sponsored byIn Search of “Perfect Process Safety”How to Ensure Sustainable Continuous ImprovementLearning from the ML    i...
“Perfect Process Safety” What is it? Is it possible? What are the barriers?                                               ...
Compliance with Existing         Regulations Is Not Enough            Regulations provide minimum framework, but          ...
Seems to Be Four Types of Companies In theory, requirements and enforcement practices should be matched to these various “...
Simple Lessons Baker Panel-CSB Reports                     Panel- Ineffective PSM system with weak performance evaluation,...
Lessons from Major Learning Sources Failure to execute – primary lesson We are not taking advantage of all “internal”     ...
Characteristics of a Learning-Disabled Company(Steve Arendt, Armchair Process Safety Psychologist)   Dysfunctional safety ...
Definition of the Perfect PS Leading IndicatorThe Perfect Risk Model                         Or…a “Live Risk” Model       ...
Improvements in Process Safety/HSE                                  Technology                                  and standa...
Current PSM/HSE Auditing and RCAPractices Don’t Go Far EnoughPSM/HSE audits generally issue findings and areasfor improvem...
21What Is Safety Culture?Our Company and Individual DNA Cu tu e is t e te de cy in a o us – a d ou Culture s the tendency ...
To Address Unsafe Acts, Some CompaniesHave Implemented BBS ProgramsIndustry experience has varied   Worked for some; did n...
Process Safety Culture – Essential Features1.   Establish safety as a core     7.    Defer to expertise     value       l ...
2. Strong Leadership Visible, active, consistent support from all levels of company management    Through communications, ...
4. Formalize a Culture ApproachCulture cannot be designed or manufactured, but ...Document key principles or activities th...
6. Individual Empowerment  Clear delegation of, and accountability for,  responsibilities  Provision of requisite authorit...
8. Open and Effective Communications  Vertical communications (both up and down)    Management hearing as well as speaking...
10. Mutual Trust   Employees for managers     Trust that managers will do the right thing in support     of safety   Manag...
12. Continuous Monitoring of     Performance   Curiosity/anxiety for ”How are we doing?                          How      ...
Examples of Culture Influencing Events    A VP pressures the plant manager to defer the plant    turnaround through the bu...
PAR Process Safety Performance vs. Culture Map                                        Culture survey results and other sou...
How to Change PS/HSE Culture  Embracing the idea that YOU affect culture  Understanding potential root causes  Determining...
Small Group/Individual Mentoring and CoachingWorkshops and role play   Examples of accidents that occurred due to safety c...
Sense, Learn, and Fix at Every Level                                 Put sensors, not censors, at every level             ...
Evaluating PSM Element Failure Modes  Determine basic element steps    Review element written program    Identify life-cyc...
Evaluating PSM Element Failure Modes Determine corrective and preventive actions to reduce chance of element performance f...
Ensuring Sustainable PSM/HSE  Performance Improvement      Make technical corrections to PSM element      performance     ...
MOC Program Life-Cycle Phases   Design and development   Implementation and rollout   Operation   Monitoring and improveme...
MOC System Rollout Failure Modes  Inadequate workforce involvement  Inadequate awareness training of workforce            ...
MOC System Operation Failure ModesEmergency MOC review procedure not finishedMOC authorization inadequate - wrong, missing...
Top MOC Operating Phase Failure Modes % of MOC                                            Issues   Failure to identify a p...
Unrecognized Change Led to Release  Original position     Modified position                                              6...
Company PS Metrics Related to Incident     Number of open MOCs     MOC action item aging     Process piping inspection agi...
MOC Failure Was a Root Cause Several MOC failures occurred   Development – failure to account for change type   Rollout – ...
Strategy for Process Safety Performance Management  Evaluating PSM failure modes  Determining PSM failure culture causal f...
Example of a Faulty Pyramid                    Accidents                     Incidents                    Precursors      ...
Monitor Warning Signs – Company           Organizational change/stress without sufficient HSE           impact evaluation ...
Process Safety Metrics – Arendt Suggestions1. Process Safety incidents – ANSI/API RP 754 Tiers 1 and 22.2 Process Safety i...
