Have We Really Learnt From Process Safety Accidents?reeforum.org/downloads/D R - Have We Really...

Rajender Dahiya, CSP, MIChemE-PPSE Sr. Technical Services Manager AIG Global Property Engineering

AIG Global Property Engineering

Have We Really Learnt From Process Safety

Accidents?

REEF Meeting, Houston July 8, 2016

2 AIG Global Property Engineering

About Rajender

Rajender has more than 24 years of extensive international experience working in India, Saudi Arabia, Kuwait,

Canada and USA in large petrochemicals, oil & gas and insurance industries in diversified cultures.

As a subject matter expert, provided process safety and risk assessment/management technical expertise to senior

management, technical safety experts, project managers and operating personnel at corporate, major projects and

operating sites globally for upstream onshore/offshore, midstream/downstream refinery, petrochemicals, pipelines,

and power plants.

His key expertise are; loss prevention insurance surveys, PSM, PHA/HAZOP, LOPA, Bow-Tie, consequence

modelling, inherent safety, design safety, fire protection, risk assessment & management, audits & inspections,

process safety training, incident investigation, safety cases etc. Inherent safety application in projects and operations

is his passion.

He has presented in national and local process safety & HSE conferences. Rajender volunteers for an international

humanitarian organization, “Art of Living”; The Mission is to creating a stress free and violence free society.


Why I Chose This Topic?

Process Safety accidents cost Billions of $$$$ every year

Substantial insurance claims

Loss of Life, Property and Business

People are looking for help

Engineering & Design

Operating facilities

We can make a difference

We are very much visible across the globe

Our words work, make noise

We have the power to influence


Agenda Overview of Major Process Safety Accidents

Most Common Learning

Bhopal Accident Review & Comparison (32 years)

What has changed and what NOT?

Key Issues & Focus on Accident Prevention

Major Gaps & How Can We Help

Engineering & Design Stage

Operating Stage

Path Forward

Conclusion

Overview of Major Process Safety Accidents

What is Process Safety?

Let’s Look Back

What was Most Common in All?

Bhopal Accident Review

What has changed and what NOT?


What is Process Safety?

A safety management system approach focused on the prevention and mitigation of

catastrophic releases of chemicals or energy from a process associated with a facility.

Process Safety focuses on:

Technology

Facilities

Personnel

Process Safety Accidents:

Low Probability and High Consequences.

Causes may not be visible like occupational safety accidents.


Let’s Look Back


Many more……


What was Most Common in All? All were process safety accidents

They were preventable

Learning’s were shared

There were several precursors (warning/weak signals) before these major accidents

Good occupational safety records

Consequences: loss of life, environment and property damage

Mutual root causes

Management failure to identify and manage the risks of highly hazardous materials and processes.

Management failure to maintain the integrity of the safety critical equipment & systems.


Process Control

Safety System

Alarms & Response

Runaway Reaction

Mechanical Integrity

ESD Relief System

40 tons toxic gas

release - MIC

>20 K fatalities

100s thousands

injuries

Emergency response

F&G

detection

Water Spray

Flare system

Caustic Scrubber

Bhopal Accident – 1984

Prevention Mitigation

Offsite alarm

Several smaller incidents occurred before this disaster. Leaders, managers, employees, union,

public, media were aware about this risk Truth None of these Safeguards Failed


What Has Changed – Enormous Developments Regulations & Industry Standards

Tools and Techniques – HAZID, PHA, QRA, 3Ds, Simulations …

R&D – hardware, software, materials, QA/QC, process technology

Technology and Reliability – instrumentation, automation

Global e-learning – industry, training, regulations, google guru …..

Culture and behavior – has improved but more dependent on technology

Management think; Engineers will take care,

Engineers think standards and technology will take care……….

Complex Tools – Too Much Information


Compare 1974 – 2016 (42 Years) Inherent hazards Toxic, flammable, explosive, Rx.

Onsite & offsite impact People, property, env.

Culture Production vs Safety, Cost cutting

HIRA HAZID, PHA, MoC

Application of hierarchy of controls Depends on last resort

Reg. & Mgmt. systems gaps Regulatory oversight – Overlook of recs.

Safeguards availability Inspection, testing, maintenance

Incidents investigation Learning


Learning Opinion Poll

Have we really learnt from these accidents?

