUBSTANCE RELEASE FROM EMPLOYEE
NOZZLE, CAUSING INJURY HOSPITALIZED
Insufficient work steam purging No indicator that The procedure None

process to was improvised revealed high did not support
identify hazards without Hazard liquid level the situation, so
in startup, Review for they deviated
shutdown and Shutdown without hazard
commissioning activities assessment
OPERATOR,
TECHNICIAN
Transient operations Actively audit on transient Make sure activities do Stop the activity
DO operations.
(startup, shutdown, not run outside the when the procedure
(de)commissioning) written instructions. no longer is fit for the
are likely to create Timely prepare for situation.
incidents. Guarantee alternative solutions.
a solid work process.
Assume PHA and Give transient operations Turn a blind eye for only Be brave and solve
DON’T little time, because 95%
work permit have a small moment because the issue even if the
covered all risks of the time is continuous the situation needs to procedure does no
operation. get solved. longer support the
activities.
“Stop all activities when the procedure no longer is fit for the situation”
PREPARE A PIPELINE FOR MAINTENANCE
81
Preparation of an acid
07:30 AM containing pipeline for
Acid spray from a flange 1 injury (lost workday case)
a WEDNESDAY in 2019 maintenance
An operator was assigned to prepare an acid containing

HCL
HCL pipeline for a maintenance activity.
Nitrogen Nitrogen Line
Line
CLOSE OPEN
He purged the line with nitrogen, however it had a dead
head; the pressure had no way to go.
When the pressure rose, a small amount of acid sprayed

from a nearby flange connection on his eyes and face.
SERIES - OPERATIONAL DISCIPLINE SABIC CLASS B INCIDENTS PREPARE A PIPELINE FOR MAINTENANCE - SABIC CLASS B TIER 1 SEVERITY 3 82
01 02 03 04 05

Hazard
ACID LEAK, SPRAYING EMPLOYEE
ON OPERATOR WHEN LOST WORK DAY
PURGING LINE
N2 coupling No pressure No pressure Not following Standing in line

position puts relief valve indicator or procedure, of fire
operator in line alarm to warn of so path to purge
of fire. Flange is Flange is not high pressure was not cleared Only standard
likely to leak due tightened to a PPE used, not
to frequent use specific torque specific for acid
OPERATOR,
TECHNICIAN
Talk with and ask Actively review how Talk to operators and Follow procedures
DO
operators and procedures are applied technicians to
technicians about the and solve any obstacle understand if and why If they are hard to
problems they run into they do not follow perform, raise the issue
procedures. Solve
problems and obstacles
DON’T Delegate such talks Wait for an incident to Wait for issues to be Improvise your own way
and never check happen to correct any raised officially to make the activity easy
yourself issues to perform
“Create the conditions that make procedures are followed”
ACID OVERFLOW FROM A TANK
85
INCIDENT IMPRESSION
SERIES - OPERATIONAL DISCIPLINE SABIC CLASS B INCIDENTS ACID OVERFLOW OF A TANK - SABIC CLASS B TIER 1 SEVERITY 3 86
Routine activity of filling the 2,130 kg concentrated acid 1 injury (lost workday case)
≃02:20 AM acid day tank
a TUESDAY in 2019
During routinely filling of the acid day tank, acid began to

Desiccator Desiccator
Acid Feed Line overflow from desiccator at the top of tank.
Acid Flow
After closing the acid flow, an operator attempted to
reset the field alarm, but his leg accidently got exposed to
an acid splash
ACID ACID
DAY DAY The injured operator was transferred to hospital for
TANK TANK
further treatment.
01 02 03 04 05

