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Hirak Dutta
Executive Director
Oil Industry Safety Directorate
27th Sept, 2013
Agenda
 Size of Petroleum Industry in India
 Pillars of PSM
 Systemic approach in PSM
 Ignoring warning signals & its ...
Size of the Petroleum Industry in India
Once a petroleum product deficit country, India today is exporter of
petroleum pro...
Petroleum Industry in India
 India is the 4th largest consumer (at 569 Million Metric
Tonnes of Oil Equivalent) in the ye...
Process Safety
Management
Pillars of Process Safety
Process Safety
Operational
Integrity
Maintenance
Integrity
Asset
Integrity
Design
Construction
Startup
Shut down
Emergency
Handling
System &
Procedures Best
Practices
Warning
Devices Engineered
Saf...
Accidents do not
happen just like
that…
Prior to any major accident there are always
warning signs which, had they been responded to,
would have averted the incid...
Warning signals
 Process equipment not functioning as intended.
 Frequent process excursions outside the safe operating
...
Warning signals
Common response by organization
Ignores signals on the premise that these
can be addressed later
(or if th...
Illustration on failure to recognize
warning signals
Buncefield
• Failed to recognize that the level gauges were not worki...
Illustrations on failure to recognize
warning signals
Pemex, Mexico
• Ignored the early signal i.e. drop in the pipeline p...
Strategy for response
Recognize a warning sign
Focus resources and efforts
on gap liquidation
Investigate the
situation to...
CAUSE
Total
Incidents
Non adherence
to SOP 24
Equipment
Failure 11
Non adherence
to Work permit
system
7
Miscreant
activit...
Reasons for accidents
 Risks are not identified; even where HAZOP study has
been carried out mitigation measures not take...
Key Lessons: OISDs experience
 Holistic approach to HSE and Asset Integrity
Management is needed to avert major accidents.
 Hazardous industry like ou...
Key Lessons (contd.)
 When near-miss / accidents occur:
 Diagnose the systematic failure.
 Don’t look at only what went...
 Building a safety culture through inspiring leadership
at all levels is a must.
 Focus should be more on leading rather...
On the following drivers:
 Procedures for operation and maintenance (SOP)
 Hazard Identification
 Risk reduction Action...
Cornerstones of Safety
Safety
Cornerstones of Safety
Employee Engagement
Managing Asset Integrity
Risk Assessment & Hazard Study
Adherence to Sys...
Thank you for your patience
Questions?
Critical Review of  PSM In Petroleum Industry | Mr. Hirak Dutta, Executive Director, Oil Industry Safety Directorate
Critical Review of  PSM In Petroleum Industry | Mr. Hirak Dutta, Executive Director, Oil Industry Safety Directorate
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Critical Review of PSM In Petroleum Industry | Mr. Hirak Dutta, Executive Director, Oil Industry Safety Directorate

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Global HSE Conference | Sept 26-27 | New Delhi | India

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Critical Review of PSM In Petroleum Industry | Mr. Hirak Dutta, Executive Director, Oil Industry Safety Directorate

  1. 1. Hirak Dutta Executive Director Oil Industry Safety Directorate 27th Sept, 2013
  2. 2. Agenda  Size of Petroleum Industry in India  Pillars of PSM  Systemic approach in PSM  Ignoring warning signals & its consequences  Key Lessons  OISD’s focus in ‘Process Safety Management’  Cornerstones of PSM
  3. 3. 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 annum CAPACITY Current Projected (2016-17) 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
  4. 4. 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 the country.  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.
  5. 5. Process Safety Management
  6. 6. Pillars of Process Safety Process Safety Operational Integrity Maintenance Integrity Asset Integrity
  7. 7. Design Construction Startup Shut down Emergency Handling System & Procedures Best Practices Warning Devices Engineered Safety Devices Safety Equipment Fire Fighting Facilities Event Systemic Approach in Process Safety Management  Learn from Near Misses  Mock Drills  Task Observation  Accident-Incident  Change Mgmt. System  Continuous training & Education  Work Permit  Internal Audit  Review of P&ID  QRA/HAZOP  Inc. best engg. Practices  Safety Instrumentation  3D Model Review  PSV  ESD  BOP  SCSSCV Hazards  HC Detector  Alarms in Control Room  SOP  Simulator  Pre-com Check list  Blow down System  Equipment Spacing  Deluge
  8. 8. Accidents do not happen just like that…
  9. 9. 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
  10. 10. Warning signals  Process equipment not functioning as intended.  Frequent process excursions outside the safe operating envelope.  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 procedures.  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.
  11. 11. Warning signals Common response by organization Ignores signals on the premise that these can be addressed later (or if the problem escalates).
  12. 12. Illustration on failure to recognize warning signals Buncefield • Failed to recognize that the level gauges were not working properly/ instrumentation system not working. Bhopal • The critical safety system was kept bypassed / not working properly for a long period/ No MOC/ improper maintenance. Richmond, California • 70 % metal loss in gas oil draw-off line from CDU; under the insulation corrosion; pointed out by inspection. MHN • Inclement weather - cyclonic conditions; Dynamic positioner of rescue vessel perhaps impaired.
  13. 13. Illustrations on failure to recognize warning signals Pemex, Mexico • Ignored the early signal i.e. drop in the pipeline pressure noted in the control room due to rupture of the LPG pipeline. Piper Alpha • 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. Jaipur • Instrumentation cable was impaired /equipment not meeting good engineering practices.
  14. 14. Strategy for response Recognize a warning sign Focus resources and efforts on gap liquidation Investigate the situation to find facts Follow up to ensure the issue is addressed Response Strategy
  15. 15. CAUSE Total Incidents Non adherence to SOP 24 Equipment Failure 11 Non adherence to Work permit system 7 Miscreant activities 8 Lack of Supervision 6 Slip/fall, Negligence 14 Total 70 Non adherence to SOP 34% Equipment Failure 16% Non adherence to Work permit system 10% Micreant activities 11% Lack of Supervision 9% Slip/fall, Negligence 20% Major Incidents:2012-13 (In plant)
  16. 16. 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; poor reliability.  Disregard to the extant systems & procedures.  Inadequate personnel competency  Violation of standard operating procedure.  Knowledge gap & poor supervision.
  17. 17. Key Lessons: OISDs experience
  18. 18.  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 Management. Key Lessons
  19. 19. 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 analysis:  Not for fault finding purpose  To identify root causes  To improve the system & avoid recurrence.
  20. 20.  Building a safety culture through inspiring leadership at all levels is a must.  Focus should be more on leading rather than lagging indicators.  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.)
  21. 21. On the following drivers:  Procedures for operation and maintenance (SOP)  Hazard Identification  Risk reduction Action Plan  Focus on leading indicators  Management of change  Permit to work  Plant integrity  Critical controls (bypass policy)  Incident investigation  Process safety training  Emergency preparedness OISD’s Focus
  22. 22. Cornerstones of Safety
  23. 23. Safety Cornerstones of Safety Employee Engagement Managing Asset Integrity Risk Assessment & Hazard Study Adherence to System & ProceduresAccident Incident Analysis Management of Change
  24. 24. Thank you for your patience Questions?

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