Characteristics of Good ProcessSafety CompaniesNot blind or arrogant – willing to look into the mirrorSafe questioning/lea...
Keys to Future Process Safety Success To pursue zero or perfect PS – you’ve got to change the ways you are doing some thin...
“Perfect Process Safety”   Is a worthy and valuable goal   Can only be pursued by highly reliable   organizations that emb...
Time for Questions                     sponsored byIn Search of “Perfect Process Safety”How to Ensure Sustainable Continuo...
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Steve Arendt runcorn uk presentation 8 21-12 final

  1. 1. sponsored byIn Search of “Perfect Process Safety”How to Ensure Sustainable Continuous ImprovementLearning from the ML i f th Macondo D d Deepwater H i t Horizon Bl Blow O t Out August 21, 2012 Runcorn, UK Steve Arendt, Vice President, P.E. North America Process Industries Organizational Performance Assurance Center sarendt@absconsulting.com Steve Arendt, P.E. 30+ years in process safety and risk assessment Vice President, ABS Consulting, NA Process Sector and Organizational Performance Assurance Center ABSC project manager for the Baker Panel PSM reviews Conducted 100s of PSM audits, incident investigations, and best practice reviews, including 20+ offshore facilities 60+ articles and books on PSM and risk management Guidelines for Risk-Based Process Safety Guidelines for Management of Change A Compliance Guide for EPA’s Risk Management Program Rule Managers Guide to Quantitative Risk Assessment Resource Guide to the Process Safety Code of Management Practices y g Guidelines for Hazard Evaluation Procedures, Second Edition A Managers Guide to Implementing and Improving MOC Systems Risk Communication Guide, Chemical Educational Foundation ProSmart - CCPS PSM Performance Metrics System Center for Chemical Process Safety Fellow Recipient of Mary Kay O’Conner PSC Merit Award Center for Offshore Safety work group member 2 1
  2. 2. “Perfect Process Safety” What is it? Is it possible? What are the barriers? 3A Vision For “Perfect Process Safety” A culture based on proper ownership of HSE Risk-informed sensitivity that g y guides everything y g Effective, fit-for-purpose management systems PS practices embraced and followed with good operational discipline at ALL levels Learning from ALL sources – internal, external and outside industry group Well-formed/visible performance pyramid; metrics at every level that drive intended behaviors Goals and actual performance that improves 4 2
  3. 3. Compliance with Existing Regulations Is Not Enough Regulations provide minimum framework, but industry practices have bypassed regulations Minimum standards may not be enough for all facilities We have not really learned from our experience Minimalistic compliance approach does not lead to robust future performance Fragility due to economic cycles Culture challenges Organizational stresses Aging assets and changing people 5The Problem with Some Companies…They Are Taught a Lot of Lessons, But They Never Seem to Sustain Learning Accidents They either don’t see y hazards below the Or they don’t waterline know how to Incidents identify and fix root causes Precursors Management System Failures g y Their “fixes” don’t stay fixed Unsafe Behaviors and Attitudes Culture – Individual and Organizational Tendencies© ABSG Consulting, Inc. 6 3
  4. 4. Seems to Be Four Types of Companies In theory, requirements and enforcement practices should be matched to these various “needs” needs Know what to do and do a pretty good job Know what to do, but dont do a consistent job Know what to do and "intentionally" dont do a good job Dont really know what to do – ignorant or confused Difficult to make happen. Seems like we want “one happen one paint brush” and the “same type of painter” no matter what the need 7Learning from Experience Outside your industry Inside your industry Inside your company One BIG problem in industry is that we get taught the same lesson over and over, but don’t truly LEARN so that the problems don’t repeat p p A critical skill is to find something relevant to learn and improve on out of EVERY significant incident 8 4
  5. 5. Simple Lessons Baker Panel-CSB Reports Panel- Ineffective PSM system with weak performance evaluation, corrective action, and corporate oversight Lack of follow-up in ALL areas p Huge backlogs in inspections and corrective actions Not following consensus standards – nor their own Poor risk awareness and assessment Superficial audits Inadequate metrics Poor management review at local level Not focused on process safety at corporate level Inadequate corporate safety culture – had symptoms in every PS culture problem area Blind spots Arrogant Complacent Superficial Glacial, non-agile In denial 9Macondo – Lessons and Potential Impacts Classes of root causes - plenty to go around Inadequate process safety culture for DH adequate p ocess sa ety cu tu e o Inadequate GOM operating environment culture Complex offshore operating environment Process safety management system failures Inadequate GOM regulatory environment Potential influences for onshore regulations g Enhanced reporting and third-party audits Prescriptive independent verification of safety critical elements QRA and safety case 10 5