Hazard
ACID OVERFLOW
FROM TANK,
CAUSING INJURY OPERATOR
HOSPITALIZED
None Unavailability of No interlock that Procedures not Only standard

level switch to stops flow at followed Personal
avoid overfilling high level Protection
Equipment was
No level used
indication in PLC
OPERATOR,
TECHNICIAN
When out in the field, Ensure operators and Make sure operators Make sure you
DO understand the
ask what operators technicians know the and technicians contact
or technicians would chemical hazards and you before improvising chemical hazards
do in an unexpected how to deal with and solving unexpected before acting
situation them issues
Assume your team is Assume training and Depend on the operator Act very quickly when
DON’T you detect
perfect experience are judgement to solve
enough to deal with unexpected issues something goes
hazardous chemical wrong in the plant
“Stop and think before improvising. Keep following procedures”
TROUBLE SHOOT A FLOW ISSUE
90
Correcting a process flow and

18:27 PM pressure issue on the request
Hot water (90℃) released 2 injuries
(1 hospitalization, 1 lost workday)
a WEDNESDAY in 2019 of a console operator

Valve got operated
Few months before the incident, a pneumatic actuator
Plug remotely, without
operators being aware was installed via MOC, to replace a manual valve.
Diverter
On the day of the incident, three operators attempted to
correct a process flow and pressure issue with a powder
fines scrubber. Strainer B was online and had to be
switched to strainer A.
They moved the pneumatic selector switch to the point

where it indicated flow to strainer A. However, the Key
Verification Points showed Strainer A was offline and B
Strainer
Strainer
Strainer
Strainer
online. They discussed something was not right.
A
A
B
B However they, proceeded, opened the lid of strainer A,

and a sudden loud pop was heard, followed by hot water
A B A B (90℃) flowing out, causing burns to both operators.
SERIES - OPERATIONAL DISCIPLINE SABIC CLASS B INCIDENTS TROUBLE SHOOT A FLOW ISSUE - SABIC CLASS B TIER 1 SEVERITY 3 91
01 02 03 04 05

Hazard
HOT WATER RELEASE 2 OPERATORS INJURED,
DURING CLEANING 1 HOSPITAL ADMISSION
OPERATIONS AND
TROUBLESHOOTING
None No manual valve No interlock to Procedure did Not all specified
used to prevent prevent the not explain the PPE were used
release of hot actuator from new situation,
water, no removal switching nor specify when
of instrument air to ask for
from actuator technical support
OPERATOR,
TECHNICIAN
Develop the employee Give support in Give additional Do troubleshooting

DO
capability & skill to identifying hazards, attention to according to procedures
identify hazards especially for abnormal troubleshooting and understand how to
conditions situations. Assure safeguard your work
conditions are right place – if not sure, ask for
technical assistance
Spot-check because Be overconfident that Assume operators Assume you understand

DON’T
the EHSS management the operators and always know when to the situation when new
system is solid technicians know those ask for troubleshooting equipment is installed
details better assistance
“Troubleshooting ? Expect the Unexpected”
TROUBLE SHOOT A BILLET ROLLER
94
INCIDENT IMPRESSION
Second
worker
First
worker
SERIES - OPERATIONAL DISCIPLINE SABIC CLASS B INCIDENTS TROUBLE SHOOT A BILLET ROLLER - SABIC CLASS B TIER 1 SEVERITY 3 95
Troubleshoot a Roller
07:30 AM machine
Hot water & steam splash 2 Technicians injured
a TUESDAY in 2019
Operations noticed slow roller movement, heard them

jamming together, causing the roller to stop rotating.
Maintenance was called for troubleshooting and decided

to remove the geared motor to free the roller.
A work permit was issued without joint inspection, proper

isolation (LOTO), Job Safety Analysis and workers
M M signatures.
While two mechanical technicians were removing the inlet

water-cooled rotary union, steam and hot water splashed
towards them, resulting in burn injuries.
01 02 03 04 05

