Capacity  Development Programme  in  Industrial Disaster Risk Management Crisis Management: Avoiding and Mitigating Major ...
Professional Profile Christian Jochum <ul><ul><li>Born 1943 in Frankfurt a.M./Germany </li></ul></ul><ul><ul><li>PhD in Ch...
European Process Safety Centre (EPSC)  www.epsc.org <ul><li>Network funded by 40+ mainly European based (petro)chemical mu...
<ul><li>Mandated by the Federal Emission Control Act   </li></ul><ul><ul><li>Advises government as well as plant operators...
Outline 1 Case Study: Hoechst Incidents 1992 Improving Existing Plants 3 Lessons Learnt 2 Conclusions 4
Case Study: Hoechst Incidents 1993 1 <ul><li>In 1993 three major incidents occurred at 2 Hoechst sites near Frankfurt/Germ...
Hoechst Incidents: Severe Consequences 1 <ul><li>Although the Feb. 22 emission did not cause serious injuries, it led to t...
Outline 1 Case Study: Hoechst Incidents 1992 Improving Existing Plants 3 Lessons Learnt 2 Conclusions 4
Hoechst Incidents: Lessons Learnt 2 <ul><li>Crisis management assessment should cover all parts of emergency- and crisis- ...
Hazards 2 <ul><li>Hazards have to be identified systematically ... </li></ul><ul><li>eg. „classical“ EHS-hazards, loss of ...
Prevention 2 <ul><li>Avoid or control risks </li></ul>Assess  procedures Define  safety measures <ul><li>Minimise hazards ...
Risk Communication 2 <ul><li>Communicate remaining risks </li></ul>Internal External <ul><li>eg. training, drills  </li></...
Mitigation 2  <ul><li>Mitigate consequences </li></ul>The bigger a corporation,  the higher the expectations even for smal...
Claim management  2 <ul><li>Remediate damages  </li></ul><ul><ul><li>... do not handle damages as insurance cases  only </...
Confidence Management 2 <ul><li>Restore trust  </li></ul><ul><ul><li>... prepare the fundament before the crisis  </li></u...
Crisis Management Systems: can the unpredictable be planned? 2 <ul><li>Define as much as possible in advance, because ... ...
Drills  2 <ul><li>Major incidents hopefully become less frequent. This makes drills even more important ... </li></ul><ul>...
Outline 1 Case Study: Hoechst Incidents 1992 Improving Existing Plants 3 Lessons Learnt 2 Conclusions 4
Plant & Process Safety: improvement of existing (“old”) plants 3 <ul><li>Make best use of limited resources by a stepwise ...
“ Swiss Cheese Model” (after J. Reason, modified by Mike Broadribb, BP) Lagging Indicator Leading Indicator
Plant & Process Safety: Use existing knowledge 3 <ul><li>Most accidents and eco – incidents have a previous history ... </...
Plant & Process Safety: The Human Factor 3 <ul><li>Workers are risks and resources for safety </li></ul><ul><ul><li>They h...
Safety Operating Procedures 3 <ul><li>Examples for visualization of safety information </li></ul><ul><li>Acetone Ladders <...
Emergency Preparedness 3 <ul><li>Accidents may happen even in most modern plants. They cannot be planned, but they should ...
Emergency Response 3 <ul><li>The basic principle: the faster and more effective the initial response, the smaller the cons...
T he Role of Authorities 3 <ul><li>The cooperation between authorities and companies at an incident depends on their coope...
Neighbours, Journalists and Environmentalists 3 <ul><li>The basic issue: Neighbours and the general public share the risks...
Outline 1 Case Study: Hoechst Incidents 1992 Improving Existing Plants 3 Lessons Learnt 2 Conclusions 4
Conclusions 4 <ul><ul><li>Investing in safe and eco-efficient plants pays off at least on the long term  </li></ul></ul><u...
