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Process Safety | Process Safety Management | PSM | Gaurav Singh Rajput

This document provides an overview of process safety and major accident hazards. It defines process safety as proactively identifying, analyzing, and evaluating releases of hazardous substances and process accidents. The goal is to minimize the risk of major accident events and ensure necessary mitigation and emergency preparedness. Major accidents are defined by their severe consequences for people and the environment. The document discusses past major accidents and emphasizes preventing such events through inherent safety design, barriers, safety management systems, and a safety culture.

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1 | 2015 Process Safety Management
2 | What is Process Safety Process Safety is  The proactive identification, analysis, and evaluation of the releases of hazardous substances and process accidents.  It applies to the management of hazards associated with the chemical and physical properties of the substances handled in our oil, gas and energy activities.  It aims to:  Minimize the risk of a major accident event MAE  Ensure that the necessary mitigation and emergency preparedness mechanisms are in place
3 | Likelihood of occurrence Tolerable Risk Intolerable Risk Occupational Safety  Process Safety
4 | What Process Safety is about Preventing MAJOR ACCIDENTS
5 | What is a Major Accident & Major Accident Hazard?  Major Accident (realisation)  This is an accidental event which has major or severe consequences for people or environment. The definitions of ‘major’ and ‘severe’ consequences in this context, are provided in the risk matrix.  Major Accident Hazard (potential)  Any substance or energy which if not contained could seriously harm people or the environment, either directly or by initiating events which could lead to a major accident. Major Accidents exclude: - Occupational health and personal safety hazards - Business critical hazard severity categories  Major Accidents are defined by their consequences
6 | Definition of Major Accident Consequence People Environment 5 Severe 1 fatality of public >1 fatality of workforce > 6 people of workforce and/or public hospitalised Serious long term environmental damage. Significant impact on highly valued or sensitive species, habitat or ecosystem 4 Major 1 fatality of workforce > 3 people on-site hospitalised 1 person of public hospitalised 1 person of workforce with onset/signs of severe irreversible health effect >1 person of public with reversible health effect Very severe, persistent environmental damage extending over large area. Long term impairment of ecosystem function 3 Moderate 1 person of workforce >2 days lost 1 person of workforce with onset/signs of moderate irreversible health effect 1 person of public with moderate reversible mid-term health effect Serious mid-term environmental impacts 2 Minor 1 person of workforce 1 or 2 days off work 1 person of workforce with moderate reversible mid-term health effect 1 person of public with minor reversible short term health effect Moderate reversible environmental damage extends beyond site boundary 1 Slight 1 person of workforce injured, able to continue work but first aid needed 1 person of workforce with minor reversible short term health effect Slight reversible on-site environmental damage
7 | Summary of Process Hazards
8 | Major Accidents
9 | 20” bypass piping fabricated on-site from shop stock. This pipe ruptured and released Cyclohexane which exploded. On June 1, 1974 the Nypro Co. site at Flixborough, England was severely damaged by a large explosion. Twenty-eight workers were killed and a further 36 suffered injuries. It is recognized that the number of casualties would have been more if the incident had occurred on a weekday, as the main office block was not occupied. Cyclohexane Release & Explosion – 28 fatalities Flixborough, England – June 1, 1974
10 | On the night of December 2-3, 1984, a sudden release of about 30 metric tons of methyl isocyanate (MIC) occurred at the Union Carbide pesticide plant at Bhopal, India. The accident was a result of poor safety management practices, poor early warning systems, and the lack of community preparedness. The accident led to the death of over 2,800 people (other estimates put the immediate death toll as high as 8000) living in the vicinity and caused respiratory damage and eye damage to over 20,000 others. At least 200,000 people fled Bhopal during the week after the accident. Estimates of the damage vary widely between $350 million to as high as $3 billion. Methyl Isocyanate Tank Rupture and Release Bhopal, India – Dec. 2-3, 1984 Photo Source: Indian state government of Madhya Pradesh Source: United Nations Environment Programme
11 | On the day the disaster occurred, the day shift maintenance crew was working on the condensate pumps which compressed gas. One of the pumps was removed for routine maintenance and the condensate pipe was temporarily sealed with a flat metal disk. Because the work could not be completed before the next shift change-over, the metal disc was left in place as the day shift went off duty. The shift coming on duty was unaware of this. Later in the evening, when the other condensate pump stopped working, the pump under maintenance was started up. Gas leaked out at high pressure, ignited and exploded. Gas Release & Explosion – 167 fatalities Piper Alpha, North Sea – July 6, 1988
12 | On March 23, 2005, during the startup of an isomerisation unit, the associated raffinate splitter tower was overfilled and overheated. A substantial volume of hydrocarbon liquid and vapour were forced into an adjacent blowdown stack, rapidly exceeding its capacity. Ignition of the resulting vapour cloud caused an explosion that extended to nearby temporary trailers and resulting in 15 deaths, more than 170 injuries, and significant economic losses. Condensate Release & Explosion – 15 fatalities BP Texas City Refinery, Texas– March 23, 2005
13 | Deepwater Horizon oil spill 20 April – 15 July 2010, Gulf of Mexico, US Oil Spill (up to 4.9 mln barrels), 11 people died, 17 injured
14 | Fukushima Daiichi 11 March 2011, Fukushima 1 Nuclear Power Plant, Japan Release of radioactive materials, 37 injured
15 | When will the next Major Accident occur?
16 | PROCESS SAFETY MANAGEMEMENT
17 | What must we focus on? Process Safety Operating Integrity  Operate within operating envelope ▪Alarm management ▪Process control and procedures ▪Incident investigation and close-out ▪Competencies and Capabilities Maintenance Integrity ▪ Asset Integrity Management Plan ▪ SCE inspection, testing & maintenance ▪ Deviation analysis and close-out Design Integrity ▪ Design reviews: ALARP; engineering codes; standards ▪ SCE Safety Critical Elements (and performance standards) ▪ MOC Management of Change (with technical authorities) ▪ Robust Assurance (WSE - Written Schemes of Examination)
18 | PSM Elements  Process Safety Information  Process Hazard Analysis  Operating Procedures  Employee Participation  Training  Contractors  Pre-Startup Safety Review OSHA PSM Elements (14)  Mechanical Integrity  Hot Work Permit  Management of Change  Incident Investigation  Emergency Planning and  Compliance Audits  Trade Secrets
19 | PSM Elements  Process safety culture  Compliance with standards  Process safety competence  Workforce involvement  Stakeholder outreach  Process knowledge management  Hazard identification and risk analysis  Operating procedures  Safe work practices  Asset integrity and reliability CCPS Risk-Based Process Safety Elements (20)  Contractor management  Training and performance  Management of change  Operational readiness  Conduct of operations  Emergency management  Incident investigation  Measurement and metrics  Auditing  Management review and continuous improvement
20 | PROCESS SAFETY ENGINEERING
21 | Safety Life Cycle
22 | Safety Life Cycle
23 | Safety Life Cycle & Risk Assessment
24 | Safety Life Cycle & Risk Assessment
25 | Risk Assessment steps & toolkits
26 | What should we do about it?  Hierarchy of control for Process Safety  Inherent Safety – reduce the hazard  Prevention measures – keep it in the pipe  Control measures – minimise size and duration of hazardous event  Mitigation – protect people, the environment and assets  Layers of defence  Risk Control systems
27 | Hierarchy of control for Process Safety
28 | Inherent Safety 1. Substitute - Replace material with a less hazardous substance. 2. Minimize/Intensify - Use smaller quantities of dangerous substances. 3. Moderate/attenuate – Change the conditions to reduce hazard severity in the event of accidental release. 4. Simplify – Strive to eliminate unnecessary complexity which increase the potential for incorrect operation, particularly in the event of abnormal operating conditions.
29 | Bow Tie – Defence in Depth
30 | How & Why defences fail
31 | Key risk control systems classification
32 | SAFETY CRITICAL ELEMENTS MANAGEMENT
33 | What is a Safety Critical Element?  Safety Critical Element – any part of the facilities, the failure of which could cause or contribute substantially to a major accident, or the purpose of which is to limit the effects of a major accident  So, there are two distinct types of SCE Prevent: Those, the failure of which could cause a major accident, and Mitigate: Those required to intervene passively or actively to limit the effects of a major accident
34 | Management systems, people & processes SCEs are hardware-only But: Management systems, people, processes, are important parts of the Integrity assurance process used to manage the hardware barriers/SCE
35 | Safety Critical Activities  Are management systems, procedures, people/competence safety critical?  Yes, but as safety critical activities, not SCEs  SCEs = hardware (& associated software)  How are safety critical activities dealt with?  They are inherent to the SCE assurance process  Examples of safety critical activities/tasks  Permit to work system  Management of change  Risk assessment  Competency training  Quality assurance  Operating envelopes  Defeats register
36 | How SCEs fit into hazards management  Management of major accident consequences is based on a hierarchy  Industry has evolved models to support/demonstrate this  The Integrity Barrier or “Swiss Cheese” diagram is one Hierarchy of Risk Reduction Prevention Systems to control the primary initiating events Detection Systems to detect the primary safeguards have failed Control Systems to prevent the event from escalating and bring plant to a safe state Mitigation Systems to minimize the effects of an event Emergency Response & Lifesaving Systems to allow you to safely muster and evacuate
37 | How SCEs fit to hazards management ‘barriers’ concept Inspection, maintenance and testing are activities to prevent barrier degradation. GAS
38 | Barrier Concept for Hazards Management Escalating Consequences STRUCTURAL INTEGRITY - Drilling systems - Structural supports for safety critical equipment - Lifting equipment in wellhead /HC process areas - WHP jacket & foundations - Vessel hull , mooring & ballasting systems IGNITION CONTROL - Haz area HVAC - Non-haz area HVAC - Certified electrical equipment & instruments - Inert gas blanketing - Earth bonding - Fuel gas purge system - Ignition control eqpt - Flare tip ignition system PROTECTION SYSTEMS - Deluge system - Fire & expl protection - Firewater main & pump - Gas, foam & spray fire extinguishers - Corrosion protection e .g. sand filters & chemical injection - Passive fire protection - Navigation aids & collision avoidance EMERGENCY RESPONSE - Temp refuge /muster - Escape/evac routes - Escape lighting - Emergency comms - UPS - Helicopter facilities - Emergency power - Hazardous & non- hazardous open drains PROCESS CONTAINMENT - Pressure vessels - Heat exchangers - Rotating equipment - Tanks - Pipelines /piping - Relief system - Well containment - Gas/oil fired heaters - Gas tight floors /walls - Tanker loading systems - Wireline equipment - Oily water control DETECTION SYSTEMS - Fire detection - Gas detection - H2S detection - Corrosion detection SHUTDOWN SYSTEMS - ESD system - Depressurisation syst - HIPPS - Well isolation - Pipeline isolation valves - Process ESDV - SSIVs - Well control eqpt LIFESAVING - Personal survival equipment - Rescue facilities - TEMPSC /lifeboats - Tertiary escape systems Prevention Detection Control & Mitigation Emergency Response Lifesaving Safe Operation
39 | What are the benefits?  Achieve & sustain acceptable level of major accident management  Focus & prioritise resources on the aspects of systems and equipment that manage major accidents  Not how many, but how you manage them  Ensure this is achieved by  Defining the critical functions, and  Aligning inspection and maintenance with these functions
40 | How to identify SCEs System Level List of systems and equipment to reduce risk (plant barriers) No No No No Could failure of this element cause a MAE? Is the purpose of this element to prevent a MAE? Could failure of this element contribute substantially to a MAE? Is the purpose of this element to limit the effects of a MAE? Yes Yes Yes Yes SCE Screening This item is a SAFETY CRITICAL ELEMENT This item is not a Safety Critical Element Major accident hazard identification Tag Level
41 | Performance Standard – Key requirements  Performance Standards (PSs) are parameters that are measured or set so that the suitability and effectiveness of SCEs can be assured and verified.  Performance criteria:  SCE integrity assurance activities  Independent Verification Body (IVB) activities Functionality  The intended purpose and fundamental design performance requirements of the SCE (relative to major accidents) Reliability & Availability  The probability that the system will work on demand and be available when required Survivability  The ability of the SCE to survive loadings from major accidents it is intended to manage Dependency  Identification of other SCEs the performance of which the SCE is dependent on
42 | Generic Performance Standard Structure November 15 Presentation title
43 | WHY DO IT? What happens when the SCE integrity assurance process is either not in place or not implemented effectively…
44 | EXERCISE
45 | SCE Identification Practical NGL piping manual isolating valves Sales gas booster compressor Glycol storage tank Diesel oil storage day tank Crude oil export pump Why SCE? – Yes/No System or Equipment Prevents or Mitigates?