Hazard
HOT WATER RELEASE TWO TECHNICIANS

DURING MAINTENANCE INJURED
Design allowed No draining None No Loto, JSA, None

trapped liquid in possibility joint inspection
the line
No troubleshoot
procedure
OPERATOR,
TECHNICIAN
Go out in the field Audit work permits Verify if work permits Follow work permit
DO
and personally check periodically successfully are setting and procedure. Ask
work permits of any safe conditions, and give questions when
activities going on extra attention in case of perceiving the work
unexpected situations permit is not
complete
DON’T Allow a culture where Assume work permits Consider there is no risk stop reporting any
contractors can work are performed similar since technicians know observations
without strictly in scheduled and non- their job, no hazardous whatever tiny it is
following safety rules scheduled cases substances are involved
and other tasks require
your attention now
“Work permits shall set conditions to perform the work safely”
SABIC CLASS C INCIDENT CASES
99
SABIC CLASS C INCIDENTS
1 2
Ice Formation on Tank Trailer

a Pipeline Manhole Leak Test

ICE FORMATION ON A PIPELINE
101
INCIDENT IMPRESSION
SERIES - OPERATIONAL DISCIPLINE SABIC CLASS C INCIDENTS ICE FORMATION ON A PIPELINE - SABIC CLASS C TIER 1 SEVERITY 1 102
Ice formation on a pipeline

02:30 AM during normal operation
Liquid Oxygen Pipeline rupture and fire
US$ 220,000 damage
a SATURDAY in 2011
A leak and ice formation were observed on and around

the flange of a liquid oxygen pipeline and reported to
maintenance. 13 days later maintenance closed the order
as they did not observe a leak.
A month later another observation of leakage was

reported. Maintenance tightened the flange to stop the
leak. However, this enabled N2O and acetylene to
accumulate in the confined annular space of the pipeline
coupling.
Two weeks later the coupling exploded during lack of flow

in the pipeline. It is believed that lack of internal cooling
by the product resulted in auto-decomposition of the
entrapped acetylene.
01 02 03 04 05

Hazard
ACCUMULATION AND EXPLOSION & FIRE
AUTO-DECOMPOSITION
OF ACETYLENE/N2O
MIXTURES
No hazard and Mechanical No detection of No maintenance None
risk assessment bayonet joint is accumulated procedure or
available prone to leak, hydrocarbons or training for this
tightening it higher activity
creates a temperature
confined space
OPERATOR,
TECHNICIAN
Do spot-checks to Pro-actively audit allow maintenance Ask for a maintenance

DO
check if all maintenance maintenance procedures activities to be only done procedure when it is
activities are backed up to identify if all hazards with a valid procedure not available
by valid procedures are properly addressed
DON’T Rely on maintenance Wait for incidents to Perform the maintenance Perform maintenance
only to report any happen before reviewing anyway because no without a procedure or
deficiencies the hazards procedure is available clear written instruction
“No maintenance without a procedure”
TANK TRAILER MAN HOLE LEAK TEST
106
INCIDENT IMPRESSION
SERIES - OPERATIONAL DISCIPLINE SABIC CLASS C INCIDENTS TANK TRAILER MAN HOLE LEAK TEST - SABIC CLASS C TIER 2 107
≃ 2:30 PM
Lid Tightness after the Leak 22 kg Nitrogen 1 medical treatment,
test of the tank trailer 1 first aid
a TUESDAY in 2019

Two maintenance contractors conducted a leak test on
an empty truck vessel, for hazardous substance, with a
work permit.
At 2 bar-gage nitrogen pressure, the 12” manhole on

top of the vessel leaked, so they attempted to tighten
the bolts.
The manhole lid suddenly popped up, causing a minor

cut on the knee of one contractor and a minor
contusion on the skin of the other.
Nitrogen
01 02 03 04 05

Hazard
PRESSURE BUILT UP, MEDICAL TREATMENT
CAUSING SUDDEN & FIRST AID
OPENING OF A
MANHOLE OR VESSEL
RUPTURE Nitrogen inlet to Damage in the None SOP did not Inadequate
the truck is 7 Bar flange bolt include leak-test, Supervision &
while the truck holder Fixing leaks lack of training
design is 2.5 Bar (not identified in under pressure
inspection) violated SMP
OPERATOR,
TECHNICIAN
Encourage people to Review availability of Make sure all jobs are If no procedure is
DO
refuse to do the job if procedures and their done according to available or you are not
not properly written appropriate training procedure and front- trained to do that job,
in an accepted liners are trained don’t do it !
procedure
Stay silent because