  6. 6. Lessons from Major Learning Sources Failure to execute – primary lesson We are not taking advantage of all “internal” internal sources of learning opportunities In the U.S., we have incomplete value generation from 20 years of regulatory PSM incidents - inadequate collective analysis, trending, sharing, and learning Failure to learn from other types of industry accidents Will process safety leading indicators suffer the same fate? We have a culture challenge 11 Six Characteristics of a Learning Organization (Harvard Professor David Garvin) Supports discussion and evaluation of divergent opinions and data Provides timely feedback and flexibility in the means used to conduct work activities Stimulates new ideas to promote a step change in risk understanding and operational performance Maintains an external focus by not automatically discounted outside ideas and ways Treats errors/mistakes as investments. Learns from them. Encourages proper risk-taking Routinely updates a learning plan to increase competencies 12 6
  7. 7. Characteristics of a Learning-Disabled Company(Steve Arendt, Armchair Process Safety Psychologist) Dysfunctional safety culture People hide things and kill messengers p g g Fail to question; procedures not followed without accountability Mixed/improper safety/production messages Complacency, low trust, silo mentality Misplaced safety ownership, invisible/ineffective leadership Superficial causal analysis of problems Things dont get fixed No company memory Add in your own… 13Characteristics of Good Risk ManagementNecessary, but Not Sufficient for Perfect PS Pervasive understanding of what risk is Consistent practices driven using fit-for-purpose g HSE management system Life-cycle wide and enterprise deep risk visibility Flexible tool set and relevant data sources Competent practitioners Appropriate risk tolerance concepts/tools employed Effective risk reduction issue management Regular executive review of risk register top issues Risk ownership throughout the organization 14 7
  8. 8. Definition of the Perfect PS Leading IndicatorThe Perfect Risk Model Or…a “Live Risk” Model Evaluates the risk impact of day-to-day facility changes and circumstances: User d fi U defines equipment th t i f il d i t that is failed, disabled, degraded etc. Operational adjustments External circumstances Evaluates the increase in risk from these changes Requires input from risk models (HAZOPsHAZIDs, LOPAs, BTs, QRAs) into risk model Operator identifies equipment that is failed or out of service LIVERISK shows you the increase in risk due to the known equipment failures/outages or operational circumstances 15LIVERISK FeaturesDashboards for Different levels within the organization ( g (facility, Business Unit, y Corporate etc.) Different departments (production, safety, inspection etc.)Accounts for the impact of changes in management systems Mechanical integrity: testing & maintenance programs; Project Quality Management (PQM), etc. Health, Safety and Environmental: results of HSE audits, Class surveys, etc. surveys etc Integrate HSE/process safety metrics (leading indicators) Integrate safety culture issues OthersAccounts for operational profile and external events 16 8
  9. 9. Improvements in Process Safety/HSE Technology and standards HSE management Culture ate systems • Organizational andRisk/Incident Ra individual behaviour aligned with goals Standards • “Felt” leadership • Engineering improvements • Personal accountability • Hardware improvements • Shared purpose & belief • Design review • Compliance Management Systems Improved • Integrated HSE MS culture • R Reporting ti • Assurance • Competence • Risk Management Time Adapted from Kiel Centre 17 Overview of U.S. Industry Process Safety Performance Improvement Activities Center for Chemical Process Safety Risk Based Process Safety Guidelines emphasis on Learning from Experience Leading indicator work in late 90’s culminating in new PS metrics guidelines Member benchmarking project and Vision 2020 API RP 754 API/AFPM Advancing Process Safety Initiative Center for Offshore Safety Lessons from industry accidents and investigations Industry is refocusing attention and leadership away from PSM compliance to PS Performance 18 9