46 | Prevents or Mitigates? HVAC system Main power generation/distribution Electrical equipment in classified hazardous areas Pressure transmitter instrument Why SCE? – Yes/No System or Equipment SCE Identification Practical
47 | Instrument air system Flare System Pump lubricating oil system Compressor seal oil system Why SCE? – Yes/No System or Equipment Prevents or Mitigates? SCE Identification Practical
48 | Permit to Work system Firewater ring-main isolation valve Closed drain system Oil Wellhead Why SCE? – Yes/No System or Equipment Prevents or Mitigates? SCE Identification Practical
53 | PROCESS SAFETY EVENTS & PSPI
54 | Performance Monitoring System
55 | Type of indicators  Quantitative  Numbers recorded on scale and tracked over time  Ensure statistically valid interpretation  Most relevant to regularly occurring activities  Qualitative  Descriptions typically inspection and audit observations  Can be quantified using ratings and ladder assessments (comparative definition of bad to good)  Objective  Independent of assessor’s personal judgement  Subjective  Influenced by those measuring
56 | Type of indicators
57 | Example leading & lagging indicators
58 | Example leading & lagging indicators
59 | Example of Key board
60 | PROCESS SAFETY EVENTS
61 | Terminology loss of primary containment LOPC An unplanned or uncontrolled release of any material from a tank, vessel, pipe, truck, rail car etc., including non-toxic and non- flammable materials (e.g. steam, hot condensate, nitrogen, compressed CO2 or compressed air). An unplanned or uncontrolled release of any material from a process or an undesired event or condition that, under slightly different circumstances, could have resulted in a release of a material. Process safety event PSE Challenge to safety system CTSS A demand on a safety system designed to prevent a LOPC or to mitigate the consequences of a LOPC.
62 | Safety Critical Barriers GAS
63 | PSPI & Barriers © 2011 OGP Guidance Report 456
64 | Process Safety Performance Indicators Tier 1 LOPC Events of Greater Consequence Tier 2 LOPC Events of lesser consequence Tier 3 Challenges to Safety Systems Tier 4 Operating Discipline & Management System Performance Indicators incidents E.g. • Hi-Hi level alarm activated. • Defect below minimum wall thickness E.g. • Relief valve fails bench test. • Loss of experience in operations team.
65 | Process Safety Events: Accidents, Incidents, Near Miss, etc.  A Process Safety Event is:  The actual or potential loss of control or containment of hazardous materials (flammable, toxic, corrosive, etc.)  Failure or substandard performance of one or more barriers resulting in the potential or actual operation of the highest safety barrier (e.g. opening of safety valve to flare)  The presence of hazardous material in systems which are not designed to contain it Incidents Demands on Safety System Development of incident scenario prevented by a planed barrier Near Miss Just luck that no accidental consequences occurred Accident Harm to humans or environment, damage of equipment all LOPC events incl. LOPC to secondary containment PS related production loss e.g. due unavailability of barriers or equipment
66 | PSPI types of indicators Tier 1 LOPC* events with greater consequence  LOPC exceeding threshold  human harm due LOPC  asset damage after fire / explosion due LOPC not yet all LOPC without environment consequences registered Tier 2 LOPC events with lesser consequence  LOPC exceeding threshold  human harm due LOPC  asset damage after fire / explosion due LOPC not yet all LOPC without environment consequences registered Tier 3 Challenge to safety system  small fires / explosions  minor LOPC events  primary containment inspection outside limits  demands on safety system  safe operating limits excursion  critical operational deviation many of these events are not registered; some are in other systems (e.g. shift logs, computerized maintenance systems) Tier 4 Operating Discipline & Management System Performance focusing on:  Management of Change (MoC) events  Process hazard and risk analyses (PHA)  Action follow up  Inspection of safety critical systems  PS audits  PS related training  Pre-startup safety review (PSSR), etc.  PTW failures find the right leading indicators to improve your (lagging) PSE performance
67 | Tier 1 & Tier 2
68 | Decision Logic Tree for Tier 1 & 2 An employee, contractor or subcontractor “days away from work” injury and/or fatality; or A hospital admission and/or fatality of a third-party An unplanned or uncontrolled release of any material, including non-toxic and non- flammable materials (e.g., steam, hot condensate, nitrogen, compressed CO2, or compressed air) from a process that results in one or more of the consequences listed below: An officially declared community evacuation or community shelter-in-place A fire or explosion resulting in greater than or equal to $25,000 of direct cost to the Company A pressure relief device (PRD ) discharge to Atmosphere whether directly or via a downstream destructive device that results in one or more of the following four consequences: liquid carryover; or discharge to a potentially unsafe location; or an on-site shelter-in-place; or public protective measures (e.g., road closure); and a PRD discharge quantity greater than the threshold quantities Table 1 A release of material greater than the threshold quantities described in Table 1 in any one-hour period A fire or explosion resulting in greater than or equal to $2,500 of direct cost to the Company An employee, contractor, or subcontractor recordable injury A pressure relief device (PRD) discharge to atmosphere whether directly or via a downstream destructive device that results in one or more of the following four consequences:  liquid carryover; or discharge to a potentially unsafe location; or an on-site shelter-in-place; or public protective measures (e.g., road closure); and a PRD discharge quantity greater than the threshold quantities Table 2 A release of material greater than the threshold quantities described in Table 2 in any one-hour period A Company may choose to record a Tier 3 other LO PC Not a Tier 1 or Tier 2 PSE Tier 1 PSE Tier 2 PSE No No No No No No No No No No Yes Yes Yes
69 | Tier 3 Consequences  Safe operating limit excursions  Primary containment inspection outside limits  Demands on safety systems  Critical operational deviation  LOPC event below Tier 1 & 2 threshold A Tier 3 PSE typically represents a challenge to the barrier system that progressed along the path to harm, but is stopped short of a Tier 1 or Tier 2 LOPC consequence. Indicators at this level provide an additional opportunity to identify and correct weaknesses within the barrier system.
70 | Safe Operating Limit Excursion – Tier 3 The process has an excursion beyond the normal high or low alarm limits. A single initiating event may result in multiple SOL excursions (e.g. site-wide failure of a utility) and each excursion should be counted as a separate Tier 3 PSE. A process condition that hovers near the SOL value may result in multiple excursions. These excursions should be counted as a single Tier 3 PSE. Abbreviations NEL – Never Exceed Limit. RV – Relief Valve PAH – Pressure Alarm High
71 | Primary containment inspection outside acceptable limits – Tier 3 This is a test or inspection where the result is outside the acceptance criteria and triggers some form of remedial action (such as replacement in kind, repair, modification, increased inspection/ testing or de-rating of the equipment). Examples include:  A penetrating corrosion defect beyond the corrosion allowance of a pipe.  Subsidence of a pressure vessel support outside acceptable limits.  Excessive vibration of a small bore instrument tapping on a larger diameter process pipe.  Missing flange bolts on a process pipework joint.
72 | Demands on safety systems - Tier 3 Safety Systems are ones which prevent a LOPC or detect, control or mitigate the effects of an LOPC. Demand means they are activated by a valid signal from the process. The system does not have to activate. Where multiple devices constitute one system then activation of that system counts as one PSE. Examples include:  Where a vessel has a number of relief valves to provide suitable flow, activation of one or more of these valves constitutes one PSE as they represent a system.  Activation of a Safety Instrumented System  Activation of Mechanical Shutdown System The count of Demands on Safety Systems is typically segregated by system type (e.g. SIS, PRD, and Mechanical Trip).
73 | Critical operational deviation – Tier 3 This represents operational activity outside good operating practice and/ or non compliance with company Procedures. Examples include:  Operating without adequate measurement of critical process parameters.  Operating with inoperable safety systems.  Operating with uncontrolled modifications / repairs to the process plant.
