What’s Inside• Leadership Message02

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• ESP Background What, why & who

• Importance What is in it for me?

• Relevance What is my role?

• Gasco’s Methodology How are we doing it?!

• Customer’s Feedback

• ESP Pyramid

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Leadership Message

The 2nd Edition of our Process Safety Bulletin has incorporated your overwhelming feedback, while keeping the simplicity and structure as its signature.Ensure Safe Production (ESP) acronym might be new for us. But most of its components are alreadybeing practiced in Ruwais since long. We take it as an exciting opportunity to benchmark against the best in global industry and follow their trail towards achievingexcellence. We expect our Operational leaders and their teams to contribute their wealth of knowledgeand personal experience in this journey, which is paramount in delivering adherence & assurance ofprocess safety excellence within GASCO.

This bulletin covers 5 out of 9 ESP components & share the incidents, which taught their importance. I assuremy full commitment to this objective & urge all Ruwais team to gear up for this exciting ride ahead.

VP

“Leaders create cultures by what they systematically payattention to. This can mean anything from what they notice

and comment on, to what they measure, control, rewardand in other ways systematically deal with - Edgar Schein”

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I am glad to hear your feedback on the last issue and hope you find this issue as useful as the last one. Technical team has a very strong “navigator” role to perform in ESP. Starting from configuring the targets, to analyzingexcursions in operating windows & making sure the integrity limits are never breached, my team is ever involved. Ensure Safe Production constitutes a major portion of Operating Integrity framework (See figure on Pg 05) designed to operate asset safely. Being a socially responsible organization, we continually seek to share our best practices across the fence & learn from incidents that occurred internally & externally. It is only thru incorporating these learnings, we can stay up to date with technological progress and keep our safety barriers strong, round the clock on an evergreen basis. Ensure Safe Production in particular and Process Safety management in general, requires our utmost focus, active engagement and up-to-date competence, for which me and my team are ever committed.

Operations have the lead role in Ensure Safe Production. Being on the fore front, it is our job to make sure that processing plant operation remains within well defined & understood limits. Multiple serious process safety incidents have shown that human error is the most recurring primary cause or contributor, resulting in both initiationand/or escalation of an accident. ESP is designed to support the operator by providing sufficient information, training& tools to avoid/minimize abnormal situations. If, however, an abnormal situationdoes come, different layers of protectionare adequately available to mitigate/normalize the risk back under control. Adhering to ESP guidelines, will further strengthen our resolve of “no harm to people”by keeping “hazardous substances within process equipments, which are designed to keep them safely”. I welcome you on this exciting journey and request to join hands with us, as we progress towards a safertomorrow!

ORT ORO

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ESP Background

What

“Ensure Safe Production” (ESP) is a basic, standardized, operational framework thatensures plant operations within well-defined, well-understood limits. Goal is to ensure; “We know our limits and everythingruns within those limits all the time!”

Why

American Institute of Chemical Engineers (AIChE) created the Center for ChemicalProcess Safety (CCPS) in 1985 after the chemical disasters in Mexico City, Mexico,and Bhopal, India. The CCPS is chartered to develop and disseminate technical information for use in the prevention of major chemical accidents. One of their most celebrated book “Guidelines for Risk Based Process Safety, CCPS, 2007”

was produced in response to the fact that many organizations continue to be challenged by inadequate managementsystem performance, resource pressures,and stagnant process safety results.To promote process safety management excellence and continuous improvementthroughout industry, CCPS created risk-based process safety (RBPS) as the framework fornext generation of process safety management.

Brightest minds of industry pointed out the pivotal importance of developing andsustaining high standards in the Conduct OfOperations or Operational discipline.Execution of operational and management tasks in a deliberate and structured manner isan absolute must for any organization, in its pursuit of excellence in Process Safety. Thisfundamental concept evolved in to the formation of Ensure Safe Production (ESP)program, designed to minimize human errorand variations in performance.