  10. 10. Current PSM/HSE Auditing and RCAPractices Don’t Go Far EnoughPSM/HSE audits generally issue findings and areasfor improvement “at the element level” even thoughthe evidence used may point to deeper problemsIncident investigations identify PSM elements as rootcauses but don’t address safety culture factorsUse of PSM leading indicators are just becomingbroadly accepted, but their use for performancemanagement is in the “infant stage”Plenty of learning opportunities; need to adjust ourlearning and performance improvement approaches 19Center for Chemical Process SafetyMade Culture an Official SMS Element Evaluated major organizational accidents and prepared Safety Culture Awareness tool ABSC included Process Safety Culture as an element in CCPS Guidelines for Risk Based Process Safety Defined the twelve essential features of a good culture Created structure for a culture management practice 20 10
  11. 11. 21What Is Safety Culture?Our Company and Individual DNA Cu tu e is t e te de cy in a o us – a d ou Culture s the tendency all of and our organization - to want to do the right thing in the right way at the right time, ALL the time – even when/if no one is looking – ABS Group definition Culture is the result of all the actions - and inactions - in institutional/workforce memory Individual and organizational safety culture is affected by ethnic culture and off-the-job behavior Culture is hard to measure and more difficult to change; it will be the “root cause of the decade” 22 11
  12. 12. To Address Unsafe Acts, Some CompaniesHave Implemented BBS ProgramsIndustry experience has varied Worked for some; did not work for others Worked for a while, but then floundered Some have not tried it because of the resource commitment and negative feedbackProblems with BBS programs LTA management commitment; LTA resources Perceived to be a program for employees to “fix themselves” p g p y Management not viewed as a part of the problem/solution Lack of employee ownership Trivial/ineffective observations - quotas, improper reward systems, program gets stale, gets nit-picky Employees unable to provide/accept constructive peer feedback 23Organizational Accidents and Culture Challenger & Columbia Piper Alpha L f d Longford Chernobyl Flixborough Texas City Macondo 24 12
  13. 13. Process Safety Culture – Essential Features1. Establish safety as a core 7. Defer to expertise value l 8. Ensure open and effective2. Provide strong leadership communications3. Establish and enforce high 9. Establish a standards of performance questioning/learning environment4. Formalize the safety culture emphasis/approach 10. Foster mutual trust5. Maintain a sense of 11. Provide timely response to vulnerability safety issues and concerns6. Empower individuals to 12. Provide continuous successfully fulfill their monitoring of performance safety responsibilities 25 1. HSE/Process Safety As a Core Value Deeply ingrained sense of value for HSE/safety At all levels of the organization Promoted to an ethical imperative in really strong cultures Awareness of responsibility to: Self Co-workers Company Society Individual and group intolerance of those in violation of the norm 26 13
  14. 14. 2. Strong Leadership Visible, active, consistent support from all levels of company management Through communications, actions, priorities, provision of resources, etc. Committed to what is right Visionary and inspiring Open and honest Firm b t fl ibl Fi but flexible Alert and responsive to modify strategies to meet safety goals HSE/safety as line responsibility 273. Consistent Accountability to High Performance Standards Individual d I di id l and organizational i ti l Standards established, reinforced, and updated in a controlled fashion Consistency in accountability and transparency at all organizational strata – no “double standards” Avoidance of normalization of deviance Zero tolerance for willful violations of safety standards, rules, or procedures 28 14
  15. 15. 4. Formalize a Culture ApproachCulture cannot be designed or manufactured, but ...Document key principles or activities that support ormaintain its safety cultureRecord basic safety tenants, such as in a companypolicy or mission statementFormalize a culture evaluation, monitoring, andlearning activities that are expected to be carriedout by someone or some group on a periodic basis 295. Sense of Vulnerability Preoccupation with failure Constant vigilance for indications of system weaknesses Attention to “weak signals” Avoidance of complacency “Past performance not a guarantee of future success” Avoidance of putting excessive reliance on safety systems Awareness of need for resilience (multiple lines of defense) Burden of proof for safety rather than "un-safety 30 15
