Critical Review of PSM In Petroleum Industry | Mr. Hirak Dutta, Executive Director, Oil Industry Safety Directorate
Oil Industry Safety Directorate
27th Sept, 2013
Size of Petroleum Industry in India
Pillars of PSM
Systemic approach in PSM
Ignoring warning signals & its consequences
OISD’s focus in ‘Process Safety Management’
Cornerstones of PSM
Size of the Petroleum Industry in India
Once a petroleum product deficit country, India today is exporter of
petroleum products with earnings to the tune of US $ 60 billion per
CAPACITY Current Projected
Total Installed refining capacity ~ 215 MMTPA 310.9 MMTPA
Crude oil production capacity ~ 38 MMTPA 41.1 MMTPA
Gas Production capacity ~ 43 BCMPA 90.1 BCMPA
Volume of POL handling ~ 152 MMTPA 186.2 MMTPA
Petroleum Industry in India
India is the 4th largest consumer (at 569 Million Metric
Tonnes of Oil Equivalent) in the year 2011, after China,
US & Russia.
Petroleum Industry plays a vital role in providing energy
security, and contributes towards the overall growth of
Oil & gas Installations normally operate within high
temperature & pressure envelope; handling highly
hazardous & inflammable HCs.
Therefore, preservation and safety of these vital National
assets are of paramount importance.
Pillars of Process Safety
Equipment Fire Fighting
Systemic Approach in Process Safety
Learn from Near Misses
Change Mgmt. System
Continuous training &
Review of P&ID
Inc. best engg. Practices
3D Model Review
Alarms in Control
Pre-com Check list
Blow down System
Prior to any major accident there are always
warning signs which, had they been responded to,
would have averted the incident.
But they weren’t.
They were ignored.
Very often there is a whole culture of denial
operating to suppress these warning signals.
Professor Andrew Hopkins
Process equipment not functioning as intended.
Frequent process excursions outside the safe operating
Continuing Operation with impaired safeguards.
Critical safety systems kept in bypassed mode or not
functioning as intended or not tested.
Frequent process upsets.
Tolerance to failure to follow company’s systems and
Failure to learn from near misses or previous incidents.
Minor incidents not being reported.
Repeat findings occur in the subsequent audits.
Inadequacies in safety management system like failure to
perform hazard analysis, failure to recognize & manage
change, inadequate follow up on warning signs/ indicators.
Common response by organization
Ignores signals on the premise that these
can be addressed later
(or if the problem escalates).
Illustration on failure to recognize
• Failed to recognize that the level gauges were not working properly/
instrumentation system not working.
• The critical safety system was kept bypassed / not working properly for a
long period/ No MOC/ improper maintenance.
• 70 % metal loss in gas oil draw-off line from CDU; under the
insulation corrosion; pointed out by inspection.
• Inclement weather - cyclonic conditions; Dynamic positioner of rescue
vessel perhaps impaired.
Illustrations on failure to recognize
• Ignored the early signal i.e. drop in the pipeline pressure
noted in the control room due to rupture of the LPG
• Short-cuts in Maintenance activities - PSV of the
condensate pump removed but the end flange blinded
loosely - hand tightened; Failure to communicate the same
by shift operator to the next shift personnel; continued
operation with improper fire fighting facilities.
• Instrumentation cable was impaired /equipment not
meeting good engineering practices.
Strategy for response
Recognize a warning sign
Focus resources and efforts
on gap liquidation
situation to find
Follow up to
ensure the issue is
to SOP 24
to Work permit
Reasons for accidents
Risks are not identified; even where HAZOP study has
been carried out mitigation measures not taken.
Improper focus on Asset Integrity Management;
Disregard to the extant systems & procedures.
Inadequate personnel competency
Violation of standard operating procedure.
Knowledge gap & poor supervision.
Holistic approach to HSE and Asset Integrity
Management is needed to avert major accidents.
Hazardous industry like ours must ensure that the
lessons learnt from the accidents are incorporated
into the safety management system.
High concern/focus on achieving throughputs and
maximizing GRM negatively impacts safety: Safety
should not be subservient to achievement of targets.
Benchmarking the safety performance parameters is
needed to achieve improvements in Process Safety
Key Lessons (contd.)
When near-miss / accidents occur:
Diagnose the systematic failure.
Don’t look at only what went wrong but recognize
the hazards & way to control the same.
Objectively carry-out accident-incident
Not for fault finding purpose
To identify root causes
To improve the system & avoid recurrence.
Building a safety culture through inspiring leadership
at all levels is a must.
Focus should be more on leading rather than lagging
Always adhere to inherent safety principles.
Safety is 24X7 activity; yesterday’s good safety
performance does not guarantee todays safety.
No substitute for high diligence thus employee
engagement is foremost.
Key Lessons (contd.)
On the following drivers:
Procedures for operation and maintenance (SOP)
Risk reduction Action Plan
Focus on leading indicators
Management of change
Permit to work
Critical controls (bypass policy)
Process safety training