Development of Accidents in Germany since 1950 4 „ Arbeitsunfälle“ = occupational accidents „ Wegeunfälle“ = acc. on the w...
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2 Crisismanagement Jsw Steel Feb09 India

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  • EFCE is the European Federation of Chemical Engineers, IChemE is the Institution of Chemical Engineers
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  • Graphic Representation. Key here is that there are 3 possible ways to understand the key control barriers . First through hazard analysis (this is recommended by HSG 254) – BP Hull are piloting this approach Second through incident investigation &amp; analysis (not suggested by HSG 254 but used in 2007 by BP at Group Level based on desire to prevent PS MIA &amp; HIPO repeats. Auditing can also provide input. Third through shared external learnings in respect of existing management system barriers
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  • 2 Crisismanagement Jsw Steel Feb09 India

    1. 1. Capacity Development Programme in Industrial Disaster Risk Management Crisis Management: Avoiding and Mitigating Major Accidents Prof. Dr. Christian Jochum India, February 2009
    2. 2. Professional Profile Christian Jochum <ul><ul><li>Born 1943 in Frankfurt a.M./Germany </li></ul></ul><ul><ul><li>PhD in Chemistry, certified Safety Engineer </li></ul></ul><ul><ul><li>Honorary Professor at Frankfurt University </li></ul></ul><ul><ul><li>28 years experience in large chemical/pharmaceutical company (Hoechst AG) </li></ul></ul><ul><ul><ul><li>1969 – 1979 Pharmaceutical research and pilot plant operations </li></ul></ul></ul><ul><ul><ul><li>1979 – 1997 Safety department (Site and Corporate Safety Director and „Major Accident Officer“ since 1987) </li></ul></ul></ul><ul><ul><li>EHS – and crisis management consulting for different types of businesses and administration since 1997 </li></ul></ul><ul><ul><li>Commission on Process Safety (formerly Major Hazard Commission) at the German Federal Minister for the Environment (Chairman since 1998) </li></ul></ul><ul><ul><li>European Process Safety Centre (Rugby/UK): Director of Centre since 2007 </li></ul></ul>
    3. 3. European Process Safety Centre (EPSC) www.epsc.org <ul><li>Network funded by 40+ mainly European based (petro)chemical multinationals to develop best practice in major accident/process safety </li></ul><ul><li>Objectives: </li></ul><ul><ul><li>Information/know how exchange </li></ul></ul><ul><ul><li>Legislation (esp. Seveso II & ATEX) </li></ul></ul><ul><ul><li>participation & co-ordination of EU funded projects </li></ul></ul><ul><li>Outputs: </li></ul><ul><ul><li>Internal reports & books </li></ul></ul><ul><ul><li>User groups & public conferences </li></ul></ul><ul><ul><li>EU projects & working groups </li></ul></ul><ul><li>Major topics 2008/09: </li></ul><ul><ul><li>Process Safety Indicators/Learning from Accidents </li></ul></ul><ul><ul><li>Safety Critical Equipment </li></ul></ul><ul><ul><li>Fostering Senior Management Involvement in Process Safety (with EFCE) </li></ul></ul><ul><ul><li>LOPA Experience & Development </li></ul></ul>