74 | Tier 4: Operating Discipline & MS Performance Tier 4 indicators typically represent performance of individual components of the barrier system and are comprised of operating discipline and management system performance. Tier 4 indicators are indicative of process safety system weaknesses that may contribute to future Tier 1 or Tier 2 PSEs. In that sense, Tier 4 indicators may identify opportunities for both learning and systems improvement. Examples include:  Process Safety Action Item Closure  Training completed on schedule  Safety Critical Equipment Inspection  Management of Change (MoC) Compliance  Completion of Emergency Response Drills
75 | EXERCISE PSE CATEGORISATION
76 | Has a person been injured by a release of hazardous substances? Event Class Comment A blow out of a gas well occurred during cement plug. An operator was hit by mud and gas and needed hospital treatment. Tier 1 Tier 1 due to the fact of hospital treatment; additionally the release amount may also have resulted in a Tier 1 event While stealing a piece of pipework the gas released from that pipe ignited and the thefts suffered severe burns. Tier 1 Even though the reason for the injuries is a malicious act it is counted. LPG from leaking pipework ignited and blasted the retail service station causing injuries and damage of the building. Tier 1 Tier 1 event due to the injuries and the asset damage. This event will not be included in external reporting since the retail station is not operated by OMV. An operator slipped and fell while responding to a small spill of liquid with a flash point < 23 °C spill resulting in a days away from work injury. Tier 1 The operator was responding to a LOPC A scaffold builder experiences a days away from work injury after falling from a scaffold ladder while evacuating from a LOPC on nearby equipment. Tier 1 An operator walks past a steam trap that discharges to an unsafe location. The steam trap releases and the operator’s ankle is burned by the steam, resulting in a days away from work injury. Tier 1 Even though the LOPC was steam (vs hydrocarbon or chemical), the physical state of the material was such that it caused a day away from work injury and it was an uncontrolled release (i.e. unsafe location). Nontoxic and non-flammable materials are within the scope of this recommended practice. A contractor enters a vessel and dies because nitrogen inadvertently leaked into the enclosure. Tier 1 Fatality associated with an unplanned or uncontrolled LOPC A maintenance contractor opens a process valve and gets sprayed with less than the Tier 1 or Tier 2 quantity of sulfuric acid resulting in a severe burn and days away from work injury. Tier 1 Unplanned or uncontrolled LOPC that resulted in a days away from work injury. If this incident had resulted in a recordable injury, it would be a Tier 2 PSE. A PRD release of sour gas less than the Tier 1 threshold quantity is routed to a flare which exposes two personnel to toxic SO2/SO3 vapors resulting in a LWDI. Tier 1 Multiple Tier 1 consequences: Human and unsafe PRD release Classification of PS Events 1 2 3 4 5 6 7 8 9
77 | Has a person been injured by a release of hazardous substances? Event Class Comment There is a 100 kg spill of liquid with a flash point < 23 °C (73 °F) that ignites and results in damages to other equipment, a toxic gas release above the reporting threshold, along with three days away from work injuries and one fatality. Tier 1 This is a Tier 1 PSE. The site would record a single event with multiple consequences (e.g., one fatality, three day away from work injuries, fire, and threshold quantity of liquid with a flash point < 23 °C and toxic gas). During routine tour an operator suffered burns on his foot by leaking condensate from a steam tracing which required medical treatment. Tier 2 Tier 2 due to the need of medical treatment. The release of hot condensate itself would not be a PSE. A short circuit occurred in switchgear panel and caused burns of a contractor requiring medical treatment Tier 2 Following industry recommendations we consider electrical incidents in internal PSE reporting. An operator walks through a process unit and slips and falls to the ground and suffers a days away from work injury. The slip/fall is due to weather conditions, “chronic” oily floors and slippery shoes. no PSE Personal safety “slip/trip/fall” incidents that are not directly associated with evacuating from or responding to a LOPC are specifically excluded from PSE reporting. An operator slipped and fell on a spill several hours after the incident had concluded. This would not be a reportable PSE. no PSE Personal safety events that are not directly associated with onsite response to a LOPC are excluded. Slips/trip/falls after the LOPC has concluded (such as “after-the-fact” clean-up and remediation) is not directly associated with onsite response. A vessel has been intentionally purged with nitrogen. A contractor bypasses safety controls, enters the enclosure and dies. no PSE This is not a PSE because there was no unplanned or uncontrolled LOPC, but it would be recorded on the company’s injury and illness log. An operator disconnected a steam hose which was still under pressure and suffered light burns. no PSE The injury required only first aid, and the steam is no counted as LOPC of hazardous substance. A maintenance technician is turning a bolt on a process flange with a wrench. Due to improper body positioning, the wrench slips and hits the employee in the mouth, requiring dental surgery and two days off work. no PSE No unplanned or uncontrolled LOPC involved with the injury An operator takes a sample. On the way he falls, the sample container breaks and he suffers injury of the exposure to the product. no PSE LOPC is from a piece of ancillary equipment not connected to a process is not considered as PSE An employee suffered burns by a spill of hot coffee. no PSE Office incidents are not PS related While cleaning a joint screw a piece of frozen mud broke off and hit the operator causing injury. no PSE This is not a loss of primary containment. 10 11 12 13 14 15 16 17 18 19 20
78 | Has a fire or explosion occurred by a release of a hazardous substance? Event Class Comment Hot vacuum residue was released from a left open drainage, self- ignited and damaged a pump. Tier 1 The immediate damage caused by the fire was above 25.000€ An electrical fire impacts the operation of the process resulting in an acute release of 1500kg of light crude. Tier 1 This is a Tier 1 PSE since the LOPC exceeds the 1000 kg reporting threshold for light crude. A pump lube oil system fire from a leak causes damage greater than €25,000, but does not create a LOPC greater than the threshold quantity or cause a fatality or serious injury. Tier 1 A forklift truck delivering materials inside a process unit knocks off a bleeder valve leading to the release of (HC) condensate and a subsequent vapor cloud explosion with asset damage greater than €25,000. Tier 1 A bearing failure of a turbine causes high vibration and eventually leads to damage of the turbine > €100.000. Tier 1 Following industry recommendation we consider unplanned release of mechanical energy under PS in internal reporting. There is a loss of burner flame in a fired heater resulting in a fuel rich environment and subsequent explosion in the fire box with greater than €25,000 in damages to the internals of the heater. There was no release outside of the fire box. Tier 1 This would be a Tier 1 PSE since after the flameout the continuing flow of fuel gas is now an uncontrolled release. The intent is for combustion of the fuel gas at the burner and not for fuel gas to be contained in the fire box. There is a tube rupture in a fired heater causing a fire (contained in the heater) resulting in greater than €25,000 in damages to the heater internals (beyond that of replacing the failed tube). Tier 1 The tube failure is a loss of primary containment of the process fluid and combined with the additional damages greater than €25,000 makes this a Tier 1 PSE. A third-party truck loaded with a flammable product is traveling on Company premises and experiences a leak and subsequent fire and property damages of €75,000 (direct costs). Tier 1 The event will not be included in external reporting since truck incidents are excluded except when they are connected to the process for the purposes of feedstock or product transfer or being used for temporary onsite storage. A steam injection well fails with an explosion resulting in release of 10t of fluids, a mixture of hydrocarbons and water. The direct cost replacing and repairing damaged equipment was estimated over €300.000 and a worker was injured, needing medical treatment. Tier 1 Unplanned release causing fire and resulting in over €25.000 direct costs. The injury would result into Tier 2 but the higher consequence counts. The release of a hot steam from safety valve ignited wooden planks of scaffolding and damaged the scaffolding. Tier 2 The immediate damage was higher than 2.500€ but lower than 25.000€ Hydrocarbon fumes migrate into the QA/QC laboratory located within the facility and results in a fire with €5000 damage. The source of the hydrocarbon fumes is the oily water sewer system. Tier 2 This incident is a Tier 2 PSE since the LOPC was from the process and resulted in a Tier 2 consequence (a fire which results in a direct cost greater than €2500). 21 22 23 24 25 26 27 28 29 30 31
79 | Has a fire or explosion occurred by a release of a hazardous substance? Event Class Comment A pump seal fails and the resultant loss of containment catches on fire. The fire is put out quickly with no personal injuries. However, the fire resulted in the need to repair some damaged instrumentation and replace insulation. The cost of the repairs, replacement, cleanup and emergency response totaled €20.000. Tier 2 Only the costs for repair and replacement of the equipment damaged by the fire are to be considered. The cost for the repair of the equipment which led to the fire must not be considered. A vacuum truck outfitted with a carbon canister on the vent is loading a spill of hydrocarbons. The carbon canister catches fire which escalates to the point of creating more than €10,000 in damage to the vacuum truck. Tier 2 This is a Tier 2 PSE since the original spill of hydrocarbons constitutes the LOPC and the response to the LOPC results in one of the Tier 2 consequences. Product from a small flange leakage dropped on a hot steam pipe and started smoldering Tier 3 Negligible damage from a fire involving LOPC There is a tube rupture in a fired heater. The operator detects the tube cracking with only a small flame from the tube and subsequently shuts down the heater with no resultant damage from the tube flame. Tier 3 The LOPC did not result in any of the defined Tier 1 or 2 consequences. However, it was a fire resulting from an unplanned LOPC. During a hot work the sparkles ignited the vapor of an atmospheric slop inlet. The fire damaged insulation material. no PSE The fire does not involve an unplanned, uncontrolled LOPC. (see above) If the fire threatened the installation it may be reported as Tier 3 Critical Operational Deviation A vacuum truck caught fire while standing in the hangar for repair. no PSE Fire in offices, shops, warehouses, etc. are not related to PS A scaffold board is placed near a high pressure steam pipe and subsequently begins to burn, but is quickly extinguished with no further damage. The investigation finds that the board had been contaminated by some oil, but there is no indication of an oil leak in the area. no PSE no unplanned or uncontrolled LOPC if the burning scaffolding threatens the process installation and there is an increased risk of LOPC the event should be reported under Tier 3 Critical operational deviation (COD) An internal deflagration in a vessel causes equipment damage > €25,000, but there was no loss of containment. no Tier 1 or 2 PSE  Tier 3 COD Does not meet the definition of a Tier 1 or Tier 2 PSE because there was no LOPC involved. The deflagration had critical potential for a LOPC event and will thus reported under Tier 3 Critical operational deviation (COD) An electrical fire, loss of electricity, or any other loss of utility may occur that causes a plant shutdown and possibly incidental equipment damage greater than $25,000 (e.g. damage to equipment due to inadequate shutdown). no Tier 1 or 2 PSE  Tier 3 CTSS Does not meet the definition of a Tier 1 or Tier 2 PSE because there was no LOPC involved. The event needs to be reported under Tier 3 Challenge to Safety System (CTSS) There is a boiler fire at the Main Office complex, and direct cost damages totaled €75,000. no PSE Fire in offices, shops, warehouses, etc. are not related to PS 32 33 34 35 36 37 38 39 40 41
