Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
Lessons from a Management of Change
Incident
Nigel Cann, Arup
FIChemE, CEng, CEnv, RPEQ
Nigel.cann@arup.com
2
What we will cover…
• Timing of incident
• Plant process
• Plant Layout
• Incident Event
• AcciMap of Incident
• Actions...
33
Incident Timing
Timing
5 Oct 98 – I started
4
Production Process
STRIPPING
COLUMN
DEGASSER
AUTOCLAVES
STEAM
ADDITIVES
VCM TANKER
CHARGE WATER
VCM GAS
HOLDER
LIQUID VC...
Plant Layout
5 Layout
6 Layout
7
8 The Incident
9
AcciMap – Modification Control Incident
AcciMap of Modification Control Incident
Accident
Sequence
Governance /
Organisa...
10 AcciMap of Modification Control Incident
Accident
Sequence
Governance /
Organisational
Regulatory
Outcomes
3500kg VCM L...
1. Modification Control System
• Development of Electronic system
• Checksheet and reviewer inputs requiring comments
• Au...
12 AcciMap of Modification Control Incident
Accident
Sequence
Governance /
Organisational
Regulatory
Outcomes
3500kg VCM L...
13
2. Remove Utilities from Process
• Utility steam and air not intended for connection to
process streams
• Generally low...
14 AcciMap of Modification Control Incident
Accident
Sequence
Governance /
Organisational
Regulatory
Outcomes
3500kg VCM L...
15
3. Exemplar Safety Case Program
• Recognition needed to do something different
• Would need to do it twice
• Capture co...
16
AcciMap – Modification Control Incident
AcciMap of Modification Control Incident
Accident
Sequence
Governance /
Organis...
17
4. Training and Development
• First Aid
• Emergency
• Chemical
Awareness
• Fire Fighting
• Working at Heights
• Permit ...
18
Internal Audit - 2007
• 1 months MoCs 6 months previous
• Automated system functioning well and well accepted.
• Mods a...
19
Summary – Process Safety Control
Process Safety Fundamentals
Process
Safety
Control
Inherent Design Safety
20
What QUESTIONS do you have?
Questions
Upcoming SlideShare
Loading in …5
×

N cann haz aus 2013 mo c final

190 views

Published on

Lessons from a Management of Change incident utilizing AcciMap to identify causes to address including: Management of change system, Utilitiy connections to process, regulatory oversight and training