    4. 4. <ul><li>Mandated by the Federal Emission Control Act </li></ul><ul><ul><li>Advises government as well as plant operators and state and local authorities on process safety </li></ul></ul><ul><ul><li>32 members with different professional and educational background representing different stakeholders (“Round Table”) </li></ul></ul><ul><ul><li>Any group needs “allies” to win votes </li></ul></ul><ul><ul><li>Consensus intended, but majority decisions possible </li></ul></ul><ul><li>About 55 guidelines issued on different topics, e.g. </li></ul><ul><ul><li>Land Use Planning (Safety distances) </li></ul></ul><ul><ul><li>Risk evaluation and perception </li></ul></ul><ul><ul><li>Emergency Planning </li></ul></ul><ul><ul><li>Industrial parks </li></ul></ul><ul><ul><li>Provisions against terrorist attacks on chemical plants </li></ul></ul><ul><li>All publications of the Commission are available (partly in English) at </li></ul><ul><li>www.kas-bmu.de </li></ul>Commission on Process Safety (Kommission fuer Anlagensicherheit [KAS])
    5. 5. Outline 1 Case Study: Hoechst Incidents 1992 Improving Existing Plants 3 Lessons Learnt 2 Conclusions 4
    6. 6. Case Study: Hoechst Incidents 1993 1 <ul><li>In 1993 three major incidents occurred at 2 Hoechst sites near Frankfurt/Germany within 6 weeks </li></ul><ul><ul><li>Feb. 22 </li></ul></ul><ul><ul><ul><li>Runaway reaction after an unnoticed stirrer failure. Emission of 10 tons methanol containing a possibly carcinogenic substance, contaminating a large residential area </li></ul></ul></ul><ul><ul><li>March 15 </li></ul></ul><ul><ul><ul><li>Explosion of methanol – air – mixture during maintenance in a process plant. 1 worker killed, 1 seriously burnt </li></ul></ul></ul><ul><ul><li>April 2 </li></ul></ul><ul><ul><ul><li>Major sulphur trioxide emission in a process plant </li></ul></ul></ul><ul><li>The series of incidents caused a lot of public concern and nationwide media coverage. </li></ul>
    7. 7. Hoechst Incidents: Severe Consequences 1 <ul><li>Although the Feb. 22 emission did not cause serious injuries, it led to the most serious consequences for the company and the most “lessons learnt”: </li></ul><ul><ul><li>Prevention would have been possible by a thorough risk analysis leading to a simple safety device (stirrer control acting on charging valve) </li></ul></ul><ul><ul><li>Confidence in the company´s competence in emergency response was torn down by </li></ul></ul><ul><ul><ul><li>Gross underestimation of the affected area </li></ul></ul></ul><ul><ul><ul><li>Incomplete knowledge of the hazardous properties of the emitted substance </li></ul></ul></ul><ul><ul><ul><li>Inadequate wording in the first press conference </li></ul></ul></ul><ul><ul><li>Aggravation of adverse reactions by neighbours, media and authorities by arrogant behaviour of site representatives long before the incident </li></ul></ul>
    8. 8. Outline 1 Case Study: Hoechst Incidents 1992 Improving Existing Plants 3 Lessons Learnt 2 Conclusions 4
    9. 9. Hoechst Incidents: Lessons Learnt 2 <ul><li>Crisis management assessment should cover all parts of emergency- and crisis- management ... </li></ul><ul><ul><li>identify hazards comprehensively </li></ul></ul>... pursuing the goal to define and train as much as possible in advance <ul><ul><li>avoid or control risks </li></ul></ul><ul><ul><li>communicate remaining risks </li></ul></ul><ul><ul><li>mitigate consequences </li></ul></ul><ul><ul><li>remediate damages </li></ul></ul><ul><ul><li>restore trust </li></ul></ul>
    10. 10. Hazards 2 <ul><li>Hazards have to be identified systematically ... </li></ul><ul><li>eg. „classical“ EHS-hazards, loss of production, ... </li></ul>Operation hazards Network hazards Environmental hazards <ul><li>eg. failure of utilities, supplies, transportation ... </li></ul><ul><li>eg. natural hazards, adjacent plants and traffic ways, ... </li></ul><ul><li>eg. densely populated areas/buildings, natural reserves, ... </li></ul>Environmental vulnerability <ul><li>eg. plant vulnerability, neighbourhood/environment sensitivity, company image, ... </li></ul>Terrorist threats ... and transposed into scenarios.