  16. 16. 6. Individual Empowerment Clear delegation of, and accountability for, responsibilities Provision of requisite authority and resources to staff to allow success in assigned roles Management expectation and tolerance of disparate opinions Personal responsibility for safety 317. Deference to Expertise High value placed upon training and development of individuals and groups Authority for decisions migrates to proper people based upon their knowledge and expertise Rather than rank or position Independent and unassailable role for safety experts Imperative for maintaining the “critical mass” of expertise required for safe operations 32 16
  17. 17. 8. Open and Effective Communications Vertical communications (both up and down) Management hearing as well as speaking Horizontal communications All have the information they need to identify and respond to the unexpected Emphasis on observation and reporting Redundant and/or non traditional non-traditional communications channels Monitoring of communications for effectiveness 339. Questioning/Learning Environment Enhancing risk awareness and understanding as means to continuous safety improvement Appropriate and timely hazard/risk assessments Thorough and timely incident investigations Looking beyond site or company for applicable learnings Reluctance to simplify interpretations or seek the p y p simple solutions 34 17
  18. 18. 10. Mutual Trust Employees for managers Trust that managers will do the right thing in support of safety Managers for employees Trust that employees will shoulder their share of responsibility for safety performance Peers for peers p Confidence in a just system where honest errors can be reported without fear of reprisals 3511. Responsiveness to Safety Concerns Awareness of safety as a dynamic non-event A “properly tuned controller” properly controller Rapid, but not reckless, response to the unexpected in order to maintain the safety setpoint Timely response to implement learnings from audits and investigations Timely resolution of mismatches between practice and procedure t prevent normalization ti d d to t li ti of deviance Timely reporting of, and response to, employee safety concerns 36 18
  19. 19. 12. Continuous Monitoring of Performance Curiosity/anxiety for ”How are we doing? How doing?” Sensitivity to operations Process Management system Interpersonal Pertinent, clear metrics addressing both leading , g g and lagging indicators Defined Created Tracked 37Examples of Culture Influencing Events A co-worker does not object when an operator writes an “armchair permit” Supervisors consistently support workers who shut down a process they believe to be unsafe – even if they were wrong An operations manager extends a unit shutdown to await definitive evidence that a thin-walled vessel is safe to operate A plant manager does not wear appropriate PPE when walking to the control room to eat lunch with a unit crew A corporate EHS Director persists in her efforts to justify staffing resource commitments to support process safety in spite of company cost-cutting edicts Red = Negative Green = Positive 38 19
  20. 20. Examples of Culture Influencing Events A VP pressures the plant manager to defer the plant turnaround through the busy season A company SVP focuses on problem solving rather than affixing blame during a management review of a serious incident investigation A company Director eliminates corporate engineering and process safety staff positions without any management of organizational change A CEO makes an acquisition without addressing EHS/process safety in due diligence reviews A Board subcommittee spends significant time reviewing EHS/process safety performance metrics and questions the company’s 3rd-quartile performance Red = Negative Green = Positive 39Connecting the Dots – Process SafetyPerformance Assurance Review (PAR)© Strategy Process Safety/ESH CultureMapping of ESH Technical Evaluation SourcesPerformance and Culture PSM/EHS Surveys and WorkEvidence to Process interviews observations leading indicatorsSafety Culture Factors Incidents and investigationProcess results Process Safety/ESH CultureSafety/ESHPerformance Audits and Essential FeaturesInformation assessments Causal FactorsSources Action item Tenets of Operation completion history 40 20
  21. 21. PAR Process Safety Performance vs. Culture Map Culture survey results and other sources are sorted into the 12 essential features Analysis of all process safety performance data (e.g., audit actions) is sorted into the 12 essential features 41Ranking of Cultural Causal Factors Present – Summaryof Study Results Cultural Causal Factor – Decreasing Frequency1. Normalization of deviance2. Non-responsiveness to safety concerns3. Lack of a questioning/learning environment4. No performance monitoring/pursuit of improvement5. Lack of sense of vulnerability6. Lack of trust – unsafe reporting environment 42 21
