Operational discipline in practices - Build the safety culture
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- 1. See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/344809410 Operational discipline in practice Article in Process Safety Progress Β· June 2021 DOI: 10.1002/prs.12207 CITATIONS 6 READS 1,945 5 authors, including: Muhammad Imran Rashid University of Engineering and Technology, Lahore 48 PUBLICATIONS 585 CITATIONS SEE PROFILE Chaudhry Haider Ali University of Engineering and Technology, Lahore 30 PUBLICATIONS 568 CITATIONS SEE PROFILE Muhammad Athar Khwaja Fareed University of Engineering & Information Technology 29 PUBLICATIONS 334 CITATIONS SEE PROFILE All content following this page was uploaded by Muhammad Imran Rashid on 23 October 2020. The user has requested enhancement of the downloaded file.
- 2. O R I G I N A L A R T I C L E Operational discipline in practice Muhammad Imran Rashid1 | Chaudhry Haider Ali1 | Kashif Mukhtar1 | Emad Benhelal2 | Muhammad Athar3,4 1 Department of Chemical, Polymer and Composite Materials Engineering, University of Engineering and Technology (KSK Campus), Lahore, Pakistan 2 Discipline of Chemical Engineering, The University of Newcastle, Newcastle, Australia 3 Centre for Advanced Process Safety (CAPS), Chemical Engineering Department, Universiti Tecknologi Petronas, Seri Iskandar, Malaysia 4 Department of Chemical Engineering, Khwaja Fareed University of Engineering and Information Technology, Rahim Yar Khan, Pakistan Correspondence Muhammad Imran Rashid, Department of Chemical, Polymer and Composite Materials Engineering, University of Engineering and Technology (KSK Campus), 39021, Lahore, Pakistan. Email: imranrashid@uet.edu.pk Abstract A general guideline to improve operational discipline is required. Operational disci- pline can be improved with simple things such as floor level meeting (FLM), job cycle check (JCC), risk assessment (RA), daily safety audit (DSA), consequence analysis (CA), mechanical integrity (MI), incident investigation (II), management of change (MOC), behavior observation (BO), pre-start up safety reviews (PSSR), process hazard analysis (PHA), job risk assessment (JRA), quantitative risk assessment (QRA), and process safety management (PSM) implementation. This article presents risks identi- fied from floor level meetings, steps for job cycle check and risk sensitivity and proce- dure for daily safety audit and behavior observation audit. Consequence analysis, pre-start up safety review and why tree analysis are discussed for improving opera- tional discipline. Inclusion of consequence analysis in work instructions is discussed. Procedure for accident investigation is elaborated by investigating trainee unit shift engineer (USE) burning injury accident and why tree diagram is constructed and find- ings and recommendations are provided. PHA techniques (HAZOP, Failure Mode and Effect Analysis) methodology is presented to enhance operational discipline. This article is especially for those industries which are located in countries where PSM implementation is not mandatory and they are lacking in operational discipline. K E Y W O R D S burn injury, consequence analysis, daily safety audit, floor level meetings, incident investigation, job cycle check, operational discipline, PHA techniques, risk sensitivity 1 | INTRODUCTION Operational discipline can be defined as a commitment and dedication to perform each task in a right way, each time and shows strength of the company's safety culture.1 Three effective process safety program foundations are safety culture and leadership, process safety systems and operational discipline.2 Operational discipline is important for all safety management systems especially process safety management (PSM) programs.3 Vaughen and Klein have discussed how poor opera- tional discipline leads to loss of containment incidents and escalates process safety risk.4 Klein has demonstrated that effectiveness and improvement of operational discipline can be judged through 11 char- acteristics.3 Klein and Vaughen have simplified these 11 organizational characteristics into four primary characteristics including leadership focus, employee involvement, practice consistent with procedures and excellent housekeeping.5 They have demonstrated why opera- tional discipline is important and its implementation for organizations and individuals. Klein et al has also demonstrated concept of opera- tional discipline, its key attributes and steps an organization can take to enhance its operational discipline and conduct of operations.6 Vaughen et al has demonstrated that implementation of a behavior based safety program has improved operational discipline of a manufacturing site.7 Klein and Francisco have discussed personal involvement required in enhancing operational discipline and DuPont's operational discipline program.8 Forest has introduced a model to facilitate operational discipline, engineering discipline and Received: 18 July 2020 Revised: 4 September 2020 Accepted: 30 September 2020 DOI: 10.1002/prs.12207 Proc Safety Prog. 2020;e12207. wileyonlinelibrary.com/journal/prs Β© 2020 American Institute of Chemical Engineers 1 of 14 https://doi.org/10.1002/prs.12207