    11. 11. Prevention 2 <ul><li>Avoid or control risks </li></ul>Assess procedures Define safety measures <ul><li>Minimise hazards (  “Inherent Safety”) </li></ul><ul><li>Engineering/organisation/human factor/“Security” </li></ul><ul><li>update necessary? </li></ul>Assess safety measures <ul><li>eg. Audit programs </li></ul>“ Prevention is the best remedy”
    12. 12. Risk Communication 2 <ul><li>Communicate remaining risks </li></ul>Internal External <ul><li>eg. training, drills </li></ul><ul><li>Towards customers, neighbours, authorities – but careful regarding security risks! </li></ul>“ who always claims `zero risk´, has no credibility in his ability to control risks!”
    13. 13. Mitigation 2 <ul><li>Mitigate consequences </li></ul>The bigger a corporation, the higher the expectations even for small sites <ul><ul><li>Internal emergency planning ( above all organisation, equipment, drills) </li></ul></ul><ul><ul><li>Cooperation with external services ( neighbouring plants, public services ) </li></ul></ul>Important: ability to react fast!
    14. 14. Claim management 2 <ul><li>Remediate damages </li></ul><ul><ul><li>... do not handle damages as insurance cases only </li></ul></ul><ul><ul><li>... fears may not be justified, but are always real </li></ul></ul><ul><ul><li>... be prepared for problems of competency and competition (internal and external) </li></ul></ul><ul><ul><li>... identify “free-riders” </li></ul></ul>“ well treated wounds heal better”
    15. 15. Confidence Management 2 <ul><li>Restore trust </li></ul><ul><ul><li>... prepare the fundament before the crisis </li></ul></ul><ul><ul><li>... communicate open and clear (possible conflict regarding terrorist threats!) </li></ul></ul><ul><ul><li>... do not downplay fears </li></ul></ul><ul><ul><li>... give the company one face </li></ul></ul>You may lose trust in hours. Restoring trust needs years
    16. 16. Crisis Management Systems: can the unpredictable be planned? 2 <ul><li>Define as much as possible in advance, because ... </li></ul><ul><ul><li>Will the crisis management system be adapted </li></ul></ul><ul><ul><li>to today´s frequent organisational changes? </li></ul></ul><ul><ul><li>... crisis always happen at the wrong time and place </li></ul></ul><ul><ul><li>... your regular organisation is not sufficient to handle crisis </li></ul></ul><ul><ul><li>... all resources of the whole company have to be available in due time </li></ul></ul><ul><ul><li>... public, media and authorities expect professional handling of crisis, too </li></ul></ul>
    17. 17. Drills 2 <ul><li>Major incidents hopefully become less frequent. This makes drills even more important ... </li></ul><ul><ul><li>... to train seldom used procedures </li></ul></ul><ul><ul><li>... to reduce mental stress during incidents </li></ul></ul><ul><ul><li>... to optimise emergency- and crisis- management </li></ul></ul>The gap between resource consuming “full drills” should be filled with frequent “smaller” drills. <ul><ul><li>... to make sure that necessary resources are available </li></ul></ul>
    18. 18. Outline 1 Case Study: Hoechst Incidents 1992 Improving Existing Plants 3 Lessons Learnt 2 Conclusions 4
    19. 19. Plant & Process Safety: improvement of existing (“old”) plants 3 <ul><li>Make best use of limited resources by a stepwise approach: </li></ul><ul><ul><li>Have full knowledge about hazardous properties of all substances (e.g. Material Safety Data Sheets, data bases, etc.) </li></ul></ul><ul><ul><li>Identify and rank critical points (human- and eco – toxicity, hold-up of hazardous substances, reaction conditions, mechanical and physical hazards) </li></ul></ul><ul><ul><li>Document this in a safety study as a tool for use by the plant and by authorities </li></ul></ul><ul><ul><li>Focus improvements (manpower, money, additional safeguards etc.) and inspections on the most critical points </li></ul></ul><ul><ul><li>The higher the risk, the more independent safeguards (“barriers”) should be considered </li></ul></ul><ul><ul><li>Use the scenarios developed under (2) for emergency planning </li></ul></ul>