A. Yes

B. No

C. A & B

KEY ISSUES & FOCUS ON ACCIDENT PREVENTION Major Gaps & How Can We Help

Engineering & Design Stage


Key Issues - Challenges

Competency

Culture

Quality


Accident Prevention

Engineering Activities Maintenance Activities Operations Activities


Major Gaps & How Can We Help?

Process safety in design philosophies

Standards and specifications

Process safety activities at each stage

Hazard identification and risk assessment

Hierarchy of design solutions

Supervision and QA/QC


Ensure Quality & Consistency

Process Safety & Risk Management Project Lifecycle Approach

DBM FEED Detailed Design Construct Start-up Operations

IS: Pre-HA: HAZID: PHA: HAZOP: LOPA: SIL:

Inherent Safety Preliminary Hazard Analysis Hazard Identification Process Hazard Analysis Hazard & Operability Study Layer of Protection Analysis Safety Integrity level

QRA: PSSR: MOC: PSI: MI: OP: HFE:

Quantitative Risk Assessment Pre-Startup Safety Review Management of Change Process Safety Information Mechanical Integrity Operating Procedures Human Factors Engineering

SWP: ERP: IIR: CM: QA:

Safe Work Permit Emergency Response Plan Incident Investigation & Reporting Contractor Management Quality Assurance

PS

SR

Construction Safety PHA

HAZOP / What-If LOPA / SIL

Preliminary & Detailed Consequence Analysis

Fire Protection Engineering

Inherent Safety in Design

QRA

Inherent Safety in Design Inherent Safety in Design Inherently Safer Solutions

MOC / PSI / MI / OP / SWP / ERP / IIR / CM /Audit / Training / QA

Facility Siting

Pre-HA / HAZID

Process Safety in Design & Risk Management Document (All – In – One) Handover to Operations

IS /

MO

C /

PH

A /

QR

A / H

FE /

PS

SR

/ P

SI /

MI /

OP

/ S

WP

/ ER

P /

IIR /

CM

/ A

udit

/ Tr

aini

ng /

QA

Human Factors Engineering

GAPS

Long

list

of d

efic

ienc

ies

from

pl

ant m

anag

er to

pro

ject

man

ager

Des

ign

chan

ges

and

rew

ork


Influence for Applying Hierarchy of Controls

www.cdc.gov


Hierarchy of Design Controls – Time vs Effectiveness

Procedural

Inherent

Passive & Active

Concept DBM FEED DETAIL Construction

Best Time to Carry Out the Activity


Encourage the Application of ISD throughout the Design

IPL 1

IPL 2

IPL 3

IPL 4

Acceptable Risk

Potential RiskIn

dependent P

rote

ctio

n L

aye

rs

Unacceptable Risk

IPL Bypassed

IPL Degraded

IPL Removed

IPL Good

No IPL

Inherently Safer Process

Potential Risk

Acceptable Risk

Eliminated Minimized

Design Operation Always

KEY ISSUES & FOCUS ON ACCIDENT PREVENTION Major Gaps & How Can We Help

Operations Stage


“My Plant is Built to Codes”

Opportunities for errors and mistakes over Design, Construction, Commissioning and Start-up

QA/QC

Supply chain & contractor management

FAT and SAT

Construction and Installation

Opportunities for errors and mistakes over the life of plant Operations

Operating outside limit

Changes in set points – temporary to permanent

Lack of inspection, testing and maintenance

Critical equipment, systems and alarms bypassed, disabled, replaced, degraded

Compare the “Built to Code” and “As Operated” after 1, 2, 3 …10 years

Verify the above statement


What We Have - Operation Stage? Most companies have several management systems and tools to ensure a safer operation, eg.,

Corporate Policies

Process Safety / HSE Policy and Goals

PSM / HSE-MS / Training

Operating Management Systems

Mechanical Integrity / Maintenance systems

Risk Assessment and Management

Audit / inspection and Investigations / learning, action tracking and many more……

Is it guaranteed that accident will not happen with all these systems in place?

Measure and Continuous Improvement


Question?


Major Gaps & How Can We Help?