  22. 22. How to Change PS/HSE Culture Embracing the idea that YOU affect culture Understanding potential root causes Determining ways to improve culture weaknesses Follow-thru throughout an organization 43How Leaders Influence Beliefs/Values What leaders pay attention to, measure, or control Reactions to critical incidents or crisis Criteria used to allocate scarce resources Deliberate attempts at role modeling, teaching, and coaching Criteria for reinforcement and discipline Criteria used to select, promote, or terminate employees 44 22
  23. 23. Small Group/Individual Mentoring and CoachingWorkshops and role play Examples of accidents that occurred due to safety culture problems CCPS 12 essential features of a good safety culture Taking personal responsibility for evolving your Process Safety and Occupational Safety (Total Safety) behavior and culture Understanding potential historical root causes for culture problems Soliciting ideas for improving culture Decide which culture elements you are going to address Decide who in management is needed to support your efforts Develop a plan for the next month, the next six months, the next year, and the next three years Determine what metrics will be used to monitor progress 45Some Culture Improvement LessonsIf you have poor culture, marked by mistrust orneeds large improvement, the worst thing y can g p , g youdo is too just start “talking” about it at the topThe “top” needs to first start “behaving” better toaddress culture weaknessesThen, the talk will build up from the bottomIf you survey, do it anonymous and voluntary; you surveyshould commit to sharing the results – quicklyAny education/training, etc. should extend to ALL ofthe workforce, including contractorsBUILD OWNERSHIP 46 23
  24. 24. Sense, Learn, and Fix at Every Level Put sensors, not censors, at every level Develop learnings at every level Take corrective action at every level 47 Strategy for Process Safety Performance Management Monitor PSM health For ALL PS learning opportunities: Evaluate PSM failure modes Determine PSM failure culture causal factors Ensure sustainable PSM/HSE performance improvement Avoid organizational warning signs Embrace critical success factors for PSM 48 24
  25. 25. Evaluating PSM Element Failure Modes Determine basic element steps Review element written program Identify life-cycle activities completed and current status • Design and development • Implementation and rollout • Operation • Monitoring and improvement Develop workflow diagram of element work process Review relevant incident root causes for element Review relevant element metrics - leading and lagging indicators 49Evaluating PSM Element Failure Modes Review previous two audit cycle results for element Assign incident, root causes, audit findings and observations, and metrics indicator performance to: • Life cycle phase during which the element performance issue occurred • Workflow process point where element breakdown occurred Highlight element life-cycle phase where performance issues are greatest Highlight work process point where most element performance issues have occurred 50 25
  26. 26. Evaluating PSM Element Failure Modes Determine corrective and preventive actions to reduce chance of element performance failure p occurring again Implement/redo life-cycle phase in a more reliable fashion Improve element work process design Create better leading indicators to monitor element performance area Improve use of existing relevant metrics to monitor element performance Increase management review scrutiny on element performance area All of this may not be enough 51 Evaluating PSM Element Failure Culture Causal Factors Map element performance issues to cultural features Compare performance to known culture weaknesses Identify which culture features appear to be contributing to element performance lapses 52 26
  27. 27. Ensuring Sustainable PSM/HSE Performance Improvement Make technical corrections to PSM element performance Implement culture improvement activities to address culture weaknesses Monitor culture change and improvement 53 Guidelines for Management of Change for Process Safety Recognize Classify Evaluate hazards and risks Approve (or not) or modify Get ready for the change Communicate/train Update documentation 200 pages. April 2008, US $95 ISBN: 978-0-470-04309-7http://www.wiley.com/WileyCDA/WileyTitle/productCd-0470043091.html 54 27
  28. 28. MOC Program Life-Cycle Phases Design and development Implementation and rollout Operation Monitoring and improvement 55MOC System Design/Development Failure Modes Inadequate workforce involvement Inadequate design basis - wrong change types types, inadequate review/authorization protocols MOC use rate not considered when establishing MOC resources Inadequate MOC resources designated MOC protocol complexity inappropriate for change types, resources, or workforce culture MOC system roles and responsibilities inadequate Scope of application of MOC program inadequate 56 28