    20. 20. “ Swiss Cheese Model” (after J. Reason, modified by Mike Broadribb, BP) Lagging Indicator Leading Indicator
    21. 21. Plant & Process Safety: Use existing knowledge 3 <ul><li>Most accidents and eco – incidents have a previous history ... </li></ul><ul><ul><li>Preliminary events leading up to the accidents (failure of preliminary safeguards) have not been identified </li></ul></ul><ul><ul><li>Prior to most major accidents similar smaller incidents or near misses have happened, but not evaluated </li></ul></ul><ul><li>... which should be used for prevention </li></ul><ul><ul><li>Raise the awareness of the workers </li></ul></ul><ul><ul><li>Use the experience of workers </li></ul></ul><ul><ul><ul><li>Encourage reporting of deviations, near misses and even minor incidents as well as suggestions for improvements. Consider contests and awards for groups working together </li></ul></ul></ul><ul><ul><ul><li>Have a system for following up such reports/suggestions </li></ul></ul></ul>
    22. 22. Plant & Process Safety: The Human Factor 3 <ul><li>Workers are risks and resources for safety </li></ul><ul><ul><li>They have to know the risks to cope with </li></ul></ul><ul><ul><li>Detailed written procedures are a tool both for workers and for management. They should ... </li></ul></ul><ul><ul><ul><li>describe the procedure as it is in the plant step by step </li></ul></ul></ul><ul><ul><ul><li>use a language and expressions which are understood by the workers (no scientific or technical paper) </li></ul></ul></ul><ul><ul><ul><li>highlight hazards, safety measures and critical process parameters (temperature, pressure, ...) </li></ul></ul></ul><ul><ul><ul><li>make independent double checks mandatory for critical parameters and procedures </li></ul></ul></ul><ul><ul><ul><li>include start-up, shut-down, maintenance and process-specific information for emergencies </li></ul></ul></ul><ul><ul><li>Use other procedures (e.g. Quality) for safety purposes, too </li></ul></ul><ul><ul><li>Include normal and abnormal situations in training </li></ul></ul>
    23. 23. Safety Operating Procedures 3 <ul><li>Examples for visualization of safety information </li></ul><ul><li>Acetone Ladders </li></ul>
    24. 24. Emergency Preparedness 3 <ul><li>Accidents may happen even in most modern plants. They cannot be planned, but they should be considered. </li></ul><ul><ul><li>Use the scenarios identified for prevention of major incidents for emergency planning and training, too </li></ul></ul><ul><ul><li>Cover all relevant scenarios in the emergency plan </li></ul></ul><ul><ul><li>Assign responsibilities rather than regulating details </li></ul></ul><ul><ul><li>The emergency organisation is different from the normal organisation, but has to be empowered to use it </li></ul></ul><ul><ul><li>Adjust the emergency organisation to the dimension of the incident (e.g. “blue, yellow, red alert”) </li></ul></ul><ul><ul><li>Clearly document all available resources (site, company, neighbouring sites, authorities, ...) for the different scenarios. Ensure that they can be used in emergencies (e.g. co-operative agreements) </li></ul></ul><ul><ul><li>Before you rely on off-site resources, consider the time until availability </li></ul></ul><ul><ul><li>Industrial zones with many companies close together need special attention (“domino-effects”) </li></ul></ul>
    25. 25. Emergency Response 3 <ul><li>The basic principle: the faster and more effective the initial response, the smaller the consequences for men, environment and economy. </li></ul><ul><ul><li>Provide the infrastructure for fast response (fire brigade, emergency control room, notification and availability of key personnel, etc.) </li></ul></ul><ul><ul><li>Encourage immediate reporting of incidents (not to wait until own efforts failed ...), do not blame for false alarms </li></ul></ul><ul><ul><li>Site fire brigades (or shared with adjacent sites) usually are faster and more efficient than municipal brigades, which rather serve as a back-up </li></ul></ul><ul><ul><li>If the fire brigade is (partly) staffed by operators be aware of the risks of understaffed production </li></ul></ul><ul><ul><li>Better start with a higher level of alarm (worst case assumption) and grade it down later than vice versa </li></ul></ul><ul><ul><li>Notify and involve public fire brigades and authorities as soon as possible </li></ul></ul><ul><ul><li>Analyse every incident and the response without blaming anyone to improve the emergency organisation </li></ul></ul>