COMMIT TOPROCESS SAFETY MANAGE RISK

UNDERSTANDHAZARDSAND RISK

Proc

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y Cu

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Com

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nce

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and

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Safe

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PROCESS SAFETYMANAGEMENT SYSTEM

Cont

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LEARN FROMEXPERIENCE

CCPS Risk Based Process Safety

Figure Source: Guidelines for Risk Based Process Safety, CCPS

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How

ESP explains basic standards for “Safe Operations” by clarifying “expectedbehavior”, based on continuous situational awareness.

The Ensure Safe Production work process is build around a number of key concepts:

• Operational limits must be known and should be within all engineering limits. Engineering constraints, Operational limits and predefined responses to Exceedence must reside in a single repository.

• Philosophy change from “machine calls man” to “man is ahead of machine”

• Traditional pre-alarm disappears, as a result of proactive monitoring rounds

• Any deviation from a Safe Limit, follows a simple alarm hierarchy and has a predefined, accessible response

• Proactive instead of reactive operation, always aware of situation. It is not acceptable to wait for an alarm to get aware of an abnormal situation.

• Every operator›s duty is to independently take (predefined) measures to get the process back into safe limits, including shutting down. Leadership shall fully support this through unconditional empowerment of all operators.

• Elimination of “normalization of the deviance”, whereby no abnormal situations are considered normal after sometime.

• Embedding the work process in management systems (such as organograms, job descriptions, procedures etc.), including accountable owners of (various parts of) the work process.

• Management measures performance by simple KPIs.

Normalization of deviance is defined as: “The gradual process through which unacceptable practice or standards become acceptable. As the deviant behavioris repeated without catastrophic results, it becomes the social norm for the organization.”

GA

SCO

ESP

Ope

ratin

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tegr

ity

Shift log reportand records.

Shift handover and

Orientation

Shift TeamMeeting

OperatingProcedures and

Work instructions

Statement of FitnessPCM Registers Isolation

of Energy

OperatingWindows

AlarmManagement

Override ofSafeguarding

System

Management Abnormal Situations

ProactiveMonitoring

GA

SCO

ESP

Ope

ratin

g In

tegr

ity

Shift log reportand records.

Shift handover and

Orientation

Shift TeamMeeting

OperatingProcedures and

Work instructions

Statement of FitnessPCM Registers Isolation

of Energy

OperatingWindows

AlarmManagement

Override ofSafeguarding

System

Management Abnormal Situations

ProactiveMonitoring

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Importance

What’s for me?

ESP helps maximize an organization’s value to all of its stakeholders. It focuses on improvinghuman performance - as an individual and as an organization - by establishing clearexpectations and consistently performing tasks in accordance with those expectations. In other words, it helps establish a culture in which deeds match words.

Many different industries and organizations have implemented ESP in particular and Operational Discipline systems in general and have universally seen their performance improve as a result. The proven benefits include:

Improved Safety Performance

High Motivation & team work

Creativity & subsequent Profitability

High morale of organization

Improved emergency handling

High levels of service

Procedural awareness and compliance

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Relevance

My Role

• Emergency Procedures• Proactive monitoring• Alarm KPI’S and analysis• Operating within limits

OPERATIONS • Effective RCA & proactive techniques• Plant integrity• Process Equipment integrity• Maintenance Excellence

MAINTENANCE

• Inherent design Safety• Risk assessment• Steward Alarm management• Compliance to RAGAGEP• MOC

TECHNICAL SERVICES • HSEIA• HSE-MS• Audits• Leading/ Lagging indicators

HSE

Key Terminologies:

RCA Root cause analysis

KPI Key performance indicators

MOC Management of Change RAGAGEP

HSEIA

HSEMS HSE Management System

HSE Impact assessment

Recognized and generally accepted good engineering practices

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Discussion

1 The foundation of good operations is about getting “Everyone on the same page”, All components of lower layer are tailored to ensure that incoming shift has 100% situational awareness on key issues e.g. Operations, HSE, Overrides etc.

