Lp2007 216
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The paper provides an illustration of how some control measures are identified as “critical control measures” and how examples of identifying “critical events” related to “critical control measures” from incidents, monitoring programs and annual reviews of performance measures lead to continuous improvement of safety and a high degree of assurance that Major Hazard Incidents can be prevented.
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Lp2007 216
- 1. “Critical Events” Applying Continuous Improvement to Incident Reporting Nigel Cann General Manager Australian Vinyls
- 2. Buncefield
- 3. Texas City
- 4. Flixborough 1 June 1974 •Modification Control •Use suitably trained, educated and responsible people •Know what you don’t know
- 5. Seveso July 1976 • Understanding safe state to leave reactions • Multiple layers of protection • Automated Reaction stop systems for exothermic systems
- 6. Piper Alpha 6 July 1988 •Good functioning Permit to Work System including monitoring •Never defeat Safety Systems •Understand the hazards, their consequences and fit appropriate control measures
- 7. Longford 25 September 1998 Sale Barry Beach Marine Terminal Long Island Point Fractionation Plant, Crude Oil Tank Farm and Liquids Jetty Longford Gas & Oil Processing Port Phillip Bay c Melbourne Altona Monotower Sub-sea Well Oil Platform Gas Platform Concrete Structure Barracouta Marlin Snapper Gooding Compression (GTC) c c • “cold temperatures” • Training needs to impart and refresh knowledge. • Must identify other hazards and provide relevant training. •Corporate knowledge must be captured and kept alive
- 9. All of these introduced Major Hazards Legislation • In Victoria, Australia – Occupational Health and Safety (Major Hazard Facilities) Regulations 2000 – Victoria giving effect to the National Code of Practice for Major Hazard Facilities
- 14. Occupational Health and Safety (Major Hazard Facilities) Regulations 2000 • 302 Identification of major incidents and hazards • 303 (1) …must conduct a comprehensive and systematic safety assessment… • 304 (1) … must adopt control measures which… • 306 (1) … must review, and as necessary revise…
- 15. The Deming PDCA Model PlanAct DoCheck What Major Incidents can occur?
- 16. What Major Incidents can occur? PlanAct DoCheck What Hazards exist that can cause those Incidents?
- 17. What Major Incidents can occur? What Hazards exist that can cause those Incidents? PlanAct DoCheck What Control Measures can be used to manage and contain those hazards?
- 18. What Major Incidents can occur? What Hazards exist that can cause those Incidents? What Control Measures can be used to manage and contain those hazards? PlanAct DoCheck What Safety Management System (SMS) Maintains those Control measures?
- 19. What Major Incidents can occur? What Hazards exist that can cause those Incidents? What Control Measures can be used to manage and contain those hazards? What Safety Management System (SMS) maintains those control measures? The Deming PDCA Model PlanAct DoCheck How does the Operator maintain SMS performance by reviewing KPI’s and SOP’s?
- 20. Australian Vinyls STRIPPING COLUMN DEGASSER AUTOCLAVES STEAM ADDITIVES VCM TANKER CHARGE WATER VCM GAS HOLDER LIQUID VCM STORAGE VCM RECOVERY PLANT BAGGING AND PALLETIZING BULK SUPPLY SLURRY TANK STORAGE SILO FLUID BED DRYER CENTRIFUGE PACKAGED SUPPLY
- 21. Plan Government Level Acts Regulations Codes of Practice and other guidance Commonwealth 7 7 20 Victorian State 18 29 28 Local Laws 2
- 22. Plan • Safety Management Systems should not exist! • Identify a framework – ISO 9000 & 14000 series – API 9100 – AS/NZS 4801 – AS ISO/IEC 17025
- 23. Maintaining performance via a SMS • Top Down • Permit to Work System • Induction procedures • Control of Third Parties • Auditing program • Purchasing procedures • Recruiting processes • Personnel and organisational change processes • Engineering Modification controls • Emergency Response Procedures • Incident Investigation processes • Bottom up – Identified control measures must be managed – Set Performance Standards – Put in place Monitoring Systems – AUDIT – Draw conclusions and take action to close the loop.
- 24. • Need to develop robust system – Eg HAZOP keywords • Be systematic in identifying Incidents – Recommend use of LOC • Use of Databases and “Bow ties” Hazard Identification and Safety Assessment
- 25. The Laverton Resin Plant
- 26. Hole > 150mm in Storage Tank HAZARD S • Working wrong tank •Corrosion •Vehicle Hits it •Flange breaks •Overpressure •Fire under tank •Bullet Hole •Overfilling •Wrong Material Tank Design Control Measures Control Measures Hazard & Control Measure Identification •Permit to Work •Barriers •Speed Limit •Signs •Stand by •Security •Bunds
- 27. How does a Control Measure become CRITICAL?