80 | Was there an unplanned release of hazardous substances? Event Class Comment A gas pipe broke and ~300m3 natural gas with 10% H2S was released Tier 1 For mixtures the highest category counts. From given data ~45kg H2S have been released. The amount of natural gas would classify as a Tier 2 event. Ten bbl of gasoline (1400 kg) leak from piping onto concrete and the gasoline doesn't reach soil or water. Site personnel estimate that the leak occurred within one hour. Tier 1 LOPC of 7 bbl (1000 kg) or more of liquid with a flash point < 23 °C in any one-hour period. If the spill had been less than 1000kg, but equal to or greater than 100kg, it would be a Tier 2 PSE. A faulty tank gauge results in the overfilling of a product tank containing liquid with a flash point < 23 °C. Approximately 50 bbl (7000 kg) of liquid overflows into the tank’s diked area. This incident is a Tier 1 PSE since it is a Tier 1 Release of 1000kg or more within any one-hour period, regardless of secondary containment. An operator is draining water off a flammable crude oil tank with a flash point of 60 °C or less into a drainage system designed for that purpose. The operator leaves the site and forgets to close the valve. Twenty bbl of crude oil are released into the drainage system within an hour. Tier 1 Release of crude oil is unplanned or uncontrolled and it is greater than the release criteria of 14 bbl. If the drainage system goes to an API separator and the oil is recovered (secondary containment), this would still be a Tier 1 event because the crude oil was released from primary containment. A process vessel low level cutout fails to close a valve allowing 550kg of a flammable gas to a floating roof tank resulting in a minor damage to the tank roof. Tier 1 Unplanned release above the Tier 1 threshold. An operator discovers an approximate 10 bbl liquid spill of aromatic solvent (e.g. benzene, toluene) near a process exchanger that was not there during his last inspection round two hours earlier. Tier 1 Since the actual release duration is unknown, a best estimate should be used to determine if the TQ rate has been exceeded (it is preferred to err on the side of inclusion rather than exclusion). This incident is a Tier 1 PSE because the solvents involved are Packing Group II materials and the threshold quantity of 7 bbl is exceeded if the time period is estimated to be less than one hour. A leak on a high pressure hydrochloric acid line results in a spill of 860kg of hydrochloric acid. Flash calculations indicate that greater than 100kg of hydrogen chloride would be released as a vapor. Tier 1 The 860kg release of hydrochloric acid would not a reportable Tier 1 PSE since this liquid is categorized as a “Packing Group II” corrosive liquid with a 1000kg reporting threshold. However, since the liquid flashed or was sprayed out as an aerosol, producing more than 100kg of hydrogen chloride, the event is be a reportable Tier 1 PSE due to exceeding the 100kg or more of toxic chemical within 1 hour. A pipe fitting in a specialty chemicals plant fails, releasing 1800kg of a mixture of 30% formaldehyde, 45% methanol, and 25% water in less than one hour. Calculations show that 450kg formaldehyde and 850kg methanol is released. Tier 1 This mixture is not classified by the UN Dangerous Goods/U.S. DOT protocols; therefore, the threshold quantity mixture calculation is applied. The pure component reporting threshold of formaldehyde is 2000kg and methanol is 1000kg. For the current release formaldehyde is 27% of the Tier 1 threshold and methanol corresponds 85% of the Tier 1 threshold. In total 112% of Tier 1 is achieved 42 43 44 45 46 47 48 49
81 | Was there an unplanned release of hazardous substances? Event Class Comment A pipeline leaks and releases 900kg of flammable vapor above ground within one hour; however, the release occurred in a remote location outside the facility fence. Tier 1 Remoteness is not a consideration and it exceeds a Tier 1 threshold quantity. For R&M operated pipelines the PSE will not be included in external reporting (see Chapter ‎ IV). A pipeline leaks and releases 900kg of flammable vapor above ground within 1 hour. A public road bisects the main facility and its marine docks. This pipeline originates in the facility and goes to the docks. The leak site happens to be off the site’s property in the short segment of piping that runs over the public road. Tier 1 Although the leak technically occurs off-site, this is a Tier 1 PSE since the facility owns and operates the entire segment of pipeline. A DOT covered pipeline that is owned, operated, and maintained by Company A crosses through Company B’s property. The DOT covered line has a 700kg release within an hour from primary containment of flammable gas and causes a fire resulting in greater than €25,000 damage to Company A’s equipment. Tier 1 This is not a PSE for Company B since the pipeline is not owned, operated or maintained by Company B. This would be a transportation incident for Company A. A third-party barge is being pushed by a tug and hits the Company dock. A barge compartment is breached and releases 50 bbl of diesel to the water. Tier 1 The event is not included in external reporting since the barge was not connected to the process for the purpose of feedstock or product transfer. A third-party truck/trailer on Company Premises has a spill of gasoline greater than 7 bbl in less than an hour while loading. Tier 1 The incident is included in external reporting since the truck was connected to the process for the purpose of feedstock or product transfer. A pipe containing CO2 and 10,000 vppm H2S (1 % by volume) leaks and 7000 kg of the gas is released within an hour. Calculations show that the release involved about 55 kg of H2S (TIH Zone B chemical). The release is a Tier 1 PSE because it exceeded the threshold quantity. Tier 1 If the H2S concentration is 50 vppm, then the calculated release quantity would be 0.3 kg of H2S and would be counted as Tier 3. A drilling subsurface blow-out comes to surface (along the casing path to the surface) resulting in release of over 10t of flammable gas to atmosphere Tier 1 During and extended well test at slug of liquid extinguished the flare flame resulting in a release of combusted natural gas as 250.000 SCF per hour until the flare was reignited 10 min later. Tier 1 Uncontrolled release because the flare failed to operate as designed after the flame out. The released amount is above 500kg within one hour. While drilling a well, a shallow gas pocket was stuck, causing a loss of well control. Mud, cuttings, and 100 barrels of oil wer released to the environment and over 64.000kg of gas were discharged to atmosphere. Tier 1 50 51 52 53 54 55 56 57 58
82 | Was there an unplanned release of hazardous substances? Event Class Comment A bleeder valve is left open after a plant turnaround. On start-up, an estimated 15 bbl of fuel oil, a liquid with a flashpoint above 60 °C, is released at 38 °C (below its flashpoint) onto the ground within an hour and into the plant’s drainage system before the bleeder is found and closed. This is a Tier 2 PSE. Tier 2 Unplanned or uncontrolled release If the release temperature would be above the flashpoint; thus, it would be a Tier 1 PSE An operator opens a quality control sample point to collect a routine sample of product and material splashes on him. The operator runs to a safety shower leaving the sample point open and a Tier 2 threshold quantity is released. Tier 2 Unplanned or uncontrolled release A Company railcar derails and spills more than 7 bbl of gasoline while in transit. Tier 2 The incident is not included in external reporting since it is not connected to the process for the purpose of feedstock or product transfer. During loading a truck was overfilled and 150l heating oil spilled on the paving. Tier 2 Unplanned release of a category 7 substance (see Table 2) regardless whether the release is mitigated by secondary containment. A valve leak occurred in a gas turbine acoustic enclosure. The quantity of gas released was 40kg. Tier 2 The quantity released exceeds the threshold quantity for an indoor release of flammable gases. While troubleshooting a higher-than-expected natural gas flow rate, operating personnel find an open block valve on the natural gas line releasing to an elevated vent location. Upon further investigation, it is determined that a total of 1 million lb of natural gas was relieved at a steady rate over a 6 month period. Tier 2 This is not a Tier 1 PSE as the release rate (~100 kg per hour) did not exceed the threshold quantity of 500 kg or more within one hour); however, it is a Tier 2 PSE because it did exceed the threshold of 50 kg or more within 1 hour. An underground pipeline operated by the facility leaks and releases 450kg of diesel (flash point > 60 °C) at a temperature below its flash point within the facility over a period of three days (6.5kg/hr). Tier 2 The spill results in contaminated soil that is subsequently remediated. This is a Tier 2 PSE since the leak rate was greater than the Tier 2 threshold quantity. A Company operated Marine Transport Vessel that had just disconnected from the process has an onboard 10 bbl spill of material with a flash point > 60 °C released at a temperature below its flash point. Tier 2 The event will not be included in external reporting since Marine Transport Vessel incidents are specifically excluded, except when the vessel is connected to the process for the purposes of feedstock or product transfer. A third-party survey boat is pulling a tube screen for seismic survey and a shark bites into the tube releasing 7 bbl of hydraulic fluid into the water. Tier 2 The event will not be included in external reporting because exploration activities are not in the scope. 59 60 61 62 63 64 65 66 67
83 | Was there an unplanned release of hazardous substances? Event Class Comment 100kg of diesel spills within an enclosed area during a period of 30min while transferring fuel to a drilling platform while in-hole. Tier 2 The spill exceeds the indoor threshold and occurred during transfer of fuel to a MODU (e.g., jack-up or drill ship). An underground gasoil pipe was found leaking over several months. Soil was contaminated and the loss was calculated 10l per hour. Tier 3 Here the amount released in any one-hour period is below the Tier 2 threshold even though the total loss is higher. A rupture of a flow line created a spill of 1000 l saltwater (oil fraction negligible) Tier 3 Unplanned release of saltwater shall be recorded as Tier 3 PSE if the exceeded 100l. There is a 10 bbl spill of gasoline that steadily leaks from piping onto soil over a two week time period. Simple calculations show the spill rate was approximately 0.03 bbl per hour. Tier 3 This is not a Tier 1 or Tier 2 PSE since the spill event did not exceed the threshold quantity in any one-hour period. A Company may choose to count this as a Tier 3 other LOPC event. Infrared scans identified that the separator floatation treater was leaking 10.000 SCFD (standard cubic feet per day) from an agitator seal. The separator continued to operate for 10 days until the treater was taken out of service and its seals replaced Tier 3 unplanned release below the thresholds for Tier 1 and 2 in any one hour period After collecting a load from an adjacent unit, a vacuum truck is parked at the wastewater treatment facility awaiting operator approval to discharge. While waiting the vacuum truck malfunctions and vents a small amount of process material to the atmosphere. Tier 3 This event will not be reported externally since vacuum truck operations are excluded unless loading, discharging, or using the truck’s transfer pump. A low pressure steam pipe broke in winter and freezing condensate caused icing of the pathway no PSE Steam is considered as LOPC of hazardous substance unless there is injury caused by the release. An operator purposely drains 20 bbl of material with a flash point > 60 °C (140 °F) at a temperature below its flash point into an oily water collection system within one hour as part of a vessel cleaning operation. no PSE The drainage is planned and controlled and the collection system is designed for such service, this is not a reportable Tier 1 or 2 PSE. Routine monitoring of waste water indicates increased load of H2S but below maximum allowable tolerance. no PSE Emission within the allowable permits are not PSE 68 69 70 71 72 73 74 75 76