- 3. management discipline.9 A general guideline to improve and imple- ment operational discipline for practicing industries is missing in the literature. This article provides guideline and a procedure to imple- ment operational discipline to enhance industrial process safety and safety culture and especially how operations departments can contribute in improving process safety. Here it is demonstrated that operational discipline excellence can be achieved through different acts which include process hazard analysis, task risk assessment, daily safety audit, floor level meetings, incident investigations, job cycle check, mechanical integrity and risk sensitivity. TABLE 1 Example of FLM meeting form completed after meeting for communication Floor level meeting of operation department Scope: To conduct safety meeting Participants: ---------------------------------------------------------------------------- HSE topics/issues discussed: Safety issues of ammonia, urea, utility plants ACTIONABLE POINTS Sr. No. Recommendations Responsibility Target Status (Open/ Close) Ammonia unit 1. PICe-8-789. Valve proper approach to be provided 2. ID-789-Fan, Barring door to be fixed with hinges. 3. 575# steam silencer, internal inspection is needed, because broken and corroded piece fall from it during start up. 4. 789-101-B Furnace, auxiliary burners peep holes proper approach to be provided. Urea unit 5. E-219-789-ABC Exchangers, Local drain lines are under capacity. During draining, urea splash out. Procedure modified, with P-987 urea solution will be recycled to TK-987. 6. Reactor B: main angle valve east side railing is not strong enough. 7. E-789-AF: NH3 Inlet lines missing chain valves to be provided. 8. TP-789B/789B Steam turbine: Proper approach (monkey ladder platform) to be provided for operating inlet/outlet steam isolating valves. 9. Definition or function of the Equipment/Instrument/ Machine should be mentioned in documents. Utility unit 10. Instrument air valve to ammonia/urea unit to be relocated for better approach. 11. 600#/55# steam valves at TCB-789-B needs a platform for better approach. 12. B-789-AB, Silencer to be provided for super heater vent line. Bagging and shipping unit 13. CV-789 (1-85): mesh to be provided on roller safeguard to cover the gaps 14. CV-789 (A to L): mesh to be provided on roller safeguard to cover the gaps 15. Warehouse-A-789: west side on floor grouted amaber bolts are to be removed on edge of platform 16. Ammonia filling open drain pit is to be covered with metal sheets (East-South corner of empty cylinder yards) 2 of 14 RASHID ET AL.
- 4. 2 | RISKS FROM FLOOR LEVEL MEETINGS Floor level meetings can be conducted during night or day shifts including senior engineer in charge, unit shift engineers, board panel supervisors and area process operators of each ammonia, urea, utility and bagging and shipping areas. In group meetings each participant from each facility highlights safety progress of their respective sec- tions. Employees individually pinpoint risks and hazards present on their plants or sections or sub-sections. One employee note down minutes of these meetings and these minutes are conveyed to the management for implementation and action or follow up. Highlighted risks from one floor level meeting are presented in Table 1. Chemical process industries which are not covered under PSM rule can conduct these floor level meetings to identify different risks and improve oper- ational discipline. It is recommended that each department (operation department, engineering department, process department, safety department and inspection department) conduct these meetings sepa- rately (because of the expertise in each area by each specific depart- ment) and convey identified risks and hazards to management for remedial action. Floor level meetings are useful in identifying risk situ- ations and operability issues. Addressing these issues immediately will improve conduct of operations. 