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N cann haz aus 2013 ptw presentation

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Lessons from a Permit to Work incident with includes an AcciMap of the key findings that include poor management control, poor handover, no fatigue management, training, system, regulatory oversight and a process issue.

Published in: Leadership & Management
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N cann haz aus 2013 ptw presentation

  1. 1. Lessons from a Permit to Work 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. 3 Incident Timing Timing 5 Oct 98 – I started
  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 4 Process
  5. 5. Plant Layout 5 Layout
  6. 6. The Incident 6 Incident
  7. 7. 7 LinkedIn – discussion groups LinkedIn
  8. 8. Longford - AcciMaps 8 AcciMap
  9. 9. 9 AcciMap – Permit to Work Incident AcciMap of Permit to Work Incident Accident Sequence Organisational Governance Regulatory Outcomes VCM released to environment Ritag valve opened, pathway to atmosphere Working on Wrong autoclave Spool opening to remove build up Disperses in atmosphere Sister autoclave on hold Human Factors Turned wrong way 2. No checking b4 manual valve operation 4. Poor signage 1. Poor PTW Management Control 2. Poor shift handover control 2. No Fatigue Control 3. Inadequate training in PTW system 5. Poor Regulatory Oversight Fatigue Desire to finish job 6. Build up problem unsolved Assistant on first day on site 3. Inadequate Training System
  10. 10. 10 AcciMap – Permit to Work Incident AcciMap of Permit to Work Incident Accident Sequence Organisational Governance Regulatory Outcomes VCM released to environment Ritag valve opened, pathway to atmosphere Working on Wrong autoclave Spool opening to remove build up Disperses in atmosphere Sister autoclave on hold Human Factors Turned wrong way 2. No checking b4 manual valve operation 4. Poor signage 1. Poor PTW Management Control 2. Poor shift handover control 2. No Fatigue Control 3. Inadequate training in PTW system 5. Poor Regulatory Oversight Fatigue Desire to finish job 6. Build up problem unsolved Assistant on first day on site 3. Inadequate Training System
  11. 11. 11 1. Redesign Permit to Work System • Seven international standards and guidelines reviewed • Parent companies, API, HSE, IChemE, Confined Space Regs • PTWs signed in field • JSA to be prepared by work teams • Monitoring program revamped • Response plans for standbys • Rescue equipment in place before start • Induction improvements PTW System 1. Poor PTW Management Control
  12. 12. 12 AcciMap – Permit to Work Incident AcciMap of Permit to Work Incident Accident Sequence Organisational Governance Regulatory Outcomes VCM released to environment Ritag valve opened, pathway to atmosphere Working on Wrong autoclave Spool opening to remove build up Disperses in atmosphere Sister autoclave on hold Human Factors Turned wrong way 2. No checking b4 manual valve operation 4. Poor signage 1. Poor PTW Management Control 2. Poor shift handover control 2. No Fatigue Control 3. Inadequate training in PTW system 5. Poor Regulatory Oversight Fatigue Desire to finish job 6. Build up problem unsolved Assistant on first day on site 3. Inadequate Training System
  13. 13. 13 2. PTW Authoriser Changes • PTW signed in field • PTW authorization ended at shift change • Enforced a rest period • New shift aware • Changing conditions to be considered: • Weather • Temperature • Fatigue Authorisers 2. No checking b4 manual valve operation 2. Poor shift handover control
  14. 14. 14 AcciMap – Permit to Work Incident AcciMap of Permit to Work Incident Accident Sequence Organisational Governance Regulatory Outcomes VCM released to environment Ritag valve opened, pathway to atmosphere Working on Wrong autoclave Spool opening to remove build up Disperses in atmosphere Sister autoclave on hold Human Factors Turned wrong way 2. No checking b4 manual valve operation 4. Poor signage 1. Poor PTW Management Control 2. Poor shift handover control 2. No Fatigue Control 3. Inadequate training in PTW system 5. Poor Regulatory Oversight Fatigue Desire to finish job 6. Build up problem unsolved Assistant on first day on site 3. Inadequate Training System