DON’T people may use the Assume it is ok Stay silent because Be good for your boss
argument for not because hardly requiring procedures will by not complain and
doing their work incidents happen create a lot of work for doing the job without
the organization procedure and training
“Without procedure, you shall not do the job”
SABIC HIGH POTENTIAL EVENT CASES
111
SABIC HIGH POTENTIAL INCIDENTS
1 2
Valve Switching to the

Maintenance stand-by pump

VALVE MAINTENANCE
113
INCIDENT IMPRESSION
Leaking Valve
Leak location
Valve to be
maintained
SERIES - OPERATIONAL DISCIPLINE SABIC HIGH POTENTIAL EVENT CASES VALVE MAINTENANCE – SABIC CLASS D – HIGH POTENTIAL 114
Instrument Valve Maintenance 8 kg acid gas release No injury (class D)

≃09:00 AM Potentially class B injury
a Sunday in 2020
An instrument technician was doing maintenance on a

valve in a line that normally transports acid gas.
South
Valve Some acid gas was released through the packing gland of
a valve in an adjacent line.
The technician went to the warehouse to collect spare

parts, but when returning after 30 minutes, he saw a
white cloud.
North
Valve If the technician would have been working at that location
at the moment of release, then injury is very likely.
01 02 03 04 05

Hazard
ACID GAS LEAK CAUSING POTENTIAL INJURY

INJURY TO TECHNICIAN
DURING MAINTENANCE
Job allowed to
Gland packing None Gas detectors Minor leak not Required PPE not
continue despite
nut was found failed to alarm properly used
knowing a
untightened during the leak reported,
release was
immediately Proceeding work Technician
possible
without luckily was away
considering leak during release
OPERATOR,
TECHNICIAN
Establish a culture of Assist to distinguish Make sure to discuss Report irregularities

DO
reporting irregularities between potential any irregularities immediately and
and “sense of un-ease” hazardous and non immediately discuss its potential
hazardous releases consequences before
proceeding
DON’T Delegate the risk Wait for questions to Assume a minor leak Assume you can
management of minor come will stay a minor leak proceed because you
observations to front- always performed this
liners because they are job previously
only minor observations
“Stop work when coming across unexpected events”
SWITCHING TO THE STAND-BY PUMP
118
INCIDENT IMPRESSION
SERIES - OPERATIONAL DISCIPLINE SABIC HIGH POTENTIAL EVENT CASES SWITCHING TO THE STAND-BY PUMP – SABIC CLASS D - HIGH POTENTIAL 119
Switching to the Stand-by Water No injury,

≃17:30 pump Material damage
a MONDAY in 2020 Potential class B injury
An operator noticed a minor leak at a vacuum pump and

informed the mechanic team.
Outlet Outlet
Vacuum
Vacuum
The technicians concluded the pump could not be fixed
Closed immediately, so the operator switched to the spare pump
Closed
and left.
Water About 30 minutes later, a loud noise came from the line.
Water The spare vacuum pump was found displaced and had hit
Inlet
Inlet the electrical panel box.
Closed
Vacuum Pump Spare Pump
01 02 03 04 05

Hazard
HIGH PRESSURE IN
VACUUM PUMP WHEN
POTENTIAL INJURY
VALVES ARE CLOSED
No engineering No Pressure No pressure or No operation Technician and

protection Relief System temperature procedure for operators luckily
around pump interlock or starting spare were away
alarm pump, during the
Operator failed release
to check valves
OPERATOR,
TECHNICIAN
Actively challenge start- Review procedures to Make sure procedures Get help when in an
DO
up and shut-down understand if they properly are up to standard and unforeseen situation
programs and other backup unforeseen unforeseen situations where the procedure is
potential hazardous situations and solve any are properly described not clear and you are
activities that are only issues that are identified by not certain how to act
done rarely operations
DON’T Have a “nothing will Ignore issues with Assume procedures are Improvise and assume
happen” mind-set procedures because they ok because operators you know how to do
because start-ups and are very time demanding have found a way to deal the job
shut-downs are only with it
done very few times
“Get help when in unforeseen situations”
THANK YOU
THANK YOU

