Spring 2024 IE 4306/5306

03. System Safety Process and

Safety Management System

January 20, 2024

Changwon Son, PhD, CSP

Department of Industrial, Manufacturing, & Systems Engineering
A Quick Survey

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System Safety

“System Safety is a rational pursuit of acceptable mishap [or

incident] risk within a systems perspective; one in which the
system is treated holistically, accounting for interactions among
its constituent parts.”

What process should occur in order to accomplish system safety?

System Safety Process

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System Safety Process

A system safety process is continuous efforts to reduce the risk of a

system to an acceptable level.

• Continuous efforts

• Reduce the risk

• An acceptable level

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System Safety Process

Continuous efforts

‘8 Steps of a system safety process’ (MIL-STD-882E)

1. Document 4. Identify risk

system safety 2. Identify 3. Assess risks reduction
approaches hazards measures

6. Verify and 5. Implement the

8. Manage 7. Accept validate risk measures to
lifecycle risks residual risks reduction reduce risks

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 System Lifecyle

UK Health & Safety Executive (HSE)

Conceptual design

Decommissioning
Commissioning
Construction &
Manufacturing

Installation &

Operation
Feasibility

Detailed
analysis

Design
FEED*

*FEED = Front-End Engineering Design – technical requirement, major equipment, major hazards, etc.
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FEED

Front-End Engineering Design (FEED)

• FEED is a basic engineering phase where preliminary engineering design is

conducted before detailed design.

• Outputs of FEED include:

ü Overall facility siting plan
ü General arrangements for main equipment and main pipework
ü Cost estimating
ü Piping and instrumentation diagram (P&ID)
ü HAZOP (Hazard and Operability study) report
ü Project execution plan
ü HSE (health, safety, and environment) plan

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Risk Reduction Opportunities

System Lifecyle and Risk Reduction

Importance of designing a safer system

Opportunity to reduce risks Cost of change

Feasibility Design Construction Operation Decommissioning 8

Inherently Safer Design (ISD)

Inherently Safer Design (ISD) “What you don’t have, can’t leak.” (Trevor Kletz, 1977)

• A safety approach to eliminate or reduce risks of a system from the design phase

Four ISD Principles

1. Substitute – Use less hazardous materials and processes

2. Minimize – Use small quantities of hazardous materials or the size of equipment

3. Moderate – Use alternative processes of less hazardous conditions (e.g., dilution, refrigeration)

4. Simplify – Eliminate unnecessary complexity and design user friendly plants.

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Inherently Safer Design (ISD)

Substitution

• Use less hazardous materials and processes

[Examples]
Water-based paint Oil-based paint
Water-based paint
eliminates hazards of
fire, toxicity, and
environmental
hazards

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Inherently Safer Design (ISD)

Minimize

• Use small quantities of hazardous materials or the size of equipment

[Examples] A pipe reactor A large batch reactor

Use a continuous
pipe reactor instead
of a large batch
reactor of hazardous
chemical production
(e.g., nitroglycerin –
very toxic and
explosive chemical)

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Inherently Safer Design (ISD)

Moderate

• Use alternative processes of less hazardous conditions (e.g., dilution, refrigeration)

[Examples] Large pellets Fine powder

Use pellets to handle

combustible solid
(e.g., metal, grain,
sugar) in stead of
find power to avoid
dust explosion.

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Inherently Safer Design (ISD)

Simplify

• Eliminate unnecessary complexity (e.g., processing steps) and design user friendly plants.

[Examples]

Remove old piping

(no longer in use)
from a plant to make
it impossible to
accidentally transfer
materials into a
reactor.

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System Safety Process

A system safety process is continuous efforts to reduce the risk of a

system to an acceptable level.

• Continuous efforts

• Reduce the risk

• An acceptable level

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System Safety Process

Risk Reduction
Impact
• Reduce the probability of
incidents in a system Residual risk

• Reduce the severity of incidents

in a system

Probability
Original risk 15
System Safety Process

A system safety process is continuous efforts to reduce the risk of a

system to an acceptable level.

• Continuous efforts

• Reduce the risk

• An acceptable level

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 Acceptable Risk

As Low As Reasonably Practicable (ALARP)

Risk Risk

Unacceptable risk
(Risk must be reduced)

Upper limit

ALARP – Tolerable risk ALARP - Risk is tolerable

but only when further risk
reduction is not practical
Lower limit (=less cost-effective).

Acceptable risk
(Risk is insignificant) Cost 17
 Acceptable Risk

As Low As Reasonably Practicable (ALARP)

Risk A company with over
40K employees
Unacceptable risk
(Risk must be reduced) 300 Lost time injuries & 10 fatalities / year

Upper limit How much

additional cost?