84 | Was there a release of a pressure relief device to atmosphere? Event Class Comment There is a unit upset and the PRD fails to open, resulting in overpressure of the equipment and a 10-minute release of 900kg of butane from a leaking flange before it can be blocked in. Tier 1 A relief valve operates and vents 250kg of a flammable gas directly to atmosphere with a small liquid carry over estimated at 10kg hydrocarbons Tier 1 The total mass exceeded the thresholds and there was a small liquid carryover The flare system is not functioning properly due to inactive pilots on the flare tip. During this time, a vapor load is sent to the flare due to an overpressure in a process unit. Tier 1 The volume of the vapor through the PRD is greater than the Tier 1 threshold and it results in the formation of a flammable mixture at grade to be considered as unsafe release. A PRD activates resulting a substantial release exceeding Tier 1 thresholds on an offshore platform causing precautionary down- manning or platform abandonment. Tier 1 This is equivalent to an onshore situation resulting in an onsite shelter in place. 100 bbl of naphtha liquid are inadvertently routed to the flare system through a PRD. The flare knockout drum contains most of the release; however, there is minimal naphtha rainout from the flare. Tier 1 This is a Tier 1 PSE since the volume released from the PRD to a downstream destructive device does exceed the threshold quantity in Table 1 and resulted in one of the four listed consequences (i.e. liquid carryover). During a routine procedure of bleeding off of casing pressure the well operators accidentally fully opened the valves. The bleeding off release was estimated higher than 500kg. Tier 2 Unplanned release of a category 5 substance (see Table 2) There is a unit upset and the PRD opens to an atmospheric vent that has been designed for that scenario, resulting in a release of 150 of propane to the atmosphere requiring on-site shelter in place. Tier 2 This is a Tier 2 PSE because it both exceeded the threshold quantity and resulted in one of the defined negative consequences. A process upset caused a low pressure safety valve to open to atmosphere no PSE blow off is on a safe location, steam not considered as hazardous substance unless nobody is injured A sour gas vessel has a PRD that was identified in a recent PHA to be undersized. In the process of making a transfer, the vessel overpressures. A release of 30kg sour gas (TIH Zone B material) occurs through this PRD to a safe location over a period of 25 minutes. no PSE This would not be a Tier 1 or Tier 2, regardless of the HAZOP finding, so long as it did not result in a liquid carryover, on-site shelter-in-place, public protective measure or other indication of discharge to an unsafe location. It is not counted as a Tier 1 LOPC since the system the overpressure opening is included in normal operations design (although it is not a recommended design). 77 78 79 80 81 82 83 84 85
85 | Was there a need of community evacuation or shelter in place due to the release of hazardous substances? Event Class Comment A leakage of a gas system which contains up to 10% H2S requires evacuation of neighbors. Tier 1 Unplanned release of a category 2 substance requiring evacuation A PRD discharges to a srubber that vents to atmosphere. The scrubber is overwhelmed by a flow rate greater the its design resulting in a discharge that is detected by fence-line monitoring system and a publich shelter in place order is issued Tier 1 The release quantity is estimated less than the Tier 1 threshold. However, the need for shelter in place classifies to Tier 1 PSE A small quantity of very odorous material enters a cooling water system via tube leak. The material is dispersed into the atmosphere at the cooling tower. An elementary school teacher decides not to conduct recess outside due to a noticeable odor even though officials deemed no shelter-in-place was necessary. no PSE This is not a Tier 1 or Tier 2 PSE because of no official declared shelter in place. Less than 0.5kg of Hydrogen Sulphide gas is released while unloading a truck at a refinery. The release is detected by a local analyzer and triggers a unit response alarm. An off-duty police officer living in a nearby home advises his neighbors to evacuate because “an alarm like that means there’s a problem at the refinery.” no Tier 1 PSE  Tier 3 LOPC This is not an officially declared evacuation or shelter-in-place because in this situation the officer is acting as a private citizen suggesting a precautionary measure; therefore this is not a Tier 1 or Tier 2 PSE. Evacuation because of bomb threat or other crime act no PSE Robbery, assault, crime acts (if not associated with hazardous substance) are not PS related. 86 87 88 89 90
86 | Have the safe operations limit of a process installation exceeded? Event Class Comment A sealing of the pump was damaged after the pump pressure increased due to a blocked valve downstream of the pump Tier 3 The shut off head of the pump is obviously higher than the design pressure of the sealing A nozzle rated 16bar was accidentally installed at a 60bar pipeline. It was found out during testing. No release created. Tier 3 The 60bar is well above the safe operating limit of the nozzle. Overfilling of a fuel tank but not creating a spill. Tier 3 In the overhead section of a process installation product stared to freeze because of very cold winter. Tier 3 A faulty pump bearing was identified by a temperature high alarm. The system was shut down to avoid further damage to pump and process. Tier 3 If the operation could have been continued with a spare pump it will not be counted as PSE. While drilling a well there was a loss of hydraulic overbalance resulted in a well kick. The standard procedure to reestablish the well resulted in a planned venting of the kick through the rig's choke and kill system and de-gasser. Tier 3 The release is planned and does not count under LOPC PSE. The event counts under demand of safety system. The car wash needs to be stopped because of lack of cleaning substance. no PSE Not relevant for safe process. Have been inspection or testing results of primary containment found outside acceptable limits? Event Class Comment Routine inspection of fuel tank yield critical degradation of the wall thickness. Tier 3 A moving truck squeezes the fuel hose which suffers cracks. Tier 3 During routine testing of a flow line a leaking flange has been identified Tier 3 The leak is considered as fugitive emission and does not count under LOPC Parts of the metal cover of control cabinet loosened. no PSE Not relevant for safe process. 91 92 93 94 95 96 97 98 99 100 101
87 | Was there an unplanned shutdown of a process installation or of its subsystems? Event Class Comment A technical failure of the LNG compressor causes the unit to shut- down. Tier 3 Customer forgot the fuel hose in the car after filling and drove away. The hose broke and the dispenser shut down automatically. Tier 3 T3 Challenge to safety system: demands on safety systems designed to prevent or mitigate a LOPC event. A propane tank over-pressures through a PRD to the flare system. The pilots on the flare system are not working properly, and the flare does not combust the vapors. The event transpires over a period of 45 minutes. The volume of propane release was estimated to be 600kg and the release dissipated into the atmosphere above grade and above any working platforms. Tier 3 Even though the PRD release exceeded the Tier 1 threshold quantity, this is not a Tier 1 PSE since the discharge was routed to a downstream destructive device with no consequence listed under Tier 1 PRD. An upset causes a PRD to open and release fuel gas to the facility flare system. The flare system works properly and combusts the vapor release which came from the PRD. Tier 3 This is not a Tier 1 or Tier 2 PSE since the PRD release was routed to a downstream destructive device that functioned as intended (i.e. did not cause one of the four listed consequences). A short circuit stopped power supply of the station. no PSE The shut-down is not cause for safety reasons. A faulty flame detector triggered fire alarm. Firefighting checked the situation and confirmed faulty alarm. no PSE No shut-down of the system. Was there an event within the process area which has no immediate PS consequence but had critical potential for a PS event? Event Class Comment On a hot, dry summer day bushes close to a well site caught fire. Firefighting services could prevent flash over to the installation. Tier 3 The fire threatened the installation and had thus the potential for a severe process accident. While refueling a customer car caught fire. Tier 3 The fire threatened the retail station. A sewer pit exploded due to electrostatic ignition of the hydro-carbons contained in the waste water. The sewer cover flew several meters and damaged windows. Tier 3 The explosion does not involve an unplanned, uncontrolled LOPC. Acc. definition Tier 1 & 2 explosions and fires need to result from LOPC. A theft was stealing cables from the cathodic protection system. Tier 3 A truck damaged the support structure of a pipe rack. Tier 3 An internal leakage of a water cooler was identified by increased HC in backflow cooling water. The unit had to shut down for repair. Tier 3 Marginal release. The unmanaged leak could have ended in more severe consequences. A car crashed into the shop window. not PS No risk to end up in a PS event. 102 103 104 105 106 107 111 108 109 110 112 113 114
88 | Does the finding or hazard indicate an increased likelihood of a PS event? Event Class Comment Earthing cables found loosened / degraded / missing during inspection. Tier 4 Critical operating parameters changed without proper management of change (e.g. increased H2S content) Tier 4 Slippery / icy paving. not PS Not relevant for PS Are Process Safety relevant barriers missing or failing? Event Class Comment PS related docs not up to date (e.g. emergency plan for LOPC, explosion protection documentation) Tier 4 Design data for equipment not available. Tier 4 A subcontractor entered the site using the access card of his colleague. not PS Event Class Comment Missing emergency response devices (e.g. firefighting, oil spill, emergency numbers) Tier 4 A safety instrumented function is bypassed without appropriate compensation measures and communication Tier 4 A safety valve did not pop at the set pressure at the test bench. Tier 4 Missing first-aid box not PS First-aid box and PPE have only limited PS relevancy. Is there a deficiency of a management procedure related to PS 115 116 118 119 121 122 120 123 124 117
89 | INTRODUCTION TO OFFSHORE SAFETY CASE
90 |  The Offshore regime is based around the Safety Case Regulations (2005) which requires operators to have a safety case for fixed and mobile installations accepted by the Health and Safety Executive (for UK operators)  The safety cases need to be maintained and submitted to the HSE at various times throughout the life cycle of the installation. Offshore regulatory regime
91 | Offshore regulatory regime The contents of a safety case are detailed in the Safety Case Regulations (2005) and should include:  Description of installation (with drawings)  Location plan of installation  Operational parameters  Maximum number of persons on installation  Well control arrangements  Description of pipelines including contents, dimensions and layout
92 | Offshore regulatory regime  Description of compliance with PFEER regulations which include description of risk assessments and the performance standards for safety critical elements.  Arrangements for protection against toxic gas  Measures or arrangements for protection from hazards of explosion, heat, smoke, toxic gas or fumes including provision for temporary refuge.  Specification for design of installation/plant and description of suitability of safety critical elements.
93 | HAZARD A situation which poses a threat to life, health, property or environment RISK The probability that an hazard will cause a given damage under given circumstances Hazard and Risk High Risk Low Risk
94 | Hazard and Risk
95 | Risk Assessment – General Tolerability Criteria
96 | Risk Assessment – Individual Risk
97 | Safety Case – Hazard Identification The Safety Case has to consider the hazards that can occur in the field, from both external and internal origin: Internal  Loss of Containment: • Fire, Explosion • Gas and Smoke Dispersion  Process Hazards (HAZOP Review)  Workplace hazards  Transportation hazards (Helicopter) External  Marine Hazard (impacts)  Dropped Objects
98 | Safety Case – Study Structure QRA Performance Standards HAZID Escape, Evacuation and Rescue Analysis Fire & Explosion Analysis Gas & Smoke Dispersion Analysis Emergency Systems Survivability Analysis Marine Hazard Analysis Dropped Object Study SIL Analysis MAE  SCEs HAZOP
99 | Safety Case Activities As part of the Safety Case the following studies have to be developed.  HAZOP Review  Safety Integrity Level (SIL) Review  Marine Hazard Analysis  Dropped Object Study  Fire and Explosion Analysis  Gas and Smoke Dispersion Analysis  Emergency Systems Survivability Analysis (ESSA)  Escape, Evacuation and Rescue (EER) Study  Performance Standards & Verification Scheme for SCE  QRA Report  HSE Management System Review Report  Operational Safety Case
100 | Safety Case – Engineering studies – Marine Hazards Purpose: to assess quantitatively the incidental collision frequencies between ships passing in the vicinity of the field facilities, shuttle tankers visiting the field, supply vessels and fishing vessels in the area. Collision Scenarios:  Passing vessels (commercial, passenger, recreational boat) powered and drifting;  Shuttle tankers;  Supply vessels (powered and drifting);  Fishing ships. The parameters considered to assess the impact frequency are:  Ship breakdown frequency;  Probability of human error;  Emergency response.