2 Second layer is meant for “knowing the limits” of a Process. Be it alarm limits, operating windows or safeguarding system, all limits must be adhered to at all times. Procedures must be in place for guidance on deviation controls, actions & authorizations. Good understanding of limits also eradicates normalization of deviance, by continually challenging current conditions against process limits, rather than experience.

3 Proactive monitoring is the centerpiece. The goal is to monitor and control unit and equipment, so as to avoid exceeding a safe limit while meeting all operational and business targets

4 Abnormal Situation management requires smooth handling of HSECES non-availability, reduced manning, impaired competence, external risks & operating window exceedences.

ESP Pyramid

Situational Awareness Stage

Monitor & Control Stage

Abnormal Situation Management

Proactive MonitoringProactive Monitoring

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Shift log reportand records.

6Shift handover

andOrientation

7

Shift TeamMeeting

8Operating

Procedures andWork instructions

9

Shift log reportand records.

6Shift handover

andOrientation

7

Shift TeamMeeting

8Operating

Procedures andWork instructions

5

OperatingWindows

3

AlarmManagement

4Override of

SafeguardingSystem

5

OperatingWindows

3

AlarmManagement

4Override of

SafeguardingSystem

1Management

Abnormal Situations

1Management

Abnormal Situations

ProactiveMonitoring

2

ProactiveMonitoring

2

Abnormal Situation Management

Monitor & Control Stage

Situational Awareness Stage

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An abnormal situation is one where a process variable (flow, pressure, temperature, concentration, level etc.) goes outside its operating envelope and, if not brought undercontrol by appropriate response, may escalate to an emergency situation (e.g. loss of containment).

It is essential to implement measures, which reduces residual risk to ALARP/tolerable level. In GASCO these cover 06 categoriesessentially;

Management of Abnormal Situation

PEOPLEPROCEDURES

PLANT DOWNGRADED CONDITIONS INCREASED RISK

(Inherent+External)system

override

OPERATING WINDOWEXCEEDENCE

MAINTENANCEOVERRIDES

The input to the Longford gas plant is a mixture of gas, light hydrocarbon liquids and water. The components of the mixtureare separated in a complex process of heating, cooling and pressure changes. The morning of the accident, a severe process upset caused an automatic shutdown of the circulation of “lean” oil which warmed the plant. This caused a heat exchanger to become extremely cold about – 50 degrees C.The operators and their supervisors thenmade a critical error – they decided to

reintroduce the warm oil into the heat exchanger after it had become super cold. Just like a cold glass shatters, if boiling water is poured into it; a metal which has been chilled below freezing temperature becomes brittle and can fracture in the same way, if suddenly warmed. This is exactly what happened on the day of the accident. Exchanger fractured in a catastrophic way,allowing huge quantities of hydrocarbons to escape, find an ignition point and catch fire.Inability to handle the abnormal situation ledthe company to a crippling catastrophe.

Incidents that taught Abnormal Situation Management - Esso Longford

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Operator Proactive Monitoring

PRACTIVEMONITORING

Product QualityObservations

PipelineSurveillance

Area Operatorrounds

DCSmonitoring

EquipmentCondition

Monitoring

Objective is to ensure that facilities are proactively monitored, so as to retain best possible level of situational awareness. This promotes early detection & appropriate intervention to an arising abnormal situation. This monitoring involves field operator, Paneloperator and monitoring by Technical

personnel as well. Each position has an important role to play, since monitoring duplication is rare. An abnormal sound in the pump, a broken stem of a control valve or deteriorating performance of a column – all are picked up by relevant discipline andworked upon to avoid a process upset.

In the predawn hours of March 28, 1979, a pressure valve suddenly malfunctioned at the Three Mile Island nuclear power plant near Harrisburg, Pennsylvania. The accident startedat the plant’s Unit 2 reactor when a small pressure relief valve failed to close, causing cooling water to drain from the nuclear core. The core (fuel) quickly began to overheat.