3 | JOB CYCLE CHECK Klein et al has described that if operator does not use specific check- list needed for performing a given task, he has violated operational discipline.6 Job cycle check is an important task to do in each process industry. Sometimes people do same job again and again and usually get used to it or bored or fed up and do it carelessly or consider it a routine. JCC is in place for these kind of jobs for example, dissolving urea from waste urea powder in a dedicated tank. A filled JCC form for urea prill tower bucket change over is shown in Table 2. It is rec- ommended that each area operator complete this form to have better understanding of the steps involved in a task and get awareness about the risks associated with procedure deviation. Job cycle checks are useful for evaluating standard operating procedures implementation gap. JCC audits are usually performed by experienced management. JCC audits improve machines reliability and ensure smooth operation of plant. These audits make sure that operators follow standard and approved practices for their routine tasks. 4 | RISK ASSESSMENT: EXAMPLE FROM UREA UNIT Risk sensitivity can be measured by examining work instructions or standard operating procedures. Standard risk assessment form is shown in Table 3. It is better that risk sensitivity forms are completed for all work instructions or standard operating procedures and are available for unit shift engineers, trainee engineers, area operators and trainee operators. Everyone should play his role in reducing operational risks.2,10,11 Indicating risks present in day-to-day activities will reduce the accidents and improve operational discipline. Risk assessments are useful in identifying risks, hazardous situations and operability issues for tasks described in work instructions or standard operating procedures. These will be a quick source of information regarding risks before performing any task. 5 | DAILY SAFETY AUDITS Daily safety audit must be conducted daily by all employees. DSA helps to identify unsafe acts and unsafe conditions and how to avoid near miss reports. If a certain employee is busy, DSAs may be deferred for 2 or 3 days or a week but must be after consulting the area super- vision. Daily safety audits can be used to check damaged insulation, damaged earth cables of exchanger, damaged asbestos sheets, motor fan covers, motors coupling guards, steam condensate leakages, steam tracing lines insulation, drain channel covers, rain protection covers, uncovered pits, extended pipes of scaffolding in the walkways, TABLE 2 Example of JCC form to produce excellence in different routine jobs Job cycle check to control work method Section: Urea Prill Tower USE Name: __________ Trainee Operator: __________ Mentor/Evaluator/Section in Charge: _________ Tasks/Sub Tasks of Job: SB-241 change over Prepare the stand by bucket β‘ heck the stand by bucket for free rotation β‘ Close the flushing steam in reflux line β‘ Ask board supervisor to divert the valve SV-789 to tank TK-789 β‘ Operator will divert the local; selection to reflux line β‘ Check SV-789 that indication has turned from yellow to red β‘ Open flushing steam for 2 to 3 minutes for bucket flushing β‘ Reduce bucket speed to 120 RPM β‘ Check that selection at local panel is at local position β‘ Stop bucket from local panel and ensure that speed has become zero β‘ Close flushing steam valve to bucket and isolate jacketing steam β‘ Also de-pressurize the jacketing steam and disconnect steam/ condensate hose pipe β‘ Unlock the flexible flange of urea hose pipe and raise bucket β‘ Unlock and revolve the prilling device and put stand by bucket into prilling hole β‘ Turn selection to local position and turn lock to OFF position β‘ Lower the bucket in operating position and connect the steam and condensate flexible hoses β‘ Lock flexible urea hose flange and take jacketing steam in service β‘ Start the bucket and raise the speed up to 220 RPM β‘ Turn on flushing steam for 2-3 minutes to pre-heat the bucket and turn switch to feed position β‘ Ask board supervisor to start prilling and flush reflux line β‘ Open the flushing steam into reflux line and clean the stand by bucket β‘ Evaluation: OK/Not OK. If Not OK, Then Reasons from Mentor/Section in Charge: _______________ RASHID ET AL. 3 of 14