- 29. Hole > 150mm in Storage Tank HAZARD S • Working wrong tank •Corrosion •Vehicle Hits it •Flange breaks •Overpressure •Fire under tank •Bullet Hole •Overfilling •Wrong Material Tank Design Control Measures Control Measures Hazard & Control Measure Identification •Permit to Work •Barriers •Speed Limit •Signs •Stand by •Security •Bunds
- 30. Hole > 150mm in Storage Tank HAZARDS • Working wrong tank •Corrosion •Vehicle Hits it •Flange breaks •Overpressure •Fire under tank •Bullet Hole •Overfilling •Wrong Material Tank Design •Relief Valves •Gasholder Venting Procedure •High Pressure Alarms •Return to Service Procedure Control Measures Control Measures Hazard & Control Measure Identification
- 31. Draw a “Bow-Tie” Hole > 150mm in Storage Tank Tank Design Vessel exceeds pressure Relief Valves Procedure for venting to gasholder High Pressure Alarms Procedure for Return to Service Vessel out for Maintenance Air in Vessel Supports Earthquake designed Vehicle impacts supports Speed LimitRoad BarrierPTW Vehicle needs to access area
- 32. Draw a “Bow-Tie”
- 33. Derive Performance Measures – No failure on demand – No failure on testing. – As received from duty, pop test to be within 10% of setting – Inspection and test to be no more than 3 months overdue
- 35. Latent Unsafe ConditionsDecision- Makers Latent Unsafe ConditionsLine Management Latent Unsafe ConditionsPre- Conditions Active FailuresProductive Activities Active Failures and Latent Unsafe Conditions Defences The Reason “Swiss Cheese” Model: Stages to an Accident Accident & InjuryAccident & Injury
- 36. Investigation of Critical Events
- 37. Operator failed to detect significant Reaction Temperature Deviation
- 38. Operator failed to detect significant Reaction Temperature Deviation • 16 Actions that resulted 1. Resolve persistent Panel Alarms that should not be there 2. Generate list of Critical Alarms 1. Review list of Critical Alarms to see what is on DCS 2. Review list of Critical Alarms on DCS 3. Review High Pressure Alarm Recipe settings 1. Set appropriate High Pressure Limits for S1 A/C’s 2. Change High Pressure Limits for S1 4. Check S2 Agitator Motor Current settings in DCS 3. Review Trip 18 conditions on DCS 4. Reinforce the importance of the Panel with CRO’s
- 39. Operator failed to detect significant Reaction Temperature Deviation 5. Specify Temperature Deviation alarm sensitivity at either end of phase 6 1. Change Temperature Deviation Alarm Sensitivity at either end of phase 6 6. Check DCS for S2 Temperature Deviation Alarms 1. Put Temperature Deviation Alarm on DCS 7. Alarm Controller Output of 09 Valves 8. Assess Effectiveness and Completeness of changes to DCS alarms
- 41. Suggestions for other Industries • Flammable, Toxic or Radioactive Materials – LOC
- 42. Suggestions for other Industries • Complex Machinery – Catchpoints – Energy Sources – Access Points – Cleaning
- 43. Suggestions for other Industries • Electricity – Distribution – HV Switching – Working at Heights
- 44. Suggestions for other Industries • Public Transport, Logistics, Port Operations – Third Party collisions – Single vehicle collisions – Derailing – Lifting operations etc
- 45. SUMMARY
Editor's Notes
- Hierarchy of Controls: Eliminate Prevent Reduce Mitigate Reliance is a combination of how good is the Control measure at reducing the risk and how much confidence operators/maintainers have in its ability. Inherent Risk is a relative term assuming no controls! A pool of liquefied flammable gas is more inherently dangerous than a pool of 25% caustic Soda. MIC – how big is the bang, what damage can it do, how many people will be affected directly, indirectly.
- We can describe an incident or an accident as involving latent unsafe conditions that are waiting for the influence of an active failure. At the top end Decision Makers drive for performance over safety – Longford – or fail to act to put in appropraite rules (NSW currently?) Line Managers don’t apply Management Systems on site at a working level, fail to monitor and correct. Focus on Slips, Trips and falls rather than MHI presusers. The Active failures play a part. A worker makes a mistake, an unexpected deviation from raw material input, maintenance done on the wrong piece of equipment, no systems to check for corrosion etc. Finally defences are weakened – alarm overload, untrained emergency response, trip fails due to poor maintenance, fire system leaks or valve left closed… All these precursers can prevent MHI’s. Andrew Hopkins – “if only for…”