Ineffective field and panel monitoring and confusing instrumentation led the operators to believe that relief valve was closed and too much water was being injected into the

reactor vessel. So the plant operators shut off the emergency water system that would have cooled the core and prevent an accident.What occurred next was a combination of technical failure, human error, and bad luck that resulted in the worst nuclear accident in American history. For five nerve-wrackingdays, engineers struggled to control arunaway reactor, government officials debated whether to evacuate the area, and residents contemplated the ultimate horrorof a nuclear meltdown.

Incidents that taught Proactive Monitoring - Three Mile Island

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Alarm Management

Alarm management is meant to define and verify limits and alerts. Whenever an alarm becomes active there should be sufficienttime to respond. It also requires

consideration of human factors, along with adequate design & architecture of the alarm system in order to direct the operator attention.

A huge explosion and subsequent ensuing fires disrupted the silent town on July 24, 1994 atMilford Heaven, UK. An abnormal situation occurred at site because of electrical storm.

Poor handling of that situation led to release of about 20 tonnes of flammable hydrocarbon,which formed a huge vapour cloud, that found

an ignition source from nearby flaredrum.Direct causes of the incident were attributedto poor design, maintenance, training andmanagement of alarm system.

Incidents that taught Alarm Management - Texaco Refinery

AlarmPhilosophyDocument

NoUnnecessary

Alarms

OperatingWindow

Definition

Training &Information

of Users

Audits

Top 10Alarms &Resolution

Alarm/LimitDatabase

Alarm OffRegisters

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Disabling an alarm or safeguarding device (instrumented or non instrumented) needs to be authorized by to appropriate level depending on the risk level. High risk will lead

to stabilizing, slowdown and shutdown of production. Current facility status needs tobe clear to operations and management..

Disaster initiated from a Hydrocarbon leak thru pipe work connected to a condensate pump. A safety valve had been removed from this pipe work for overhaul and maintenance.The pump itself was undergoing maintenancework. When the pipe work from which the safety valve had been removed was pressurized at start-up, the leak occurred from removed PSV flange.

Automatic fire water deluge system was put on manual due to a job that occurred earlier that day. After completion of job, system was not taken back in service, which resulted in absence of an important mitigation system.

CloseoutImplementationAnd Monitoring

Risk EvaluationAnd Approval Identification

Incidents that taught Prevention of Unnecssary Overrides - Piper Alpha

Override of safeguarding systems

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Shift team meeting & communication It ensures thorough understanding, awareness,confirmation of current plant status & discussion on way forward. Non-complianceto this requirement makes Operations vulnerable to Process Safety Incidents.

Most paper mills use chlorine dioxide (Cl02) to bleach pulp. The RIO Cl02 process requires the mill to periodically take a short outage to “boil out” for improving efficiencyof the Generator and an opportunity to perform maintenance activities on otherparts of the Cl02 process. After the boilout is complete, liquor is transferred back to the generator (reactor) and the process is restarted.

During a routine boilout, mill managementelected to do some maintenance work on the filtration system, requiring that the system be isolated, drained, rinsed, and

opened up. The work was executed safely.However, dayshift personnel failed to close one of the drain valves on filter. When evening-shift personnel arrived at 6:00 p.m., day-shift personnel reported that they had restarted the process and that it was almosttime to bring the filter online.

During the turnover, there was no mention of the work done on the salt cake filter, and there was no record of it in the shift log.

Assuming that all valves were in their normal position, night-shift personnel brought the salt cake filter online in the standard manner,causing an immediate release of C102 solution. Fortunately, the release was promptly detected and the line was isolatedwith no injuries or harm to the environment.

CURRENTCONDITION FUTURE PLAN

• Planned Maint• Training, Manpower• Activity Prioritization• Adjoining Facilities

Out going In Coming

• HSECES PMs• Compliance Audits• Planned Mitigations• Foreseen Issues

• Instructions• Special Monitoring• PTW Details• Ongoing Maint• Housekeeping Needs

• Safety issues• HSECES Functions• Safety/Environment issues• Production Targets• Production Issues

Incidents that taught Importance of Communication - Paper mill Accident

Shift team meeting & Communication

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Ensure Safe Production

Gasco’s Methodology

GASCO is in the process of ESP roll out at all sites. However, both strategic and operational guidance documents have been formulated& being practiced.