- 5. hanging sheets (metallic or asbestos), discharge lines leaky valves or bleeders and missing monkey ladder cages.12 A completed daily safety audit form is shown in Table 4. Daily safety audits are useful in identi- fying potential hazards (hanging cables, naked wires, trip/slip hazards, burn injury potentials, damaged supports, hot surfaces, ergonomics hazards, biological hazards, occupational illness hazards, industrial hygiene etc) and mark observations to responsible person for timely close out. These audits if performed effectively improve site's safety culture and operational discipline. 6 | CONDUCTING CONSEQUENCE ANALYSIS AND ADDITION IN WORK INSTRUCTIONS Klein et al has described that effective operational discipline include safe operating limits of the process and limiting conditions of opera- tion.6 This type of consequence analyses identifies safe operating limits and limiting conditions of a process and operation. Conse- quence analysis is very important for each and every equipment, com- pressor, pump, vessel, exchanger or any piece of instrument or parts of the instruments (eg, transmitters). Consequence analysis identifies potential emergency scenarios which may encounter during plant operation, their risk level, existing safeguards, and mitigation actions. CA enhances emergency handling and trouble shooting skills of opera- tions team and helps in improving plant reliability and safe/smooth operation. Consequence analysis form is shown in Table 5. These kinds of analyses should and must have been incorporated in operat- ing procedures. 7 | MECHANICAL INTEGRITY TESTING FORMS Equipment failure will be a result of poor operational discipline and weaknesses in mechanical integrity programs.4 Mechanical integrity of TABLE 3 Example of risk assessment completed form Risk assessment Sr No. Work instruction No. Risk Actionable points 1. PROD/666 Change over of urea reactor MOTOYAMA valve from Manual to Auto Engaging device can damage the hand if the valve does not put on auto, if operator feels its on auto. Wheel can hurt the hand during rotation Gland leakage 2. PROD/666 C-789A/B Compressor start up Back flow from reactor can cause blockage in CO2 line Operator can fall during closing of unloaders Operator can slip during closing bypass valves of auto drainers 3. PROD/666 Startup of High Pressure Ammonia Feed Pumps Exposure to NH3 gas during priming toward sump Plunger packing O-ring leakage during increasing pump pressure Pump can trip during pressuring 4. Continue ------------ Continue------------------------------ TABLE 4 Example of DSA form to find unsafe conditions or unsafe acts Daily safety audit Unsafe situation/audit hour Auditor: ___________________ Date: ------------------------ Sr. No. Area Description Responsibility Target date Status 1. Urea Chromate drum to be removed from synthesis section I/C Urea and Chief Process Engineer Open 2. Urea A structure girder is hindering to barring device at the time of compressor C-2111 barring, which can cause safety hazard I/C Urea, I/C Equipment and I/C Machinery Open 3. Urea Air Mask an air mask should be present near overhead condenser E-2233 in case of any leakage I/C Urea and HSE Engineer Open Note: Unit Engineer In charges (UEIC(s) to send feedback within 48 hours. With target date to HSE Office. Status will be closed when UEIC(s) will send job completion report to HSE Office. 4 of 14 RASHID ET AL.
- 7. vessels and exchangers must be intact at all times of the plant opera- tion and is difficult to do, as plant undergo many changes with time and there are many modifications and usually costly modifications are not always welcomed.12 A completed mechanical integrity testing form is presented in Table 6 which can be used to determine mechanical integrity of all process equipment. Ensuring mechanical integrity of all process vessels will contribute in enhancing operational discipline of the organization. Ensuring mechanical integrity will save operations team from emergencies arising from leakages from flanges, level glasses, PSVs, vent valves, drain valves and transmitters. TABLE 6 Example of mechanical integrity testing performa Mechanical integrity of vessels/exchangers Vessel conditions V987 E987 V789 E789 V666 Level glass β NA β NA β Flanges β Not o.k. β Not o.k. H-6102 not o.k. PSV/bleeder β PSV setting 75# NA β PSV setting 35#0 NA NA Vent valve NA NA NA NA NA Drain valve β β β β β Vessel insulation β β β β β Lines insulation Damage urea inlet line HIC-29112 line damage near NRV β β Weak solution bottle(H-6102) lines not o.k. Instrumentation conditions Control valve β NA β NA β PI/PT β/β PI shown in PIDs but not in field present) NA β/β PI present in field but not shown in PIDs NA β/β H-6102 vapor line PI not shown in PIDs TI/TT β/β β/β β/β β/β β/β LI/LT β/β NA β/β β/β β/β Abbreviations: LI, level indicator; LT, level transmitter; PSV, pressure safety valve; NRV, non-return valve; PI, pressure indicator; PT, pressure transmitter; TI, temperature indicator; TT, temperature transmitter. TABLE 7 Example of detailed incident report form for trainee USE burning injury 6 of 14 RASHID ET AL.
