process safety accidents

7/29/2019 process safety accidents

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Why We Continue To Have

Process Safety Accidents

Mark Paradies

PresidentSystem Improvements, Inc.

238 S Peters Road

Knoxville, TN 37923

865-539-2139

www.taproot.com


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Mark Paradies

President, System Improvements Seven Years in Admiral Rickovers Nuclear Navy

Nuclear Navy Engineer Qualified (Navsea 08)

MS Nuclear Eng with Emphasis on Human Factors

Process Safety Work Started in 1985 at Du Pont Co-Developer of the TapRooT System

Co-Author of the TapRooT Book

2 US & Foreign Patents for Root Cause Software

IEEE Root Cause Analysis Standard Committee

Co Author of CCPS bookGuidelines forInvestigating Chemical Process Incidents

Editor of the Root Cause Network Newsletter

Taught Root Cause Analysis Worldwide


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Rickovers Process Safety Culture

1. TOTAL RESPONSIBILITY

2. Technical competence (outstanding people)

3. Facing the facts (do the right thing despite costs)

(Total Concept - Must Work Together)

BIG THREE

www.taproot.com/wordpress/archives/16148


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4. Conservatism of design

5. Designing the plant toavoid accidents to reduce the likelihood of

the need to use emergency systems

6. Redundancy of equipment to avoid

shutdowns or activation of emergency

equipment

And these too!


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7. Inherently stable plant

with simple, direct

operator control

8. Full testing of the plant

9. Adhere to detailedmaintenance schedules


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10. Detailed operating procedures developed

by the operators, improved with experience,

and approved by the technical experts

11. Formal documentation of design and design

changes and strict change control

12. Strict control of all vendor

provided equipment with

inspections prior to acceptance


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13. Formal reporting of abnormal events(incidents) and the use of operating

experience across all plants.

14. Frequent detailed audits / inspections ofperformance by independent, highly trained,

experienced personnel that report to the top

15. Independent review of safety bygovernmental authorities

16. Personal selection of leaders (exceptionaltechnical knowledge and good judgment)


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17. One year of specialized technical trainingand practical hands-on experience prior to

first assignment

18. Advanced training and testing for more

senior assignments (Engineer, CO)

19. Extensive continuingtraining and requalification


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20. Strict enforcement of standards & disqualifi-

cation of those who violate the standards

21. Internal, frequent self-assessments


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Comparing Rickover to

PSM & NRC Safety Culture

Yes - Strong?NoFacing the facts

NoNoTechnicalcompetence

AccountabilityNoTotal responsibility

CCPS PSMOSHA PSMNuclear Navy


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NoNoRedundantequipment

Noe. Process hazardanalysis? (not really)

Design to avoidaccidents

Nod. Process safetyinformation?

(not really)

Conservatism ofdesign


Comparison

Continued


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Yes -

Requirements?

j. Mechanical

integrity

Maintenance

NoNoFull testing

NoNoInherently stable plant


Comparison Continued


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Noi. Mechanicalintegrity

Inspection of vendorprovided equipment

Yesd. Process safety

information &

l. MOC

Designdocumentation &

change control

Yes but minimal

guidance oruseage req.

f. Operating

procedures(doesnt addresstechnical participation)

Detailed operating

procedures



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Yes(but not for

management)

g. Training(but does not include

initial technical training)

Initial technicaltraining + hands on

training

NoNoPersonal selection ofleaders

NoNoIndependent review

by government



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Only Audits(not frequent)

O. Compliance

audits (not frequent)

Self Assessments

exceptionsNoStrict enforcement ofstandards

someNoExtensive continuingtraining &

requalification

NoNoAdvanced training for

senior mgmt jobs



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Rickover didnt include these

OSHA PSM

Employee participation

Contractors

Hot work permits

Trade secrets

CCPS PSM

Human Factors


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Copyright 2008 by System Improvements Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited. 21

Why Should Management Care?

Major Process Accidents Have

Management Roots

BP Texas City

Deepwater Horizon

Shuttle I & II

Davis-Besse Reactor Vessel Hole


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5 Things Management Should Know(but they usually dont)

LetLets Look at Each Ones Look at Each OneCopyright 2007, Great Systems!

1. Managements effect on process safetyimprovement

2. How process safety improvement androot cause analysis work

3. How to change behavior effectively

4. How to move from reactive to proactiveimprovement

5. Effective trending


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#1 Managements Effect

Knowledge / Standards

What They Ask For (Demand)

Budget - What Gets Cut?

Involvement/Attention/Tracking Who Is Assigned/Evaluations/Promotions

Do They Insist Their Subordinates are Trained?

What They Say But Beyond That


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Tale of Two Plant Managers

Bad Example

No Budget - No TravelBudget Approved

Big Backlog or No Tracking

Skip Quarterly Meetings

Tracking System - Mgmt Reacts

Monthly Reviews

Best of the RestTop People Assigned

Heard a Talk Once

Asks Who Did It & Fires

Asks Why Would They

Need Training?