  29. 29. MOC System Rollout Failure Modes Inadequate workforce involvement Inadequate awareness training of workforce workforce, including contractors Inadequate detailed training of MOC system participants Insufficient MOC system tools/forms/resources provided Insufficient pilot-testing 57MOC System Operation Failure ModesFailure to identify a proposed change - system circumventedChange classified as an emergency change when it did notmeet established criteriaMistakenly included a RIK in the MOC review processProposed change improperly classified - type or review pathMOC origination information inadequateMOC initial review not completed or inadequateInadequate MOC reviewersWrong MOC review method usedMOC hazard review path step missed, out of order, incompleteMOC hazard evaluation inadequate - hazards missed or risksimproperly evaluated 58 29
  30. 30. MOC System Operation Failure ModesEmergency MOC review procedure not finishedMOC authorization inadequate - wrong, missing or risksaccepted are inappropriatePSI not updated based upon changePersonnel not informed of changePersonnel not trained on changeWrong communication or training provided to personnelTemporary change left in place too long without further reviewFailure to restore system to original condition after atemporary changeMOC review records inadequate or missingMOC delayed or lost in the system 59MOC System Monitoring Failure Modes MOC metrics not properly developed or used Inadequate management review/oversight of MOC system MOC not addressed sufficiently in PSM audit 60 30
  31. 31. Top MOC Operating Phase Failure Modes % of MOC Issues Failure to identify a proposed change 61 % - system circumvented Temporary change left in place too 43 % long without further review or failure to restore system to original Personnel not informed of change g 35 % MOC delayed or lost in the system 23 % MOC hazard evaluation inadequate - hazards missed or risks improperly 18 % evaluated 61 MOC Failure Example – Offshore Gas Compressor Module 62 31
  32. 32. Unrecognized Change Led to Release Original position Modified position 63Gas Release Resulted in a “Lucky Explosion” 64 32
  33. 33. Company PS Metrics Related to Incident Number of open MOCs MOC action item aging Process piping inspection aging None of these metrics addressed monitoring the technical performance aspects of MOC that th t contributed to the incident t ib t d t th i id t 65Top MOC Cultural Causal Factors1. Establish process safety as a 7. Defer to expertise core value l 8. Ensure open and effective2. Provide strong leadership communications3. Establish and enforce high 9. Establish a standards of performance questioning/learning environment4. Formalize the process safety culture emphasis/approach 10. Foster mutual trust5. Maintain a sense of 11. Provide timely response to vulnerability safety issues and concerns6. Empower individuals to 12. Provide continuous successfully fulfill their safety monitoring of performance responsibilities 66 33
  34. 34. MOC Failure Was a Root Cause Several MOC failures occurred Development – failure to account for change type Rollout – precursors occurred during period Operation – failure to recognize, failure to evaluate Several safety culture issues were uncovered that contributed to the MOC system failures Lack of a sense of vulnerability Failure to empower individuals Lack of a questioning/learning environment Normalization of deviance 67Conclusions from Example MOC is a critical PSM element MOC performance management (audits) often dont provide sufficient improvement information We must examine MOC failure modes to support continuous improvement MOC failure prevention must consider "life-cycle improvements Culture and behavior issues MUST be addressed for sustainable improvement Leading indicators supported by frequent management review are needed 68 34
  35. 35. Strategy for Process Safety Performance Management Evaluating PSM failure modes Determining PSM failure culture causal factors Ensuring sustainable PSM/HSE performance improvement Avoiding organizational warning signs Critical success factors for PSM 69How Does a Company Tell If It Is: In a process safety ditch On th d O the edge of a ditch f dit h Getting closer to a ditch Moving away from a ditch Maintaining proper distance from a ditch AVOID loss of visibility or fidelity inperformance evidence sources – maintain a well-shaped and complete pyramid 70 35
  36. 36. Example of a Faulty Pyramid Accidents Incidents Precursors Management System Failures Unsafe Behaviors and Attitudes Culture – Individual and Organizational Tendencies 71 Recognizing Catastrophic Incident Warning Signs in the Process Industries ISBN: 978-0-470-76774-0 264 pp December 2011 US $125.00 $125 00 http://www.wiley.com/WileyCDA/WileyTitle/pro ductCd-047076774X.html 72 36