    26. 26. T he Role of Authorities 3 <ul><li>The cooperation between authorities and companies at an incident depends on their cooperation before the incident. </li></ul><ul><ul><li>Open communication about risks and safety measures on a regular basis (e.g. in a local or regional committee) builds up trust which is urgently needed during emergency response </li></ul></ul><ul><ul><li>Authorities need to know about the possible scenarios for major accidents to do their own preparations </li></ul></ul><ul><ul><li>Authorities should have clear rules about their responsibilities in handling major incidents to avoid conflicts between the different agencies (e.g. labour safety, environment, civil protection, police etc.) </li></ul></ul><ul><ul><li>Mitigation of consequences should come first, legal prosecution of individuals responsible for the incident later </li></ul></ul>
    27. 27. Neighbours, Journalists and Environmentalists 3 <ul><li>The basic issue: Neighbours and the general public share the risks of industrial sites, but not necessarily the benefits. </li></ul><ul><ul><li>Communication of relevant risks has to be done openly and in an adequate form (“not scientific”) prior to incidents (e.g. “neighbourhood councils”, brochures, ...) </li></ul></ul><ul><ul><ul><li>to build up trust in the competence of the company to handle risks </li></ul></ul></ul><ul><ul><ul><li>to enable the neighbours to react adequately during an incident </li></ul></ul></ul><ul><ul><li>The response of neighbours etc. to incidents is strongly influenced by the company´s response to requests and complaints prior to the incident </li></ul></ul><ul><ul><li>Fast and open information after an incident is crucial </li></ul></ul><ul><ul><li>Fears and worries of neighbours etc. have to be taken seriously even if they are based on emotions rather than science </li></ul></ul><ul><ul><li>On the long term, conflicts with neighbours etc. endangers the “licence to operate” </li></ul></ul><ul><ul><li>Committees with all stakeholders as the German Commission on Process Safety are an effective tool for cooperation and communication. </li></ul></ul>
    28. 28. Outline 1 Case Study: Hoechst Incidents 1992 Improving Existing Plants 3 Lessons Learnt 2 Conclusions 4
    29. 29. Conclusions 4 <ul><ul><li>Investing in safe and eco-efficient plants pays off at least on the long term </li></ul></ul><ul><ul><li>The (remaining) risks of industrial plants can be assessed and are the basis for scenarios for emergency planning </li></ul></ul><ul><ul><li>The knowledge and experience of the operators should be used by all means </li></ul></ul><ul><ul><li>Risks should be communicated as well as benefits to all stakeholders, esp. the neighbours </li></ul></ul><ul><ul><li>The resources for emergency response (manpower, equipment, communications, organisation etc) have to be planned in advance and readily available in case of an incident. People usually accept the risk of a chemical/pharmaceutical plant, but not incompetence in handling it </li></ul></ul><ul><ul><li>Authorities should involve themselves actively in emergency planning, balancing this out with their law enforcement duties </li></ul></ul><ul><ul><li>Combined efforts will definitely lead to safer and more accepted plants, as the figures from Germany may show </li></ul></ul>
    30. 30. Development of Accidents in Germany since 1950 4 „ Arbeitsunfälle“ = occupational accidents „ Wegeunfälle“ = acc. on the way to work
    31. 31. Thank you for your attention!

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