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THINK PROCESS SAFETY

SERIES # 01 OPERATIONAL DISCIPLINE

Think Process Safety Booklet

SABIC and brands marked with ™ are trademarks of SABIC or

© 2020 SABIC. All Rights Reserved 2

GETTING THE TRUTH OF EHSS

SABIC GLOBAL EHSS

HOW TO USE THIS BOOKLET

THINK PROCESS SAFETY

We recommend to use this booklet during training, tool-

SERIES - OPERATIONAL DISCIPLINE INTRODUCTION 8

“FROM LEARNING TO PREVENTION” JOURNEY

SERIES - OPERATIONAL DISCIPLINE INTRODUCTION 9

CONTROLS TO KEEP YOU SAFE

Hazards need to be kept in control. Many

When all types of control fail, an incident

The Swiss Cheese model demonstrates how

SERIES - OPERATIONAL DISCIPLINE INTRODUCTION 10

EXPLAINING THE SWISS CHEESE MODEL

DESIGN AND MECHANICAL INSTRUMENTAL PROCEDURE RESPONSE AND

EXAMPLES: EXAMPLES: EXAMPLES: EXAMPLES: EXAMPLES:

SERIES - OPERATIONAL DISCIPLINE INTRODUCTION 11

WHY THIS BOOKLET - OPERATIONAL DISCIPLINE (OD)

When observing the incidents we experienced

You will come across many examples in this

Incidents do not occur very often, and we are

Operational Discipline is an important key to

Operational Discipline establishes a consistent culture, that makes sure no human

LACK OF OD CONTRIBUTES TO MANY INCIDENTS

Insufficient Operational Discipline contributes to many PROFIT

2017 2019 2025

Class B, Tier 1 with medium severity

Class C, Tier 1 with low severity or Tier 2

• Action done when a procedure is not available COST RISK

“ Operational Discipline influences all aspects of

OUR LEADERS DRIVE OUR CULTURE

EHSS IS NOT OPTIONAL

SERIES - OPERATIONAL DISCIPLINE INTRODUCTION 14

YOU NEED TO KNOW YOUR CURRENT POSITION

3 Bad news is tolerated

SERIES - OPERATIONAL DISCIPLINE INTRODUCTION 15

NON-SABIC MAJOR INCIDENTS

NON-SABIC MAJOR INCIDENTS

Interruption of a Batch Housekeeping

SERIES - OPERATIONAL DISCIPLINE 17

CHEMICAL STORAGE DURING SHUT DOWN

WHEN ACTIVITY RELEASE IMPACT

Turnaround shutdown, 42 tons Methyl-Iso-Cyanate 3,787 formal fatalities

Normal condition During Incident WHAT HAPPENED

Due to maintenance activities, all safety and cooling

Water leaked into the tank, causing an undetected

CONTROLS THAT FAILED

DESIGN AND MECHANICAL INSTRUMENTAL PROCEDURE RESPONSE AND

TOXIC CHEMICAL 558,125 INJURED

Refrigeration Gas scrubber No alarm to warn Shutdown Alarm raised

A LESSON LEARNED – DO’S AND DON’TS

“Appropriate shut-down procedures shall be available and applied”

WHEN ACTIVITY RELEASE IMPACT

Temporary interruption of a 6 tons dioxins 3,300 animals dead

Normal condition During Incident WHAT HAPPENED

A batch reaction process was temporarily interrupted

Due to lack of demand, the stand-by steam boiler

CONTROLS THAT FAILED