Published in: Leadership & Management
  • Be the first to like this

N cann haz aus 2013 mo c final

  1. 1. Lessons from a Management of Change Incident Nigel Cann, Arup FIChemE, CEng, CEnv, RPEQ Nigel.cann@arup.com
  2. 2. 2 What we will cover… • Timing of incident • Plant process • Plant Layout • Incident Event • AcciMap of Incident • Actions that followed • What questions do you have? Agenda
  3. 3. 33 Incident Timing Timing 5 Oct 98 – I started
  4. 4. 4 Production Process 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 Production Process
  5. 5. Plant Layout 5 Layout
  6. 6. 6 Layout
  7. 7. 7
  8. 8. 8 The Incident
  9. 9. 9 AcciMap – Modification Control Incident AcciMap of Modification Control Incident Accident Sequence Governance / Organisational Regulatory Outcomes 3500kg VCM LoC via steam trapsVCM is in Utility Steam System Operator missed H2O/VCM interface Disperses in atmosphere or absorbed in water spray Human and Environmental Factors Was Operator present? Liquid VCM in Receiver Reliance on NRV Cold weather – autumn night 1. Poor Mod Control paper based system Lower SEPP VCM boundary limits 1. HAZOP boundary not including existing plant when additional capacity added 3. Poor Regulatory Oversight Back pressure in Receiver Orifice Plate inserted when additional production stream added Equipment and Design Steam used to scrub Receiver Water Orifice Plate blocked by ice Block in VCM vapour line to Recovery Water mostly in other Recovery Tank Operator observation of difficult venting not addressed 4. Loss of Plant learning culture 2. Utilities connected to Process Organisation focus on Environmental Improvements
  10. 10. 10 AcciMap of Modification Control Incident Accident Sequence Governance / Organisational Regulatory Outcomes 3500kg VCM LoC via steam trapsVCM is in Utility Steam System Operator missed H2O/VCM interface Disperses in atmosphere or absorbed in water spray Human and Environmental Factors Was Operator present? Liquid VCM in Receiver Reliance on NRV Cold weather – autumn night 1. Poor Mod Control paper based system Lower SEPP VCM boundary limits 1. HAZOP boundary not including existing plant when additional capacity added 3. Poor Regulatory Oversight Back pressure in Receiver Orifice Plate inserted when additional production stream added Equipment and Design Steam used to scrub Receiver Water Orifice Plate blocked by ice Block in VCM vapour line to Recovery Water mostly in other Recovery Tank Operator observation of difficult venting not addressed 4. Loss of Plant learning culture 2. Utilities connected to Process Organisation focus on Environmental Improvements
  11. 11. 1. Modification Control System • Development of Electronic system • Checksheet and reviewer inputs requiring comments • Authoriser provided details of comments, usually assigned conditions • Details of HAZOP and Review actions assigned and followed up via Actions Review • Notifications via email • Pre-commissioning and Post commissioning checks. • OH&S signoff 1. Poor Mod Control paper based system 1. HAZOP boundary not including existing plant when additional capacity added 11 Modification Control System
  12. 12. 12 AcciMap of Modification Control Incident Accident Sequence Governance / Organisational Regulatory Outcomes 3500kg VCM LoC via steam trapsVCM is in Utility Steam System Operator missed H2O/VCM interface Disperses in atmosphere or absorbed in water spray Human and Environmental Factors Was Operator present? Liquid VCM in Receiver Reliance on NRV Cold weather – autumn night 1. Poor Mod Control paper based system Lower SEPP VCM boundary limits 1. HAZOP boundary not including existing plant when additional capacity added 3. Poor Regulatory Oversight Back pressure in Receiver Orifice Plate inserted when additional production stream added Equipment and Design Steam used to scrub Receiver Water Orifice Plate blocked by ice Block in VCM vapour line to Recovery Water mostly in other Recovery Tank Operator observation of difficult venting not addressed 4. Loss of Plant learning culture 2. Utilities connected to Process Organisation focus on Environmental Improvements
  13. 13. 13 2. Remove Utilities from Process • Utility steam and air not intended for connection to process streams • Generally lower pressure than process units can get • Process streams need proper pressure and or flow control – NRV’s fail • (This was another indicator of loss of integrity originally designed in). 2. Utilities connected to Process Utilities
  14. 14. 14 AcciMap of Modification Control Incident Accident Sequence Governance / Organisational Regulatory Outcomes 3500kg VCM LoC via steam trapsVCM is in Utility Steam System Operator missed H2O/VCM interface Disperses in atmosphere or absorbed in water spray Human and Environmental Factors Was Operator present? Liquid VCM in Receiver Reliance on NRV Cold weather – autumn night 1. Poor Mod Control paper based system Lower SEPP VCM boundary limits 1. HAZOP boundary not including existing plant when additional capacity added 3. Poor Regulatory Oversight Back pressure in Receiver Orifice Plate inserted when additional production stream added Equipment and Design Steam used to scrub Receiver Water Orifice Plate blocked by ice Block in VCM vapour line to Recovery Water mostly in other Recovery Tank Operator observation of difficult venting not addressed 4. Loss of Plant learning culture 2. Utilities connected to Process Organisation focus on Environmental Improvements
  15. 15. 15 3. Exemplar Safety Case Program • Recognition needed to do something different • Would need to do it twice • Capture corporate knowledge • Wanted to be a leader • It was an unknown quantity • Opportunity to learn and share lessons Exemplar Safety Case 3. Poor Regulatory Oversight
  16. 16. 16 AcciMap – Modification Control Incident AcciMap of Modification Control Incident Accident Sequence Governance / Organisational Regulatory Outcomes 3500kg VCM LoC via steam trapsVCM is in Utility Steam System Operator missed H2O/VCM interface Disperses in atmosphere or absorbed in water spray Human and Environmental Factors Was Operator present? Liquid VCM in Receiver Reliance on NRV Cold weather – autumn night 1. Poor Mod Control paper based system Lower SEPP VCM boundary limits 1. HAZOP boundary not including existing plant when additional capacity added 3. Poor Regulatory Oversight Back pressure in Receiver Orifice Plate inserted when additional production stream added Equipment and Design Steam used to scrub Receiver Water Orifice Plate blocked by ice Block in VCM vapour line to Recovery Water mostly in other Recovery Tank Operator observation of difficult venting not addressed 4. Loss of Plant learning culture 2. Utilities connected to Process Organisation focus on Environmental Improvements
  17. 17. 17 4. Training and Development • First Aid • Emergency • Chemical Awareness • Fire Fighting • Working at Heights • Permit to Work • Critical Systems Training 4. Loss of Plant learning culture • OH&S Legislation • Natural Gas, Boilers and Water Quality • Project Management
  18. 18. 18 Internal Audit - 2007 • 1 months MoCs 6 months previous • Automated system functioning well and well accepted. • Mods allocated appropriate process • Mods allocated to correct personnel for review • Implementers frustrated at time to close out: • Procedures, drawings, training materials • Less concerned at safety checks and hit sheets • Changes to personnel were going through formal review processes • Small number of personnel had not completed training Internal Audit
  19. 19. 19 Summary – Process Safety Control Process Safety Fundamentals Process Safety Control Inherent Design Safety
  20. 20. 20 What QUESTIONS do you have? Questions

×