Sr. Mgmt Trained

Asks for Root Cause Analysis

Sends Subordinates to

Advanced Training

Good Example

Both Say They Support Process Safety Improvement, butBoth Say They Support Process Safety Improvement, but

Copyright 2007, Great Systems!


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25% Budget CutAfterMerger

In 2002, Flare Tie-In from ISOM Cutto Save $150,000

Big Backlog of Old Corrective Actions

People Assigned Without Technical Background

(Example: No PSM Training for HSE Manager)

3 Fatalities Think They Are Improving

Cheap Trailers Save Money

Say They Want Safety Improvement, butSay They Want Safety Improvement, but

BP Texas City

Refinery Explosion


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Management Needs To Know

Senior Manager Sponsors Process Safety Improvement

As Sponsor, Helps Design & Approves Program(See Chapter 6 of 2008 TapRooT Book)

Understands Keys to Process Safety Improvement

Understands Theory & Practice ofRoot Cause Analysis


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Plant Manager Did Sponsor Telos Report - BUT No Ownership from Above for Fixes

Senior Management Didnt Know What WasWrong with BP Root Cause Analysis Tools orReports (Including Interim Report & Mogford Report)

Senior Management Stuck in Blame Culture -Didnt Understand Keys to PerformanceImprovement (Watch Mgmt response to Interim Report or readthe Mogford Report)

How Was Senior Management Involved?How Was Senior Management Involved?

BP Texas City Refinery Explosion


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Had the six operators and one supervisor assigned tothe start-up of the refinery's isomerization unit beendoing their jobs, the explosion would not havehappened, 15 people would not have been killed and

more than 170 would not have been injured,said RossPillari, President of BP Products North America.

"The mistakes made during the start-up of this unitwere surprising and deeply disturbing,"Pillari saidduring a news conference in which BP released a 47-page interim report on its investigation.

The core issue here is people not followingprocedures,"Pillari said.

Immediate action: 5 operators and supervisors fired.

INTERIM INVESTIGATION REPORTINTERIM INVESTIGATION REPORTBP Press Statement (now retracted)BP Press Statement (now retracted)


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Effective Use of Discipline

Soon - Certain - Positive

Behavior Change Matrix


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What Happens if Management

Doesnt Know

Broken Rules

Shortcuts / Procedures Not Used Supervisors Look the other way

Real way its done

Bad Attitude

Us vs. Them


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What Happens if ManagementWhat Happens if Management

DoesnDoesn

t Knowt Know


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#4 From Reactive to ProactiveImprove Before Incidents Happen

Improve Performance/Avoid Incidents Avoids Negatives From Incidents

Continuous Improvement

Very Lean Concept


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Fast Analysis

Then Fix

Category 1

# of investigations: 1 - 5

Category 2:

30 - 100

Category100 - 1000

Category 4:

1000 - 4000

Good Root Cause

Analysis Then Fix

Very Little AnalysisThen Fix

No Analysis

Maybe Fix?

Analysis

Action

Serious Incident

Incident

Near-Miss

At-Risk Behaviors

Latent Conditions

Investigations

Based on

Significance

Reactive Improvement ApproachReactive Improvement Approach


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Root Cause Analysis

Then Fix

Category 1:

1 - 5

Category 2:

30 - 100

Category 3:100 - 1000

Category 4 & 5:

1000 - 4000

Root Cause Analysis

Then Fix

CategorizeRepair

Reactive

Investigations based

on Significance

Analysis

Action

Serious Incident

Incident

Near-Miss

At-Risk Behaviors

Latent ConditionsTargeted Proactive

Observations

Root Cause Analysis

FIX

Fix Only If

Adverse Trend

LeanLean

ImprovementImprovement

ApproachApproach

Improve

Before

Waste!


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What Happens if Management

Doesnt Know

1. Big incidents analyzed well.2. Minor incidents analyzed poorly.

3. Hundreds of poorly analyzed incidents drive correctiveaction program.

4. Result: Large backlog of dubious fixes.5. Regulators/Management focus on backlog.

6. Waste effort implementing dubious fixes.7. Trends dont help management manage.

8. Reactive approach whipsaws management withrandom events.


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Measuring Performance

Damage of Over-reacting


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LTI: What Months Are Abnormal?

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec


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October 12 Month - Take Action!

Fire Safety Manager & Guilty Parties!

Hire Consultant Send Out Memo

Safety is a Condition of Employment

Hold People Accountable


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No Months Outside "Natural Variation"

Natural

Variation


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What Did Reactive Approach &

Over-Reacting Do?


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What Did Reactive Approach &

Over-Reacting Do?


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What Do You Need To Do?

1. Managements understanding of their effect onprocess safety improvement - ???

2. How process safety improvement and root causeanalysis work - ???

3. How to change behavior effectively - ???

4. How to move from reactive to proactiveimprovement - ???

5. Effective trending - ???Im

proving

these

needsto

be

Impro

vingth

eseneeds

tobe

inyour

impro

vement

plan

inyour

impro

vement

plan


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