ALARP – Tolerable risk 30 Lost time injuries & 1 fatality / year

How much
Lower limit additional cost?
Acceptable risk
3 Lost time injuries & zero fatality / year
(Risk is insignificant)
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Other Aspects of Risk

• Risk Analysis
- Development of a quantitative estimate of risk based on engineering and mathematical
techniques to combine estimates of incident probability and severity

• Risk Assessment
- A process by which the results of a risk analysis (i.e., risk estimates) are used to make
decisions, either through relative ranking of risk reduction strategies

• Risk Communication
- Dissemination of information to diverse audiences (e.g., individuals, communities, and
institutions) facilitating their informed, independent decision making about the hazards
and risks affecting health, safety, and the environment.
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Other Aspects of Risk

• Human Perception of Risks

Imagine that a nuclear meltdown has been report from an outskirt of a

big city, which is expected to kill 6,000 people.
Two alternative plans to combat the meltdown have been proposed.

If Plan A is selected, If Plan B is selected,

2,000 people will be saved • 1/3 probability that 6,000 people

(100% guaranteed) will be saved; and
• 2/3 probability that no one (0) will
be saved
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Other Aspects of Risk

• Human Perception of Risks

Imagine that a nuclear meltdown has been report from an outskirt of a

big city, which is expected to kill 6,000 people.
Two alternative plans to combat the meltdown have been proposed.

If Plan C is selected, If Plan D is selected,

4,000 people will die • 1/3 probability that no one (0) will
(100% guaranteed) die; and
• 2/3 probability that 6,000 people
will die
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Other Aspects of Risk

• Risk Aversion (Kahneman* & Tversky, 1979)

“Human tendency to prefer avoiding losses to acquiring equivalent gains.”

• Losing $0.05 vs. Gaining $0.05

* Danial Kahneman was awarded the Nobel Prize in economics in 2002.

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System Safety Management

Hazard identification

System Safety Management involves … Risk management

“All plans and actions taken to identify hazards; assess and mitigate
associated risks; and track, control, accept, and document risks encountered
in the design, development, test, acquisition, use, and disposal of systems,
subsystems, equipment, and infrastructure.”
(MIL-STD-882E, Standard Practice for System Safety)

System components and

operating environments
System lifecycle

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Safety Management System

Safety Goal of a System

• To manage risks of the system under an acceptable level

But how?
• Through continuous and systemic efforts to manage risks of the system

Safety Management System

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 Safety Management System

• Establish safety goals of the system

The P-D-C-A Cycle (Edwards Deming) • Develop an organizational structure
and process
• Identify hazards and assess risks
• Take corrective actions
• Develop control measures
• Modify and update safety
• Determine activities, procedures,
management system goals
programs, and resources
and process

• Monitor and measure whether

plans are executed as intended
• Implement safety plans,
• Evaluate whether safety goals
procedures, and programs
have been achieved
• Review effectiveness of safety
organizations and programs
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Safety Management System Elements

US OSHA Safety and Health Management System

1. Management commitment and leadership

2. Employee participation

3. Hazard identification and risk assessment

4. Hazard prevention and control

5. Education and training

6. System evaluation and improvement

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Safety Management System Elements

1. Management commitment and leadership

• Commitment of managers at all levels to safety

• Make safety a top organizational ‘value’

• Provide resources to implement safety plans and

programs

• Demonstrate commitment to employees and others (e.g.,

customers)

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Safety Management System Elements

2. Employee participation

• Make employees participate in designing,

implementing, and evaluating the safety
management system

• Make employees participate in investigating

incidents and making recommendations for
improvement

• Incorporate employees’ skills and knowledge to manage risks

• Take employees’ safety concerns seriously (e.g., near-miss reporting)

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Safety Management System Elements

3. Hazard identification and risk assessment

• Make use of all sources of information to identify hazards

and assess risks

• Integrate findings from worksite inspections, job safety

analysis (JSA), incident investigations, inputs from
employees, and other techniques

• Assess and prioritize risks, considering the effectiveness of

current controls

• Continuously monitor and respond to the introduction of new hazards

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Safety Management System Elements

4. Hazard prevention and control

• Identify and evaluate control options for

workplace hazards

• Select effective and feasible controls to eliminate

hazards or reduce risks

• Implement control measures in the workplace

• Follow up to confirm the control measures are being

used and maintained
Lock out/tag out (LOTO)

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Safety Management System Elements

5. Education and training

• Ensure all employers and employees have sufficient

safety knowledge and skills

• Enhance awareness of workplace hazards and how to identify, report, eliminate, or

control them

• Provide specialized training for whose who are exposed to particular hazards
(e.g., a person handling toxic chemicals)

• Evaluate whether education and training programs are effective, timely, and up-to-date

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Safety Management System Elements

6. System evaluation and improvement

• Determine whether the safety management system is operating as intended

• Identify and correct deficiencies in the safety management system (e.g.,

auditing, periodic review)

• Pursue continual safety improvement by

tracking safety conditions and metrics

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Thanks

Q&A