  15. 15. 15 3. Training in Permit to Work • PTW training for different user types • Validators for all high risk work • Hot Work in Zone 1 • Working at Heights • Confined Space Entry • Building Cavity • Roof • Near Radiation Sources • Authorisers and Validators went through same training/testing • Verbal test (had to have working knowledge) • Demonstration of PTW issue PTW Training 3. Inadequate training in PTW system 3. Inadequate Training System
  16. 16. 16 AcciMap – Permit to Work Incident AcciMap of Permit to Work Incident Accident Sequence Organisational Governance Regulatory Outcomes VCM released to environment Ritag valve opened, pathway to atmosphere Working on Wrong autoclave Spool opening to remove build up Disperses in atmosphere Sister autoclave on hold Human Factors Turned wrong way 2. No checking b4 manual valve operation 4. Poor signage 1. Poor PTW Management Control 2. Poor shift handover control 2. No Fatigue Control 3. Inadequate training in PTW system 5. Poor Regulatory Oversight Fatigue Desire to finish job 6. Build up problem unsolved Assistant on first day on site 3. Inadequate Training System
  17. 17. 17 4. Signage Signs 4. Poor signage
  18. 18. 18 AcciMap – Permit to Work Incident AcciMap of Permit to Work Incident Accident Sequence Organisational Governance Regulatory Outcomes VCM released to environment Ritag valve opened, pathway to atmosphere Working on Wrong autoclave Spool opening to remove build up Disperses in atmosphere Sister autoclave on hold Human Factors Turned wrong way 2. No checking b4 manual valve operation 4. Poor signage 1. Poor PTW Management Control 2. Poor shift handover control 2. No Fatigue Control 3. Inadequate training in PTW system 5. Poor Regulatory Oversight Fatigue Desire to finish job 6. Build up problem unsolved Assistant on first day on site 3. Inadequate Training System
  19. 19. 19 5. Stakeholder Group Stakeholder 1/2 5. Poor Regulatory Oversight • Trust development • Engagement • Involvement • Reporting – Progress and Issues • Someone to tell the good things to • Formal Environmental Improvement Plan
  20. 20. 20 5. Stakeholder Group Stakeholder 2/2 Do: • Be Honest • Listen • Explain technical issues using simple language and analogies • Trust and be prepared to expose issues • Get members involved - Investigations - Exercises Don’t! • Try to hide bad news • Dismiss concerns because they are unscientific • Hide behind technicalities and jargon • Hide behind lawyers • Avoid getting members involved • Use a PR person
  21. 21. 21 AcciMap – Permit to Work Incident AcciMap of Permit to Work Incident Accident Sequence Organisational Governance Regulatory Outcomes VCM released to environment Ritag valve opened, pathway to atmosphere Working on Wrong autoclave Spool opening to remove build up Disperses in atmosphere Sister autoclave on hold Human Factors Turned wrong way 2. No checking b4 manual valve operation 4. Poor signage 1. Poor PTW Management Control 2. Poor shift handover control 2. No Fatigue Control 3. Inadequate training in PTW system 5. Poor Regulatory Oversight Fatigue Desire to finish job 6. Build up problem unsolved Assistant on first day on site 3. Inadequate Training System
  22. 22. 22 6. Build Up Problem Buildup 1/2 6. Build up problem unsolved 50% 200% 150% 100%
  23. 23. 23 6. Build Up Problem Buildup – 2/2 6. Build up problem unsolved
  24. 24. 24 SUMMARY – Permit to Work Incident • Permit to Work Controls are essential in High Hazard Industry - (Featured in 50% bow ties) • Lessons from this Incident are: - Shift handover control - Fatigue and Rest - Signs and communication - Maintenance and operations sharing responsibility - Training and testing • What I don’t see others doing… - Field sign on - Clear responsibility at worksite - Escape and emergency plans - Emergency preparedness Summary
  25. 25. 25 What QUESTIONS do you have? Questions

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