- 8. TABLE 7 (Continued) (Continues) RASHID ET AL. 7 of 14
- 9. TABLE 7 (Continued) 8 of 14 RASHID ET AL.
- 10. TABLE 7 (Continued) (Continues) RASHID ET AL. 9 of 14
- 11. 8 | INCIDENT INVESTIGATION AND CONSTRUCTING WHY TREE DIAGRAM Human error is responsible for each accident13 and improvement in operational discipline can reduce loss of containment incidents.4 Inci- dent investigation has a very direct connection with operational disci- pline of the organization. Poor operational discipline cause more risks and incidents having extreme consequences.1 Poor operational disci- pline was responsible for many accidents such as Flixborough (1974), Seveso (1976), Piper Alpha (1988), Texas City (2005), Buncefield (2005), Deepwater Horizon (2010), Amuay (2012), West Fertilizer (2013) and Airgas (2017).14-20 Incident investigation is essential to determine the underlying causes of an incident/accident and take necessary measures to prevent its reoccurrence. Rashid et al has shown that its very important to construct why tree diagrams for occurred accidents to identify the safety management systems failure.21 Improvement in these safety management systems will prevent future incidents and enhance operational discipline. First step to construct a why tree diagram is to complete a detailed incident report form. An example is presented here to demonstrate how a detailed incident report form can be completed. An engineer burning injury example is considered here to demonstrate how a detailed inci- dent report form is completed (Table 7) followed by a construction of the why tree diagram (Figure 1). Which safety management systems failed in this accident are highlighted on the diagram (Figure 1). 9 | MANAGEMENT OF CHANGE (PERMANENT/TEMPORARY) Management of change has been described as one of the attributes of management systems for effective operational discipline.6 Requisites for management of change (MOC) are explained in our earlier publication with the help of a diagram.12 An example is shown here how to complete a management of change form for permanent change (Table 8). Purpose of management of change is that management approve the changes occurring in the process plant and these changes are also documented for future use. This will improve operational discipline as no inappropriate change will be made which affect the plant operation at later stage. 10 | BEHAVIOR OBSERVATION AUDIT REPORTS Behavior observation audits are very important to observe at-risk/ unsafe behaviors and reduce chances of near miss, incidents or TABLE 7 (Continued) 10 of 14 RASHID ET AL.
- 12. accidents. In behavior observation forms, unsafe acts and behavior of working employees and personnel are observed. Different observation categories can be used such as reaction of people, position of people, tools used, procedure, personal protective equipment etc. These audits can be performed on daily, weekly, fortnightly or monthly basis. These completed B.O. audit forms are collected and analyzed on monthly basis. Vaughen et al has presented a behavior based safety observation form which can be used for auditing purpose.7 During this audit, audi- tor focuses on behavioral safety of person working in field (wearing safety harness, PPEs compliance, PTW compliance, hiding or dodging attitude, stopping the work by seeing auditor etc) and reports unsafe behavior/unsafe conditions along with injury risk potential. 11 | EXISTENCE OF WORK INSTRUCTIONS OR OPERATING PROCEDURES AND PRE START-UP SAFETY REVIEWS (PSSR) Up-to-date documentation is one of the 11 characteristics of opera- tional discipline.3 Existence of work instructions and or operating procedures and their correctness is very important for an organization or corporation. It was observed that flaws in operating procedures were responsible as a root or contributing cause for 13% of the occurred accidents or incidents.21 Existence of work instructions improve operational discipline as they enlist step wise procedure for routine jobs and chance of errors minimize. Pre start-up safety review must be performed before the start-up of the normal facility or before the start-up of a newly installed facility or part of the facility. BP Texas City refinery incident occurred because they did not perform pre start-up safety review and there were deficiencies in work permit system and job safety analysis.2 PSSR are useful to operate newly installed and running facilities safely, each and every time. PSSR may be performed before starting big compressors, pumps, generators, cooling towers, condensers, exchangers, evaporators