101 | Safety Case – Engineering studies – Marine Hazards
102 | Damage: Ships with tonnage higher than 5000 DWT are considered to cause major damage to the impacted installation Results Total frequency of collision Frequency of collision causing major damage Safety Case – Engineering studies – Marine Hazards
103 | DWT > 5000 DWT>15000 DWT > 1500 DWT <1500 Safety Case – Engineering studies – Marine Hazards
104 | It is recommended that the supply vessel approaches the platform away from the risers and to create a limitation zone around the risers. • Exclusion area of 7.1 km around the facilities; • Signalisation and inscription on the maritime maps of the field facilities; • Marine radar system; Safety Case – Engineering studies – Marine Hazards • Navigational aid systems on the platforms; • Installation of an AIS (Automatic Identification System); • Installation of a Radar anti-collision; • Fog horn installed on each platform; • Visual signals; • Presence of supply vessel warning vessels entering the exclusion area; • Supply vessel are forbidden to approach the facilities in case of bad weather; • Shuttle tankers approach assisted by tug boat and only during the day.
105 | Safety Case – Engineering studies– Dropped Objects Purpose: To evaluate quantitatively the dropped objects hit frequency on decks, jackets and on oil and gas sealines. The analysis covers the operation, drilling and work-over working phases performed on the platforms and the storage barge. Scenario:  dropped objects from monorails impacting on main deck;  dropped objects from cranes impacting on main deck;  dropped objects from cranes impacting on the jacket structure;  dropped objects from cranes impacting on the sealines. The parameters considered to assess the impact frequency are: • Drop frequency (from statistical data); • Excursion in water.
106 | Calculation technique (examples) Assess the impact energies Safety Case – Engineering studies– Dropped Objects
107 | Safety Case –EER Analysis Purpose: Objective of the Escape, Evacuation and Rescue (EER) study is to assess if successful evacuation from the manned facilities of the field can be achieved. Steps: The EER study is a qualitative assessment of the performance of the EER systems in response to the major accident events, which may or may not require personnel to evacuate the platform in an emergency. The analysis could be done by means of an “EER HAZOP”
108 | Safety Case –Fire & Gas explosion
109 | Safety Case –Fire & Gas explosion The analysis of the fire and explosion risks is performed in accordance with the following steps:  Identification of Credible Fire and Explosion Scenarios; (example) • Release diameter for Minor release: 7mm (1/4”); • Release diameter for Significant release: 25mm (1”); • Release diameter for Major release: 100mm (4”).  Evaluation of Random Rupture Frequencies; • Each identified section has been analysed in order to evaluate the expected rate of failure  Assessment of Consequences of Fire and Explosion Scenarios.
110 | Safety Case –Fire & Gas explosion  Frequency result  Consequences result • Pool fire • Explosion Release diameter Initial event frequency Frequency consequences [event/year] [mm] [event/year] Jet Fire Explosion Flash-Fire Dispersion 7 5.90E-05 5.66E-08 0 2.36E-09 5.89E-05 25 8.86E-05 5.41E-07 0 2.98E-08 8.80E-05 100 2.95E-05 7.38E-07 1.33E-08 1.19E-07 2.86E-05 Location Equipment Hole diameter Pool diameter Distance to Heat Radiation [m] [mm] [m] 37.5 kW/m2 12.5 kW/m2 5 kW/m2 - - 7 3 3.5 5.4 7.8 25 6 5 11 15.6 100 Location Equipment Hole diameter Explosive mass Peak Overpressure distance [m] [mm] [Kg] 0.5bar 0.35bar 0.1bar - - 7 0 - - - 25 0 - - - 100 17 122 126 147
111 | All the numerical results of the engineering safety studies have to be summarized in a Quantified Risk Assessment report, to demonstrate if the Company Risk tolerability criteria are met. Targets  IRPA (Individual Risk Per Annum)  PLL (Potential Loss of Life)  TRIF (Temporary Refuge Impairment Frequency) The above values are calculated for the groups of people in the facilities: • Group 1: personnel in the living quarter / offices most of the time; • Group 2: personnel in the control rooms (or other technical rooms) most of the time; • Group 3: personnel in the process areas (maintenance, etc.). Safety Case –QRA
112 | The QRA SUMS all the risks deriving from each of the hazards assessed individually in the Engineering Safety Studies. In formula:     n i i i i Group p v f IRPA Frequency of one of the hazards assessed in the safety studies “Vulnerability”. The probability that an individual will die due to the consequence associated to the hazard Probability that an individual will be present in the location, at the moment of an accident All the hazards identified Safety Case –QRA
113 | The calculation of risk requires an high number of calculations to be done: Safety Case –QRA
114 | Total IRPA P1 IRPA P2 IRPA P3 IRPA Safety Case –QRA
115 | Potential Loss of Life: PLL Safety Case –QRA

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Process Safety | Process Safety Management | PSM | Gaurav Singh Rajput

  • 1.
    1 | 2015 ProcessSafety Management
  • 2.
    2 | What isProcess Safety Process Safety is  The proactive identification, analysis, and evaluation of the releases of hazardous substances and process accidents.  It applies to the management of hazards associated with the chemical and physical properties of the substances handled in our oil, gas and energy activities.  It aims to:  Minimize the risk of a major accident event MAE  Ensure that the necessary mitigation and emergency preparedness mechanisms are in place
  • 3.
    3 | Likelihood ofoccurrence Tolerable Risk Intolerable Risk Occupational Safety  Process Safety
  • 4.
    4 | What ProcessSafety is about Preventing MAJOR ACCIDENTS
  • 5.
    5 | What isa Major Accident & Major Accident Hazard?  Major Accident (realisation)  This is an accidental event which has major or severe consequences for people or environment. The definitions of ‘major’ and ‘severe’ consequences in this context, are provided in the risk matrix.  Major Accident Hazard (potential)  Any substance or energy which if not contained could seriously harm people or the environment, either directly or by initiating events which could lead to a major accident. Major Accidents exclude: - Occupational health and personal safety hazards - Business critical hazard severity categories  Major Accidents are defined by their consequences
  • 6.
    6 | Definition ofMajor Accident Consequence People Environment 5 Severe 1 fatality of public >1 fatality of workforce > 6 people of workforce and/or public hospitalised Serious long term environmental damage. Significant impact on highly valued or sensitive species, habitat or ecosystem 4 Major 1 fatality of workforce > 3 people on-site hospitalised 1 person of public hospitalised 1 person of workforce with onset/signs of severe irreversible health effect >1 person of public with reversible health effect Very severe, persistent environmental damage extending over large area. Long term impairment of ecosystem function 3 Moderate 1 person of workforce >2 days lost 1 person of workforce with onset/signs of moderate irreversible health effect 1 person of public with moderate reversible mid-term health effect Serious mid-term environmental impacts 2 Minor 1 person of workforce 1 or 2 days off work 1 person of workforce with moderate reversible mid-term health effect 1 person of public with minor reversible short term health effect Moderate reversible environmental damage extends beyond site boundary 1 Slight 1 person of workforce injured, able to continue work but first aid needed 1 person of workforce with minor reversible short term health effect Slight reversible on-site environmental damage
  • 7.
    7 | Summary ofProcess Hazards
  • 8.
  • 9.
    9 | 20” bypasspiping fabricated on-site from shop stock. This pipe ruptured and released Cyclohexane which exploded. On June 1, 1974 the Nypro Co. site at Flixborough, England was severely damaged by a large explosion. Twenty-eight workers were killed and a further 36 suffered injuries. It is recognized that the number of casualties would have been more if the incident had occurred on a weekday, as the main office block was not occupied. Cyclohexane Release & Explosion – 28 fatalities Flixborough, England – June 1, 1974
  • 10.
    10 | On thenight of December 2-3, 1984, a sudden release of about 30 metric tons of methyl isocyanate (MIC) occurred at the Union Carbide pesticide plant at Bhopal, India. The accident was a result of poor safety management practices, poor early warning systems, and the lack of community preparedness. The accident led to the death of over 2,800 people (other estimates put the immediate death toll as high as 8000) living in the vicinity and caused respiratory damage and eye damage to over 20,000 others. At least 200,000 people fled Bhopal during the week after the accident. Estimates of the damage vary widely between $350 million to as high as $3 billion. Methyl Isocyanate Tank Rupture and Release Bhopal, India – Dec. 2-3, 1984 Photo Source: Indian state government of Madhya Pradesh Source: United Nations Environment Programme
  • 11.
    11 | On theday the disaster occurred, the day shift maintenance crew was working on the condensate pumps which compressed gas. One of the pumps was removed for routine maintenance and the condensate pipe was temporarily sealed with a flat metal disk. Because the work could not be completed before the next shift change-over, the metal disc was left in place as the day shift went off duty. The shift coming on duty was unaware of this. Later in the evening, when the other condensate pump stopped working, the pump under maintenance was started up. Gas leaked out at high pressure, ignited and exploded. Gas Release & Explosion – 167 fatalities Piper Alpha, North Sea – July 6, 1988
  • 12.
    12 | On March23, 2005, during the startup of an isomerisation unit, the associated raffinate splitter tower was overfilled and overheated. A substantial volume of hydrocarbon liquid and vapour were forced into an adjacent blowdown stack, rapidly exceeding its capacity. Ignition of the resulting vapour cloud caused an explosion that extended to nearby temporary trailers and resulting in 15 deaths, more than 170 injuries, and significant economic losses. Condensate Release & Explosion – 15 fatalities BP Texas City Refinery, Texas– March 23, 2005
  • 13.
    13 | Deepwater Horizonoil spill 20 April – 15 July 2010, Gulf of Mexico, US Oil Spill (up to 4.9 mln barrels), 11 people died, 17 injured
  • 14.
    14 | Fukushima Daiichi 11March 2011, Fukushima 1 Nuclear Power Plant, Japan Release of radioactive materials, 37 injured
  • 15.
    15 | When willthe next Major Accident occur?
  • 16.
  • 17.
    17 | What mustwe focus on? Process Safety Operating Integrity  Operate within operating envelope ▪Alarm management ▪Process control and procedures ▪Incident investigation and close-out ▪Competencies and Capabilities Maintenance Integrity ▪ Asset Integrity Management Plan ▪ SCE inspection, testing & maintenance ▪ Deviation analysis and close-out Design Integrity ▪ Design reviews: ALARP; engineering codes; standards ▪ SCE Safety Critical Elements (and performance standards) ▪ MOC Management of Change (with technical authorities) ▪ Robust Assurance (WSE - Written Schemes of Examination)
  • 18.
    18 | PSM Elements Process Safety Information  Process Hazard Analysis  Operating Procedures  Employee Participation  Training  Contractors  Pre-Startup Safety Review OSHA PSM Elements (14)  Mechanical Integrity  Hot Work Permit  Management of Change  Incident Investigation  Emergency Planning and  Compliance Audits  Trade Secrets
  • 19.
    19 | PSM Elements Process safety culture  Compliance with standards  Process safety competence  Workforce involvement  Stakeholder outreach  Process knowledge management  Hazard identification and risk analysis  Operating procedures  Safe work practices  Asset integrity and reliability CCPS Risk-Based Process Safety Elements (20)  Contractor management  Training and performance  Management of change  Operational readiness  Conduct of operations  Emergency management  Incident investigation  Measurement and metrics  Auditing  Management review and continuous improvement
  • 20.