  37. 37. Monitor Warning Signs – Company Organizational change/stress without sufficient HSE impact evaluation and mitigation p g External-induced • Regulations, enforcement, economics, disasters, M&A target, etc. Internal-induced • Competency, memory, resources, focus loss, initiative overload, M&A, overload M&A leadership instability demographics instability, shift, turnover, absenteeism Loss of visibility/fidelity in performance evidence sources – maintain a good pyramid Poor reporting, trending, sharing, monitoring 73 Metrics Layered within the Pyramid # of PS incidents Accidents # of first aids f fi t id Severity rate Incidents Number of Near Misses Reported Precursors HSE/PSM audit score Number of Overdue Action Items Corrective Actions Generated Management System Safety Meeting Attendance, % Training Completed, % Failures RC Contacts Safety Inspections Completed, % Unsafe Behaviors and Attitudes BBS at-risk observations Trend incident and Culture – Individual and management system Organizational Tendencies technical and cultural root causes as learning Conceive of cultural opportunities occur weakness metrics to collect across© ABSG Consulting, Inc. company 74 37
  38. 38. Process Safety Metrics – Arendt Suggestions1. Process Safety incidents – ANSI/API RP 754 Tiers 1 and 22.2 Process Safety incident precursors – RP 754 Tier 33. Failure to follow procedures/SWPs – BBS at-risk observation rate4. Failure to fix identified process safety problems – action item backlogs or aging, equipment deficiencies backlogs5. Failure to identify process safety deficiencies– inspection (all sources) backlog, failure to identify/report incidents or do adequate RCA6. Failure to assess risk– MOC circumvention or low quality, PHA schedule backlog, PHA quality review7. Safety culture weaknesses – Map RCs of incidents to cultural causal factors 75 Emerging Challenges with PS Metrics Don’t pick too many Make sure they roll up properly Make sure they add value Don’t just pick things you can measure; make certain they affect accident risk Think through how you will use them; anticipate unintended behaviors Make them visible – positive culture influence 76 38
  39. 39. Characteristics of Good ProcessSafety CompaniesNot blind or arrogant – willing to look into the mirrorSafe questioning/learning environmentProper safety ownership and leadershipEffective, fit-for-purpose management systemsDisciplined in execution - low/decreasing backlogsEffective action - prevention not just correction prevention, Action at multiple levels of the pyramid Builds better ownership and fosters a better culture 77Characteristics of Good ProcessSafety Companies (cont’d)Learns lessons cheaply taught from all sources - py gavoids repeat teachingPursues effective continuous improvement – seeksout better practicesHigh quality incident investigationsProper process safety metrics and discerningauditsEffective management review 78 39
  40. 40. Keys to Future Process Safety Success To pursue zero or perfect PS – you’ve got to change the ways you are doing some things that served you okay to get you to where you are at Fit-for-purpose PSM/HSE system that is well-executed Nurture culture and operating discipline Create an effective learning organization Apply root cause thinking to everything Maintain an effective corrective action process High quality incident investigations Proper process safety metrics Discerning audits Effective management review 79Teaching, Learning, and Remembering Go back to your plant, company, or organization and pick a notable incident and find out: What was done to keep it from happening again Do people remember it and the lessons What have you done to embed it in your "lore" What effective approaches still exist to prevent it What do you have to protect against PS Alzheimers Pick a notable event from another company or industry - and do the same Go up your chain-of-command and see how far the “remembering” goes 80 40
  41. 41. “Perfect Process Safety” Is a worthy and valuable goal Can only be pursued by highly reliable organizations that embody effective learning patterns Sustainable process safety does not allow learning to evaporate or “retire” Should be the stretch goal for all companies and organizations 81Swiss Cheese Model for Accident Causation 82 41
  42. 42. Time for Questions sponsored byIn Search of “Perfect Process Safety”How to Ensure Sustainable Continuous ImprovementLearning from the ML i f th Macondo D d Deepwater H i t Horizon Bl Blow O t Out August 21, 2012 Runcorn, UK Steve Arendt, Vice President, P.E. North America Process Industries Organizational Performance Assurance Center sarendt@absconsulting.com 42

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