Objective is to shift from “machine calls man” to “man is ahead of the machine“, therebypromoting proactive actions.

Pre-alarm is removed, to optimize total number of alarms. Alarm exists only when anAction has to be taken.

Every operator’s duty is to autonomously take measures to get the process back into safe limits, including slowing or shutting down. Leadership fully supports this throughunconditional empowerment.

Operators run the plant, know their equipment,understand and manage the limits in operations

In the strategic document, ESP is introduced & further subdivided in nine distinct activities, each described in a separate manual.

ESP APPLICATION MANUAL STRATEGIC GUIDANCE

GASCO - RUWAIS - OPERATIONS

ENSURE SAFE PRODUCTION (ESP) - ASSOCIATED TASKS FOR OPERATIONS - 2015ACTION BY TARGET

1

2ALARM

MANAGEMENTSYSTEM

ALARM OPTIMIZATIONREPORT OF ACTIONTO BE TAKEN ONAN ALARM

ON THE ALARM DISPLAY, WHENAN ALARM IS CLICKED - ADIALOGUE WINDOW WILL OPENDESCRIBING THE ACTION TO BEDONE. ALL CRITICAL ALARMS WILLHAVE THIS WINDOW.

TRAIN 1-PROCESS

TRAIN 2-PROCESS

TRAIN 3-PROCESS

TRAIN 4-PROCESS

UTILITY-TRAINS-

1/2/3,TRAIN 3BOILERS

UTILITY-TRAINS-4TRAINS 4BOILERS

SRU -53/59/45

SWS/FLARESYSTEMS

PROPANESTORAGE

BUTANESTORAGE

PNSTORAGE

JETTY-BERTHS1/2/3

Waiting forclearificationfrom Inst-Systems engg

ongoing

DCC ADAD B BC

PANEL OPERATORS TO REPORT IN THE PANEL LOG BOOK AS TOTAL NUMBER OF ALARMS RECEIVED AND NO OF ALARMS PERHOUR, TRAINS 1 & 2 ALARM REPORTS ARE TO BE SEGREGATED AND REPORTS TO BE FILED SEPERATELY. SEPARATE AMS REPORTSCAN BE GENERATED FOR EACH TRAIN. Weekly reports are being generated by Process Control Team with CAUSE & EFFECT studyreport with corrective actions are being generated by OEs.

OPERATIONS AND PROCESS CONTROL JOINT STUDY

BASHIFT GROUPS WILL GENERATETHE ‘ACTION TO BE TAKEN’ FOREACH CRITICAL ALARM

NO OF ALARMS PER HOURRECEIVED IN EACH PANEL-AREAWISE (ALARM/HR/AREA OR TRAIN)

RATIONALIZATION STUDY TO BEDONE. FIRE AND GAS ALARMS ARETO BE SEGREGATED.

TO REACH IEEU STANDARDOF 6 ALARMS/HOUR/OPERATOR WITH A STRETCH TARGET OF 4

TRAIN 4 ALARMTATIONALIZATION

ALARM OCCURENCES

ALARM OPTIMIZATION

3

4

ACTION DETAILSOBJECTIVEPURPOSE

Customer’s Feedback

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No

No

No

No

No

No

No

Disappointing Exceptional

Thanks, for providing your valuable feedback.

Aamish J. Khan, CSP

Asset Integrity Engineer

aakhan@gasco.ae

GASCO Ruwais

1 2 3 4 5

1 2 3 4

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Vision behind the bulletin is to “Promote Process Safety knowledge at all level of organization”. We intend to do this by clarifying concepts, emphasizing its importance, publicizing roles and responsibilities expected - in an easyto understand way.

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Gasco’s Methodology Learnt (Continued)

18

Aamish Khan, CSPAsset Integrity Engineer

Ruwais Plant DivisionP.O.Box 665Abu Dhabi Gas Industries Ltd (GASCO)Abu Dhabi, UAE