SAChE® Certificate Program Level 1, Course 4: An Introduction to … · 2020-05-19 · SAChE®...

Copyright ©American Institute of Chemical Engineers 2016. All rights reserved.

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SAChE® Certificate Program

Level 1, Course 4: An Introduction to Managing Process Safety Hazards

Unit 2 – Process Safety Culture

Narration:

[No narration]


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Objectives

Narration (male voice):

This is the second unit in the “An Introduction to Managing Process Safety Hazards” course. By

the end of this unit, titled “Process Safety Culture,” you will be able to:

• Identify the characteristics of a good process safety culture.


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SECTION 1: The Process Safety Culture Element

Narration:

[No narration]

Section 1


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The Process Safety Culture Element


Process Safety Culture is one of the elements above the Commit to Process Safety foundational

block in the Process Safety Management System.

The original models of process safety management did not show process safety culture as an

independent element even though the phenomenon was realized to be a contributor to many

major incidents.


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Texas City Incident Revisited


The BP refinery incident in Texas City in 2005 brought the aspect of process safety culture to the

attention of the Chemical Safety Board in a significant way, for arguably the first time.

Narration (female voice):

Click the Play button on the video monitor if you would like to revisit the Texas City incident by

watching an animated recreation of the event produced by the Chemical Safety Board.


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Texas City disaster video (Slide Layer)


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Process Safety Culture – Defined


One of the ways the Center for Chemical Process Safety (or CCPS) views process safety culture is

that it is “the combination of individual and group values and behaviors that determine the

manner in which Process Safety Management (or PSM) is managed. It underlies and supports

everything that happens in a PSM program.”


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Process Safety Culture – Defined (continued)


CCPS also states:

“This element has no direct corresponding element in OSHA PSM or Environmental Protection

Agency Risk Management Plan (EPA RMP) programs or state regulatory PSM programs; however,

process safety culture is recognized to be a critical foundation for a successful PSM program.

Process Safety Culture is an element of the Risk Based Process Safety (RBPS) accident prevention

block, Commit to Process Safety.”


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1.8 Effective Culture


Effective culture involves a wide spectrum of involvement. The organizational group involves a

collection of people either at the company or facility level, including senior management, middle

management, supervisory personnel, and non-management personnel. They will all hold the

same beliefs, expectations, attitudes, and behaviors that would benefit the group in supporting

the goal of managing process risk.


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Detailed Instructions are Insufficient


CCPS notes that while PSM-related management systems and their associated policies and

procedures can include adequately detailed instructions that properly reflect the desired intent

of the organization, that’s not enough.

Successful execution of those procedures requires that properly trained individuals:

• Understand the importance of the underlying intent;

• Believe in the reasons for the procedures and what they require;

• Accept their responsibility under the procedures; and

• Appreciate that taking an unacceptably risky shortcut would be wrong and inconsistent

with the values of the group.


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Characteristics of a Good Process Safety Culture


An organization with a good process safety culture will exhibit the following characteristics:

• Maintains a sense of vulnerability;

• Empowers individuals to successfully fulfill their safety responsibilities;

• Defers to expertise;

• Ensures open and effective communications;

• Establishes a questioning and learning environment;

• Fosters mutual trust; and

• Provides timely response to process safety issues and concerns.


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SECTION 2: Identifying Process Safety Culture

Narration:

[No narration]


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Common Cultural Deficiencies


Investigations of catastrophic incidents have shown a common thread of similar repeating

cultural deficiencies:

• Lack of clear expectations and enforcement of high standards regarding PSM are lacking

(in other words, little or no accountability);

• PSM activities devolve into “check-the-box” jobs;

• Diminished or no sense of vulnerability with respect to operations on the part of facility

and/or company personnel;

• Open and effective communications in the organization are lacking, either vertically,

horizontally, or both;

• Timely responses to, and resolution of, PSM issues and concerns do not occur; and

• The normalization of deviance is allowed to become acceptable status quo.


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Normalization of Deviance


You may have noticed the term “normalization of deviance” on the previous slide. Here’s an

example of a situation in a process plant; it didn’t even involve an incident, yet perfectly

illustrates the concept.

The photograph shown here shows a compromised fire water valve. There are a number of

deficient PSM elements in play here, not the least being Process Safety Culture. Click the

numbered tabs beneath the image to explore these elements.


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Asset Integrity (Slide Layer)

[When Tab 1 is clicked…]


First off, Asset Integrity comes into question. You would expect that this is critical safety

equipment that needs periodic inspection. As this vegetation growth appears to be a long time

in the making, it looks like inspections haven’t happened in years.


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Audits (Slide Layer)



Audits also are suspect. Was this never picked up?


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Emergency Management (Slide Layer)



If Emergency Management procedures include an inspection of items like this, then that

element is deficient also.


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Process Safety Culture and Workforce Involvement (Slide Layer)



Process Safety Culture and Workforce Involvement can’t be satisfactory - it’s hard to believe

that many people haven’t passed right by this situation.


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Process Safety Competency (Slide Layer)



If nobody in the facility recognizes this is a problem, then there’s also a Process Safety

Competency issue.


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After all tabs visited (Slide Layer)

[When all five tabs have been clicked…]


This looks like the type of facility where the recommended remedial action would be to hang a

garden lopper on the tree with a sign that reads “To be used in case of emergency.” You can see

where the culture issue is impacting the deficient elements you just examined.


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Values of the Group


The values of the group can help shape the attitudes of the individual. The culture should help

individuals understand why strict adherence to procedures is the “right thing to do.”


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Audit of Process Safety Culture


A meaningful audit of process safety culture is more difficult than examining other PSM program

elements. It will involve collecting a large number of opinions based on personnel “feelings”

rather than just collecting objective facts.