  • 21.
  • 22.
  • 23.
    23 | Safety LifeCycle & Risk Assessment
  • 24.
    24 | Safety LifeCycle & Risk Assessment
  • 25.
    25 | Risk Assessmentsteps & toolkits
  • 26.
    26 | What shouldwe do about it?  Hierarchy of control for Process Safety  Inherent Safety – reduce the hazard  Prevention measures – keep it in the pipe  Control measures – minimise size and duration of hazardous event  Mitigation – protect people, the environment and assets  Layers of defence  Risk Control systems
  • 27.
    27 | Hierarchy ofcontrol for Process Safety
  • 28.
    28 | Inherent Safety 1.Substitute - Replace material with a less hazardous substance. 2. Minimize/Intensify - Use smaller quantities of dangerous substances. 3. Moderate/attenuate – Change the conditions to reduce hazard severity in the event of accidental release. 4. Simplify – Strive to eliminate unnecessary complexity which increase the potential for incorrect operation, particularly in the event of abnormal operating conditions.
  • 29.
    29 | Bow Tie– Defence in Depth
  • 30.
    30 | How &Why defences fail
  • 31.
    31 | Key riskcontrol systems classification
  • 32.
    32 | SAFETY CRITICALELEMENTS MANAGEMENT
  • 33.
    33 | What isa Safety Critical Element?  Safety Critical Element – any part of the facilities, the failure of which could cause or contribute substantially to a major accident, or the purpose of which is to limit the effects of a major accident  So, there are two distinct types of SCE Prevent: Those, the failure of which could cause a major accident, and Mitigate: Those required to intervene passively or actively to limit the effects of a major accident
  • 34.
    34 | Management systems,people & processes SCEs are hardware-only But: Management systems, people, processes, are important parts of the Integrity assurance process used to manage the hardware barriers/SCE
  • 35.
    35 | Safety CriticalActivities  Are management systems, procedures, people/competence safety critical?  Yes, but as safety critical activities, not SCEs  SCEs = hardware (& associated software)  How are safety critical activities dealt with?  They are inherent to the SCE assurance process  Examples of safety critical activities/tasks  Permit to work system  Management of change  Risk assessment  Competency training  Quality assurance  Operating envelopes  Defeats register
  • 36.
    36 | How SCEsfit into hazards management  Management of major accident consequences is based on a hierarchy  Industry has evolved models to support/demonstrate this  The Integrity Barrier or “Swiss Cheese” diagram is one Hierarchy of Risk Reduction Prevention Systems to control the primary initiating events Detection Systems to detect the primary safeguards have failed Control Systems to prevent the event from escalating and bring plant to a safe state Mitigation Systems to minimize the effects of an event Emergency Response & Lifesaving Systems to allow you to safely muster and evacuate
  • 37.
    37 | How SCEsfit to hazards management ‘barriers’ concept Inspection, maintenance and testing are activities to prevent barrier degradation. GAS
  • 38.
    38 | Barrier Conceptfor Hazards Management Escalating Consequences STRUCTURAL INTEGRITY - Drilling systems - Structural supports for safety critical equipment - Lifting equipment in wellhead /HC process areas - WHP jacket & foundations - Vessel hull , mooring & ballasting systems IGNITION CONTROL - Haz area HVAC - Non-haz area HVAC - Certified electrical equipment & instruments - Inert gas blanketing - Earth bonding - Fuel gas purge system - Ignition control eqpt - Flare tip ignition system PROTECTION SYSTEMS - Deluge system - Fire & expl protection - Firewater main & pump - Gas, foam & spray fire extinguishers - Corrosion protection e .g. sand filters & chemical injection - Passive fire protection - Navigation aids & collision avoidance EMERGENCY RESPONSE - Temp refuge /muster - Escape/evac routes - Escape lighting - Emergency comms - UPS - Helicopter facilities - Emergency power - Hazardous & non- hazardous open drains PROCESS CONTAINMENT - Pressure vessels - Heat exchangers - Rotating equipment - Tanks - Pipelines /piping - Relief system - Well containment - Gas/oil fired heaters - Gas tight floors /walls - Tanker loading systems - Wireline equipment - Oily water control DETECTION SYSTEMS - Fire detection - Gas detection - H2S detection - Corrosion detection SHUTDOWN SYSTEMS - ESD system - Depressurisation syst - HIPPS - Well isolation - Pipeline isolation valves - Process ESDV - SSIVs - Well control eqpt LIFESAVING - Personal survival equipment - Rescue facilities - TEMPSC /lifeboats - Tertiary escape systems Prevention Detection Control & Mitigation Emergency Response Lifesaving Safe Operation
  • 39.
    39 | What arethe benefits?  Achieve & sustain acceptable level of major accident management  Focus & prioritise resources on the aspects of systems and equipment that manage major accidents  Not how many, but how you manage them  Ensure this is achieved by  Defining the critical functions, and  Aligning inspection and maintenance with these functions
  • 40.
    40 | How toidentify SCEs System Level List of systems and equipment to reduce risk (plant barriers) No No No No Could failure of this element cause a MAE? Is the purpose of this element to prevent a MAE? Could failure of this element contribute substantially to a MAE? Is the purpose of this element to limit the effects of a MAE? Yes Yes Yes Yes SCE Screening This item is a SAFETY CRITICAL ELEMENT This item is not a Safety Critical Element Major accident hazard identification Tag Level
  • 41.
    41 | Performance Standard– Key requirements  Performance Standards (PSs) are parameters that are measured or set so that the suitability and effectiveness of SCEs can be assured and verified.  Performance criteria:  SCE integrity assurance activities  Independent Verification Body (IVB) activities Functionality  The intended purpose and fundamental design performance requirements of the SCE (relative to major accidents) Reliability & Availability  The probability that the system will work on demand and be available when required Survivability  The ability of the SCE to survive loadings from major accidents it is intended to manage Dependency  Identification of other SCEs the performance of which the SCE is dependent on
  • 42.
    42 | Generic PerformanceStandard Structure November 15 Presentation title
  • 43.
    43 | WHY DOIT? What happens when the SCE integrity assurance process is either not in place or not implemented effectively…
  • 44.
  • 45.
    45 | SCE IdentificationPractical NGL piping manual isolating valves Sales gas booster compressor Glycol storage tank Diesel oil storage day tank Crude oil export pump Why SCE? – Yes/No System or Equipment Prevents or Mitigates?
  • 46.
    46 | Prevents or Mitigates? HVACsystem Main power generation/distribution Electrical equipment in classified hazardous areas Pressure transmitter instrument Why SCE? – Yes/No System or Equipment SCE Identification Practical
  • 47.
    47 | Instrument airsystem Flare System Pump lubricating oil system Compressor seal oil system Why SCE? – Yes/No System or Equipment Prevents or Mitigates? SCE Identification Practical
  • 48.
    48 | Permit toWork system Firewater ring-main isolation valve Closed drain system Oil Wellhead Why SCE? – Yes/No System or Equipment Prevents or Mitigates? SCE Identification Practical
  • 49.
    53 | PROCESS SAFETYEVENTS & PSPI
  • 50.
  • 51.
    55 | Type ofindicators  Quantitative  Numbers recorded on scale and tracked over time  Ensure statistically valid interpretation  Most relevant to regularly occurring activities  Qualitative  Descriptions typically inspection and audit observations  Can be quantified using ratings and ladder assessments (comparative definition of bad to good)  Objective  Independent of assessor’s personal judgement  Subjective  Influenced by those measuring
  • 52.
    56 | Type ofindicators
  • 53.
    57 | Example leading& lagging indicators
  • 54.
    58 | Example leading& lagging indicators
  • 55.
    59 | Example ofKey board
  • 56.
  • 57.
    61 | Terminology loss of primary containment LOPC Anunplanned or uncontrolled release of any material from a tank, vessel, pipe, truck, rail car etc., including non-toxic and non- flammable materials (e.g. steam, hot condensate, nitrogen, compressed CO2 or compressed air). An unplanned or uncontrolled release of any material from a process or an undesired event or condition that, under slightly different circumstances, could have resulted in a release of a material. Process safety event PSE Challenge to safety system CTSS A demand on a safety system designed to prevent a LOPC or to mitigate the consequences of a LOPC.
  • 58.
  • 59.
    63 | PSPI &Barriers © 2011 OGP Guidance Report 456
  • 60.
    64 | Process SafetyPerformance Indicators Tier 1 LOPC Events of Greater Consequence Tier 2 LOPC Events of lesser consequence Tier 3 Challenges to Safety Systems Tier 4 Operating Discipline & Management System Performance Indicators incidents E.g. • Hi-Hi level alarm activated. • Defect below minimum wall thickness E.g. • Relief valve fails bench test. • Loss of experience in operations team.
  • 61.
    65 | Process SafetyEvents: Accidents, Incidents, Near Miss, etc.  A Process Safety Event is:  The actual or potential loss of control or containment of hazardous materials (flammable, toxic, corrosive, etc.)  Failure or substandard performance of one or more barriers resulting in the potential or actual operation of the highest safety barrier (e.g. opening of safety valve to flare)  The presence of hazardous material in systems which are not designed to contain it Incidents Demands on Safety System Development of incident scenario prevented by a planed barrier Near Miss Just luck that no accidental consequences occurred Accident Harm to humans or environment, damage of equipment all LOPC events incl. LOPC to secondary containment PS related production loss e.g. due unavailability of barriers or equipment
  • 62.
    66 | PSPI typesof indicators Tier 1 LOPC* events with greater consequence  LOPC exceeding threshold  human harm due LOPC  asset damage after fire / explosion due LOPC not yet all LOPC without environment consequences registered Tier 2 LOPC events with lesser consequence  LOPC exceeding threshold  human harm due LOPC  asset damage after fire / explosion due LOPC not yet all LOPC without environment consequences registered Tier 3 Challenge to safety system  small fires / explosions  minor LOPC events  primary containment inspection outside limits  demands on safety system  safe operating limits excursion  critical operational deviation many of these events are not registered; some are in other systems (e.g. shift logs, computerized maintenance systems) Tier 4 Operating Discipline & Management System Performance focusing on:  Management of Change (MoC) events  Process hazard and risk analyses (PHA)  Action follow up  Inspection of safety critical systems  PS audits  PS related training  Pre-startup safety review (PSSR), etc.  PTW failures find the right leading indicators to improve your (lagging) PSE performance
  • 63.
    67 | Tier 1& Tier 2
  • 64.