and or reactors but must not be confused with normal start-up check lists. There must be check list for each dif- ficult task or operation and its necessary to keep a tracking record of all the check lists and their timely completion. It is recommended that before normal and simple jobs, job risk assessment is performed and for difficult and dangerous jobs, task risk analysis is performed. Feb 1, 2010 1520 hrs TK-214 Urea Unit near On Feb 1, 2010 at 1520 hrs trainee USE got injured due to hot condensates splashing from TK-214 at urea unit Trainee USE Startup Stop Trainee USE injured due to Hot condensate splashing Stop Line up activity Valve from P-2171 into TK-214 was opened USE did not confirm that line was depressurized capacity Overflow line of less Pressurized line opened in the tank solution below the level of No Line up checklist Line pressurized due to steam leakage from jacketing Line did not increased TK-214 after height increase of MOC procedure not in place at that time PHA base line or after MOC not done Risk Analysis Failure MOC Failure Failure of MIQA Failure of Procedure Get training USE To assist Senior plant Stop Normal practice at up Prepare line the checklist for section Plan and rectify TK-214 inlet line jacket leakage TK-214 Vent Line opens at height Now carry out MOC procedure dia and increase of overflow line design As per original Failure of equipment design base Study and correct inlet line to TK-214 location TK-214 head cover gasket damaged Plan and rectify TK-214 top cover gasket leakage Study and correct top over line to TK-209 vent line Carry ou risk as assessment part of MOC Legend Cause Contributory Root Cause FIGURE 1 Example of why tree diagram of trainee USE injury [Color figure can be viewed at wileyonlinelibrary.com] RASHID ET AL. 11 of 14
- 13. 12 | PHA TECHNIQUES FOR ENHANCING OPERATIONAL DISCIPLINE PHA focuses on operational problems, environment pollution prob- lems and risks associated with operating parameters deviations. PHAs are normally performed for existing facilities, new facilities, old equip- ment dismantling and transportation and during equipment design. PHA has different steps such as hazard identification, hazard evalua- tion and mitigation and incident investigation as well as planning and preparation and consequence analysis. Hazards can be identified using previous PHAs, previous accidental or incidental reports or near mis- ses or field tours or SDS and chemical interaction matrix. Most com- mon PHA techniques are check list, what-If and hazop analyses. Check list analysis use different check lists to identify all hazards. Check list analysis use well documented list for hazards evaluations and thus have pros and cons. Their usage is easier, most available, cheap, requires less skilled staff and can identify all hazards at any stage of process plant.22 Check lists have limitations as they will cover only those hazards which are known by the author and are not a detailed or thorough PHA. What-If technique is based on questions to determine effect of occurrences on the environment, process, people and personnel and equipment. This is brain storming technique based on question answer sessions.22 Hazop technique methodology is shown in Figure 2.22 Failure mode and effect analysis technique meth- odology is shown in Figure 3.22 PHA may need to be revalidated after 3 years as some changes occur due to changes in process safety information, equipment changes, or changes in the design of newly installed equipment or process lines. 13 | CONCLUSION AND RECOMMENDATIONS A completed floor level meeting form is presented which indicates many hidden hazards and risks in ammonia plant, urea plant, utility plant and bagging and shipping plant. This clearly demonstrated that floor level meetings are very effective to identify hazards and opera- bility problems which are faced by area operators. Daily safety audit also identifies hazards on daily basis and is a quicker way to tackle them on spot or on urgent basis. Job cycle check form has indicated a step by step procedure of a routine job and this form must be used by trainee and senior area operators. Risk sensitivity form has indicated risks associated with MOTOYAMA valve manual to auto operation and during high voltage CO2 compressor and ammonia pump start up. Generally small and medium size industries have not included TABLE 8 Example of MOC permanent form for permanent change in a facility Company name: XYZ MOC for permanent change (Technology/Facility/DFM) Document No: --------------- Effective date: --------------- Department: Unit/section: Urea Area: 220 Problem definition and proposed solution To be completed by the originating area and signed by the concerned area incharge MOC/Project title LIC-27108 by pass line to be provided MOC No (to be allocated by project section) PROBLEM DESCRIPTION/PURPOSE OF CHANGE: Define as clearly as possible what the problem is and what difficulties or unnecessary expenditure it is causing. This section defines the justification so it is essential that some time is spent on the wording. For scope, changes to authorized projects define why the scope needs to be changed and indicate if possible why this piece of scope was missed from the original scope. If control valve seat detach then transfer of urea solution will stop from the V-2161 resulting in shut down of urea unit. *PROPOSED SOLUTION/DESCRIPTION OF CHANGE: Provide a brief outline of the solution proposed by the area initiating the MOC form. This may not be the solution finally agreed upon but it will provide some guidance to the project lead. A bypass line to be provided with flushing provision and steam jacketing *JUSTIFICATION/TECHNICAL BASIS FOR CHANGE: What is the justification for this proposed project? Why should the business allocate funds to this project? What are the savings or capacity growth delivered? Shutdown of urea unit and production loss will be saved. Environmental pollution in case of plant shut down will be saved. Initiation: Name Designation Signature Date Originator ------------------------ Assistant Production Engineer ----------------------- Concerned Section In charge ------------------------- UEIC ------------------------ Concerned Deptt. Head ------------------------ Assistant production manager ---------------------- I agree that this proposed change is necessary and approved for study. Sr. General Manager ------------------------- Note: Secretary to Sr. General Manager is responsible to return the form to: 1. I/C Project/Project Leader (if approved for study). 2. Originator (if not approved for study). 3. Secretary to Sr. GM to track the record of all the MOC's for study. 4. I/C Project/Project Leader will assign this MOC to Sr. Project Engineer/Project Liaison Engineer for further proceedings. 12 of 14 RASHID ET AL.
- 14. these risk sensitivity sheets in their work instructions or standard operating procedures. Consequence analysis form is also presented indicating causes, consequences and control measures for the com- pressor tripping and generally these consequence analyses for pumps, compressors, blowers, fans, conveyors, prill tower buckets, scrappers, analyzers, instruments or switches are missing from standard operat- ing procedures. It is also necessary to ensure mechanical integrity of all process equipment for example, vessels, exchangers, etc. Mechani- cal integrity testing form presented in this study can be used by the industries and academia. A completed management of change form is presented which indicates requirements such as problem description, proposed solu- tion, justification for change and authorizations form top manage- ment. Significance of behavior observation audits, standard operating procedures, PSSR and checklists is briefly highlighted. HAZOP meth- odology and FEMA methodology is presented in a step-wise pattern. A detailed incident report form is completed for a trainee USE burning injury and is used to construct a why tree diagram. This incident indicates that some hidden hazards are present which can occur during plant start up or shut down activities which need special attention. Urea feed line to the tank (open from top) was leaky and got pressurized by a 33 Psig steam jacketing and resulted in a conden- sate splashing when inlet valve to tank was opened. An early EWR job completion will surely has prevented this accident. It is recommended that after all jobs completed through MOC, PHA should be repeated on regular basis possible to reassess hazards and high hazardous situa- tion survey of the area to be performed. It is expected that this article will help those companies which are not performing this type of ana- lyses (in understanding what could be used to make their processes safer). AUTHOR CONTRIBUTIONS Dr. Muhammad Imran Rashid: Conceptualization; data curation; for- mal analysis; investigation; methodology; writing-original draft; writing-review and editing. Chaudhri Haider Ali: Conceptualization; formal analysis; investigation; methodology. Kashif Mukhtar: Select Process Blocks Divide Process Blocks Prioritize on Hazard Severity Appoint PHA Team Hold PHA Team Meeting Appoint Team Leader Appoint Team Members Prepare Charter Assign Responsibilities Establish Meeting Schedule Collect Process Safety Information MSDS Chemical Interaction Matrix Incident Investigation Reports Prior PHA/of Similar Facility PIDS Operating Parameters/Process Design Information Management of change Documents Field Tour of Selected Block Identify Hazards Identify Human Factors Check Facility Issues Select Process Parameters Apply Guide Words Develop Deviations List Protections Safeguards List causes of Deviations Prevention Develop Recommendations Implement Recommendations Consequences if safeguards fail FIGURE 2 HAZOP technique methodology RASHID ET AL. 13 of 14