Operating Procedures

Procedure, training, alarms, SCE bypass, set-point change

Process Safety Training & Awareness

Management, employees, contractors

Hazard identification and Risk Assessment

HAZID, PHA, LOPA, SIL, hierarchy of control, safeguards, recommendations


Major Gaps & How Can We Help? Incident Investigation & Learning

Complex tools, operation upsets & safety system challenges, RCA – HIPOs, learning and sharing

MI of Safety Critical Equipment & Systems

List, inspection, testing, records, actions

MOC & PSSR

Risk assessment, actions closing

Performance Measurements (KPIs)

KPIs – PSM, reliability, maintenance, visible indicators to prevent accident, analysis and trending


Identify top 5 MAH using HAZID technique

Identify preventative and mitigation measures – safeguards / IPLs / barriers

Review if all MAHs are managed as per corporate risk tolerance criteria

Ensure effectiveness of management systems to ensure the integrity of safeguards

Develop a bow-tie

Print big size and make it visible – use in training, post in control / board / meeting rooms

Identify gaps if any and communicate to management with action plans

What I advise them to do…..


Sample Templates

Hazards Scenario Consequences Safeguards Remarks Fire Explosion HAZID Template

Fully Developed Bow Tie


Good News

Adequate Resources and help is available on your finger tips Chemical Safety Board (CSB)

OSHA PSM

AIChE – CCPS

Texas A&M – MKOPSC

IChemE – UK

HSE – UK

Consultants & Specialists


Not A Good News Process Safety is not a Priority – Compliance Formalities

Lack of Competency, Poorly Written Standards & Flaws in the Design

Poor Implementation of Company Standards and Procedures

Complex Tools, User Unfriendly

Lack of Quality Data & Useful Output

Too Much Information

Lack of Analysis and Learning

Design

Construction

Startup

Operations

Maintenance

Audits


Leanings & Challenges Summary Employees rewarded for violating the safety systems – production is must Process safety training for senior leaders is critical Process Safety vs. Occupational Safety – Culture Checkbox approach still prevails Inconsistent & complex processes/tools – do not deliver useful data Poorly done risk assessment and management Inadequate and complex operating procedure Mechanical integrity & availability of safety critical Repeat findings are extremely dangerous - warning signs – investigation Lessons learnt – a big voice but very little is being done in reality Training & Competency Lack of effective communication – complex & too much info; layer filters Emergency management – lack of coordination, testing & drills


Path Forward 1. Review HAZID/HAZOP reports – consequences, risk ranking and recommendation.

2. Review completed investigation reports – root causes, specific recs. & learning.

3. Check completeness of mechanical integrity of safety equipment & systems records

4. Check safety critical bypass process and log

5. Review MOC for risk assessment, PSSR and actions completion

6. Ensure KPIs are developed and improving continuously

7. Educate about hierarchy of design solutions, ISD

8. Drill down the questions & verify by documentation, interview and site visit


Conclusion Irrespective of the cause, the owner/operator is responsible for ensuring that design, safety systems and

emergency response contain the consequences of any accident with minimal damage

We know that, whatever the cause, if multiple safety systems work as designed, then the catastrophe could be avoided altogether, or be much less severe consequences

As late Professor Trevor Kletz said, “what you don’t have can’t leak” and he urged designers to adopt concepts of inherently safer plants by design

There have been many advances in process safety since Bhopal

However, inherent safety remains a philosophy that is much admired but not always practiced


3

Thank you

36

American International Group, Inc. (AIG) is a leading international insurance organization serving customers in more than 130 countries.. AIG companies serve commercial, institutional, and individual customers through one of the most extensive worldwide property-casualty networks of any insurer. In addition, AIG companies are leading providers of life insurance and retirement services in the United States. AIG common stock is listed on the New York Stock Exchange and the Tokyo Stock Exchange.

Additional information about AIG can be found at www.aig.com | YouTube: www.youtube.com/aig | Twitter: @AIG_LatestNews | LinkedIn: http://www.linkedin.com/company/aig

AIG is the marketing name for the worldwide property-casualty, life and retirement, and general insurance operations of American International Group, Inc. For additional information, please visit our website at www.aig.com. All products and services are written or provided by subsidiaries or affiliates of American International Group, Inc. Products or services may not be available in all countries, and coverage is subject to actual policy language. Non-insurance products and services may be provided by independent third parties. Certain property-casualty coverages may be provided by a surplus lines insurer. Surplus lines insurers do not generally participate in state guaranty funds, and insureds are therefore not protected by such funds.

ONE AIG

Have We Really Learnt From Process Safety Accidents?reeforum.org/downloads/D R - Have We Really...

Documents

Transcript of Have We Really Learnt From Process Safety Accidents?reeforum.org/downloads/D R - Have We Really...