The audit survey needs to take place across the hierarchy of the organization. It’s very possible

that different responses to a question, such as “Does the facility maintain a sense of

vulnerability with respect to the PSM hazards that exist?” will be elicited from the corporate

management, plant management, or shop floor levels of the organization.


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Learning from the Past


An organization with a strong process safety culture is very likely to make effective use of

lessons learned from previous non-catastrophic incidents.

CCPS states that:

“A facility with an effective process safety culture will display an excellent process safety record

and is more likely to recognize and attend to catastrophic incident warning signs when they

appear.”

The opposite would hold for a weak process safety culture.


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Leadership and Cultural-Related Warning Signs


CCPS has listed in the Concept Book, “Recognizing Catastrophic Incident Warning Signs in the

Process Industries,” this list of key leadership and culture related warning signs.

Please take a few minutes to read through the list now. Be sure to read all of the items by

scrolling to the bottom. You can learn more about the Concept Book by clicking the book icon.


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Example of Poor Process Safety Culture


Consider another example of a situation in a process plant, which again didn’t even involve an

incident, yet has culture as a strong causal thread.

The photograph on the left shows a new rotameter. The other picture shows what happened

when a rotameter was exposed to excessive pressure at high temperatures. In this case, the line

downstream of the rotameter had a history of plugging. Several times in the past, 150 psig

steam was used successfully to clear the plug. When it plugged again, steam was used but this

time the outcome was different.

The rotameter was rated for 175 psig at 200 degrees Fahrenheit. At 360 degrees Fahrenheit, the

rating drops to only 80 psig. Steam used to clear the plug was 150 psig and 360 degrees

Fahrenheit. The rotameter failed because it could not withstand the steam pressure at the

elevated temperature.


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Description of Rotameter (Slide Layer)


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Example of Poor Process Safety Culture (continued)


Using steam to clear this line had been done many times in the past but was officially

discontinued approximately two years before. However, it was practiced "unofficially" during

off-shifts.

The supervisor was uncertain of the pressure rating of the piping and rotameter and had second

thoughts. When he saw that the steam hose was already connected, he decided to proceed.


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PSM Deficiencies


As with so many process incidents, there are a number of deficient PSM elements in play here,

not the least being Process Safety Culture. Click the numbered tabs beneath the image to

explore these elements.


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Process Safety Culture (Slide Layer)



Very significantly, Process Safety Culture is in question, considering the “unofficial” off-shift

practice. As you explore the other tabs, note how the deficient culture is seen to be

contaminating all the other elements highlighted here.


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Process Safety Competency (Slide Layer)



Process Safety Competency may have been at fault if the inverse temperature/pressure

relationship for the rotameter was not on file.


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Training (Slide Layer)



Training was at fault because the operators did not understand they would be above a safe

temperature/pressure for the rotameter and were possibly not told that the procedure was

disallowed.


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Management of Change (Slide Layer)



Management of Change comes quickly to mind. The supervisor, without consultation, but with

doubts, decided nevertheless to proceed with a discredited operation.


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Operating Procedures (Slide Layer)



Operating Procedures should have indicated the accepted method to clear the line.


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Metrics to Assess the Application of PSM Elements


There are leading metrics that an organization can use to assess how effectively it’s applying any

of the PSM elements. Here are several to assess Process Safety Culture:

• Number of open recommendations (from risk analyses, incident investigations, audits,

and safety suggestions);

• Frequency with which upper managers visit the workplace, or percentage of the

scheduled visits that actually take place;

• Percentage of near misses and incidents identified as being caused by unsafe acts or

shortcuts;

• Percentage of the required attendance achieved for meetings addressing process safety;

• Average response time to the resolution of a process safety suggestion;

• Number of meetings addressing process safety that are conducted per year;

• Frequency with which relevant process safety statistics are shared with the

organization; and

• Number of process safety suggestions reported each month.


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Example: Space Shuttle Challenger


Finally, CCPS offers the NASA Challenger disaster as an example of how a deficient safety culture

can lead to catastrophic results (although this was not a process safety event in a strict sense).

In January, 1986, the space shuttle Challenger exploded 73 seconds after launch, resulting in

complete destruction of the vessel and loss of the entire seven-person crew. The event was

attributed to faulty O-rings, which allowed hot combustion gases to escape, burning through

rocket supports, which caused the rupture of the fuel tank and subsequent explosion.

There had been evidence of O-ring damage on prior flights but no further adverse effects, so

some minor assembly changes were made but no design upgrades were done. Since there was

great pressure to maintain the launch schedules, managers came to accept this situation as

manageable, effectively normalizing the deviation.


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Part 2


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Part 3


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Example: Space Shuttle Challenger (continued)


On the day of the launch, temperatures were colder than the O-rings were ever tested for. The

manufacturer’s management suggested a postponement, but under pressure from NASA,

agreed that the launch could proceed. This agreement was given against the advice of the

manufacturer’s engineers. A reading of this catastrophe’s history will show the presence of quite

a number of the culture issues we discussed earlier in this unit.

An event like this will inevitably change the safety culture of an organization, but no one would

ever accept it having to happen that way.


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Part 2


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Unit 2 Summary


We’ve reached the end of the second unit in the “An Introduction to Managing Process Safety

Hazards” course. Having completed this unit on “Process Safety Culture,” you should now be

able to:

• Identify the characteristics of a good process safety culture.

In the next unit, we’ll examine the Management of Change element in the Manage Risk

foundational block.

SAChE® Certificate Program Level 1, Course 4: An Introduction to … · 2020-05-19 · SAChE®...

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Transcript of SAChE® Certificate Program Level 1, Course 4: An Introduction to … · 2020-05-19 · SAChE®...