- 15. Conceptualization; formal analysis; investigation; methodology. Emad Benhelal: Conceptualization; formal analysis; investigation; methodol- ogy. Muhammad Athar: Conceptualization; formal analysis; investiga- tion; methodology. ORCID Muhammad Imran Rashid https://orcid.org/0000-0003-2340-4983 Muhammad Athar https://orcid.org/0000-0001-7040-4252 REFERENCES 1. Vaughen BK, Klein JA, Champion JW. Our process safety journey continues: operational discipline today. Process Saf Prog. 2018;37(4): 478-492. 2. Klein JA, Vaughen BK. Process Safety: Key Concepts and Practical Approaches. Boca Raton, FL: CRC Press, Taylor and Francis group; 2017. 3. Klein JA. Operational discipline in the workplace. Process Saf Prog. 2005;24(4):228-235. 4. Vaughen BK, Klein JA. Improving operational discipline to prevent loss of containment incidents. Process Saf Prog. 2011;30(3):216-220. 5. Klein JA, Vaughen BK. A revised program for operational discipline. Process Saf Prog. 2008;27(1):58-65. 6. Klein JA, Bradshaw WM, Heuvel LNV, Lorenzo DK, Keeports G. Implementing an effective conduct of operations and operational dis- cipline program. J Loss Prev Process Ind. 2011;24(1):98-104. 7. Vaughen BK, Lock KJ, Floyd TK. Improving operating discipline through the successful implementation of a mandated behavior-based safety program. Process Saf Prog. 2010;29(3):192-200. 8. Klein JA, Francisco EM. Focus on personal operational discipline to get work done right. Process Saf Prog. 2012;31(2):100-104. 9. Forest JJ. Management discipline. Process Saf Prog. 2012;31(4):334-336. 10. Walter R, Foottit R, Nelson B. PSM system upgrade in response to an occupational safety and health administration NEP inspection. Process Saf Prog. 2009;28(4):338-342. 11. Forest JJ. Management discipline: defining a process safety strategy. Process Saf Prog. 2014;33(2):162-165. 12. Rashid MI, Ramzan N, Iqbal T, Yasin S, Yousaf S. Implementation issues of PSM in a fertilizer plant: an operations engineer's point of view. Process Saf Prog. 2013;32(1):59-65. 13. Kletz TA. An Engineer's View of Human Error. Boca Raton, FL: Taylor Francis; 2001. 14. The Center for Chemical Process Safety (CCPS). Incidents That Define Process Safety. New York: John Wiley Sons; 2008. 15. Kletz TA. What Went Wrong? Case Histories of Process Plant Disasters and How They Could Have Been Avoided. 5th ed. London: But- terworth-Heinemann/IChemE; 2009. 16. Sanders RE. Chemical Process Safety: Learning from Case Histories. Elsevier, New York, NY: Butterworth-Heinemann; 2015. 17. US Chemical Safety and Hazard Investigation Board (CSB), Refinery explosion and fire. Investigation Report, 2005-04-I-TX, 2007. 18. US Chemical Safety and Hazard Investigation Board (CSB), Drilling Rig Explosion and Fire at the Macondo Well. Report No. 2010-10-I- OS, 2014. 19. US Chemical Safety and Hazard Investigation Board (CSB), West fer- tilizer company fire and explosion. Report No. 2013-02-I-TX, 2016. 20. US Chemical Safety and Hazard Investigation Board (CSB), Nitrous oxide explosion. Report No. 2016-04-I-FL, 2017. 21. Rashid MI, Ramzan N, Almas Q. Incident investigation in Pakistan's fertilizer industryβcommon safety management system failures and issues. Process Saf Prog. 2014;33(4):399-404. 22. Rashid MI, Ramzan N. Urea Synthesis Hazard AnalysisβPHA, HAZOP and Quantitative Risk Assessment. Saarbrucken, Germany: LAMBERT Academic Publishing AG Co. KG; 2012. How to cite this article: Rashid MI, Ali CH, Mukhtar K, Benhelal E, Athar M. Operational discipline in practice. Proc Safety Prog. 2020;e12207. https://doi.org/10.1002/prs.12207 Define objective scope Select team Select system/Component Split into sub- components List failures effects on system List failure modes List safe guards present Conduct Risk Raking Develop recommendations Implement recommendations FIGURE 3 Failure mode and effect analysis technique methodology 14 of 14 RASHID ET AL. View publication stats