    68 | Decision LogicTree for Tier 1 & 2 An employee, contractor or subcontractor “days away from work” injury and/or fatality; or A hospital admission and/or fatality of a third-party An unplanned or uncontrolled release of any material, including non-toxic and non- flammable materials (e.g., steam, hot condensate, nitrogen, compressed CO2, or compressed air) from a process that results in one or more of the consequences listed below: An officially declared community evacuation or community shelter-in-place A fire or explosion resulting in greater than or equal to $25,000 of direct cost to the Company A pressure relief device (PRD ) discharge to Atmosphere whether directly or via a downstream destructive device that results in one or more of the following four consequences: liquid carryover; or discharge to a potentially unsafe location; or an on-site shelter-in-place; or public protective measures (e.g., road closure); and a PRD discharge quantity greater than the threshold quantities Table 1 A release of material greater than the threshold quantities described in Table 1 in any one-hour period A fire or explosion resulting in greater than or equal to $2,500 of direct cost to the Company An employee, contractor, or subcontractor recordable injury A pressure relief device (PRD) discharge to atmosphere whether directly or via a downstream destructive device that results in one or more of the following four consequences:  liquid carryover; or discharge to a potentially unsafe location; or an on-site shelter-in-place; or public protective measures (e.g., road closure); and a PRD discharge quantity greater than the threshold quantities Table 2 A release of material greater than the threshold quantities described in Table 2 in any one-hour period A Company may choose to record a Tier 3 other LO PC Not a Tier 1 or Tier 2 PSE Tier 1 PSE Tier 2 PSE No No No No No No No No No No Yes Yes Yes
  • 65.
    69 | Tier 3Consequences  Safe operating limit excursions  Primary containment inspection outside limits  Demands on safety systems  Critical operational deviation  LOPC event below Tier 1 & 2 threshold A Tier 3 PSE typically represents a challenge to the barrier system that progressed along the path to harm, but is stopped short of a Tier 1 or Tier 2 LOPC consequence. Indicators at this level provide an additional opportunity to identify and correct weaknesses within the barrier system.
  • 66.
    70 | Safe OperatingLimit Excursion – Tier 3 The process has an excursion beyond the normal high or low alarm limits. A single initiating event may result in multiple SOL excursions (e.g. site-wide failure of a utility) and each excursion should be counted as a separate Tier 3 PSE. A process condition that hovers near the SOL value may result in multiple excursions. These excursions should be counted as a single Tier 3 PSE. Abbreviations NEL – Never Exceed Limit. RV – Relief Valve PAH – Pressure Alarm High
  • 67.
    71 | Primary containmentinspection outside acceptable limits – Tier 3 This is a test or inspection where the result is outside the acceptance criteria and triggers some form of remedial action (such as replacement in kind, repair, modification, increased inspection/ testing or de-rating of the equipment). Examples include:  A penetrating corrosion defect beyond the corrosion allowance of a pipe.  Subsidence of a pressure vessel support outside acceptable limits.  Excessive vibration of a small bore instrument tapping on a larger diameter process pipe.  Missing flange bolts on a process pipework joint.
  • 68.
    72 | Demands onsafety systems - Tier 3 Safety Systems are ones which prevent a LOPC or detect, control or mitigate the effects of an LOPC. Demand means they are activated by a valid signal from the process. The system does not have to activate. Where multiple devices constitute one system then activation of that system counts as one PSE. Examples include:  Where a vessel has a number of relief valves to provide suitable flow, activation of one or more of these valves constitutes one PSE as they represent a system.  Activation of a Safety Instrumented System  Activation of Mechanical Shutdown System The count of Demands on Safety Systems is typically segregated by system type (e.g. SIS, PRD, and Mechanical Trip).
  • 69.
    73 | Critical operationaldeviation – Tier 3 This represents operational activity outside good operating practice and/ or non compliance with company Procedures. Examples include:  Operating without adequate measurement of critical process parameters.  Operating with inoperable safety systems.  Operating with uncontrolled modifications / repairs to the process plant.
  • 70.
    74 | Tier 4:Operating Discipline & MS Performance Tier 4 indicators typically represent performance of individual components of the barrier system and are comprised of operating discipline and management system performance. Tier 4 indicators are indicative of process safety system weaknesses that may contribute to future Tier 1 or Tier 2 PSEs. In that sense, Tier 4 indicators may identify opportunities for both learning and systems improvement. Examples include:  Process Safety Action Item Closure  Training completed on schedule  Safety Critical Equipment Inspection  Management of Change (MoC) Compliance  Completion of Emergency Response Drills
  • 71.
  • 72.
    76 | Has aperson been injured by a release of hazardous substances? Event Class Comment A blow out of a gas well occurred during cement plug. An operator was hit by mud and gas and needed hospital treatment. Tier 1 Tier 1 due to the fact of hospital treatment; additionally the release amount may also have resulted in a Tier 1 event While stealing a piece of pipework the gas released from that pipe ignited and the thefts suffered severe burns. Tier 1 Even though the reason for the injuries is a malicious act it is counted. LPG from leaking pipework ignited and blasted the retail service station causing injuries and damage of the building. Tier 1 Tier 1 event due to the injuries and the asset damage. This event will not be included in external reporting since the retail station is not operated by OMV. An operator slipped and fell while responding to a small spill of liquid with a flash point < 23 °C spill resulting in a days away from work injury. Tier 1 The operator was responding to a LOPC A scaffold builder experiences a days away from work injury after falling from a scaffold ladder while evacuating from a LOPC on nearby equipment. Tier 1 An operator walks past a steam trap that discharges to an unsafe location. The steam trap releases and the operator’s ankle is burned by the steam, resulting in a days away from work injury. Tier 1 Even though the LOPC was steam (vs hydrocarbon or chemical), the physical state of the material was such that it caused a day away from work injury and it was an uncontrolled release (i.e. unsafe location). Nontoxic and non-flammable materials are within the scope of this recommended practice. A contractor enters a vessel and dies because nitrogen inadvertently leaked into the enclosure. Tier 1 Fatality associated with an unplanned or uncontrolled LOPC A maintenance contractor opens a process valve and gets sprayed with less than the Tier 1 or Tier 2 quantity of sulfuric acid resulting in a severe burn and days away from work injury. Tier 1 Unplanned or uncontrolled LOPC that resulted in a days away from work injury. If this incident had resulted in a recordable injury, it would be a Tier 2 PSE. A PRD release of sour gas less than the Tier 1 threshold quantity is routed to a flare which exposes two personnel to toxic SO2/SO3 vapors resulting in a LWDI. Tier 1 Multiple Tier 1 consequences: Human and unsafe PRD release Classification of PS Events 1 2 3 4 5 6 7 8 9
  • 73.
    77 | Has aperson been injured by a release of hazardous substances? Event Class Comment There is a 100 kg spill of liquid with a flash point < 23 °C (73 °F) that ignites and results in damages to other equipment, a toxic gas release above the reporting threshold, along with three days away from work injuries and one fatality. Tier 1 This is a Tier 1 PSE. The site would record a single event with multiple consequences (e.g., one fatality, three day away from work injuries, fire, and threshold quantity of liquid with a flash point < 23 °C and toxic gas). During routine tour an operator suffered burns on his foot by leaking condensate from a steam tracing which required medical treatment. Tier 2 Tier 2 due to the need of medical treatment. The release of hot condensate itself would not be a PSE. A short circuit occurred in switchgear panel and caused burns of a contractor requiring medical treatment Tier 2 Following industry recommendations we consider electrical incidents in internal PSE reporting. An operator walks through a process unit and slips and falls to the ground and suffers a days away from work injury. The slip/fall is due to weather conditions, “chronic” oily floors and slippery shoes. no PSE Personal safety “slip/trip/fall” incidents that are not directly associated with evacuating from or responding to a LOPC are specifically excluded from PSE reporting. An operator slipped and fell on a spill several hours after the incident had concluded. This would not be a reportable PSE. no PSE Personal safety events that are not directly associated with onsite response to a LOPC are excluded. Slips/trip/falls after the LOPC has concluded (such as “after-the-fact” clean-up and remediation) is not directly associated with onsite response. A vessel has been intentionally purged with nitrogen. A contractor bypasses safety controls, enters the enclosure and dies. no PSE This is not a PSE because there was no unplanned or uncontrolled LOPC, but it would be recorded on the company’s injury and illness log. An operator disconnected a steam hose which was still under pressure and suffered light burns. no PSE The injury required only first aid, and the steam is no counted as LOPC of hazardous substance. A maintenance technician is turning a bolt on a process flange with a wrench. Due to improper body positioning, the wrench slips and hits the employee in the mouth, requiring dental surgery and two days off work. no PSE No unplanned or uncontrolled LOPC involved with the injury An operator takes a sample. On the way he falls, the sample container breaks and he suffers injury of the exposure to the product. no PSE LOPC is from a piece of ancillary equipment not connected to a process is not considered as PSE An employee suffered burns by a spill of hot coffee. no PSE Office incidents are not PS related While cleaning a joint screw a piece of frozen mud broke off and hit the operator causing injury. no PSE This is not a loss of primary containment. 10 11 12 13 14 15 16 17 18 19 20
  • 74.
    78 | Has afire or explosion occurred by a release of a hazardous substance? Event Class Comment Hot vacuum residue was released from a left open drainage, self- ignited and damaged a pump. Tier 1 The immediate damage caused by the fire was above 25.000€ An electrical fire impacts the operation of the process resulting in an acute release of 1500kg of light crude. Tier 1 This is a Tier 1 PSE since the LOPC exceeds the 1000 kg reporting threshold for light crude. A pump lube oil system fire from a leak causes damage greater than €25,000, but does not create a LOPC greater than the threshold quantity or cause a fatality or serious injury. Tier 1 A forklift truck delivering materials inside a process unit knocks off a bleeder valve leading to the release of (HC) condensate and a subsequent vapor cloud explosion with asset damage greater than €25,000. Tier 1 A bearing failure of a turbine causes high vibration and eventually leads to damage of the turbine > €100.000. Tier 1 Following industry recommendation we consider unplanned release of mechanical energy under PS in internal reporting. There is a loss of burner flame in a fired heater resulting in a fuel rich environment and subsequent explosion in the fire box with greater than €25,000 in damages to the internals of the heater. There was no release outside of the fire box. Tier 1 This would be a Tier 1 PSE since after the flameout the continuing flow of fuel gas is now an uncontrolled release. The intent is for combustion of the fuel gas at the burner and not for fuel gas to be contained in the fire box. There is a tube rupture in a fired heater causing a fire (contained in the heater) resulting in greater than €25,000 in damages to the heater internals (beyond that of replacing the failed tube). Tier 1 The tube failure is a loss of primary containment of the process fluid and combined with the additional damages greater than €25,000 makes this a Tier 1 PSE. A third-party truck loaded with a flammable product is traveling on Company premises and experiences a leak and subsequent fire and property damages of €75,000 (direct costs). Tier 1 The event will not be included in external reporting since truck incidents are excluded except when they are connected to the process for the purposes of feedstock or product transfer or being used for temporary onsite storage. A steam injection well fails with an explosion resulting in release of 10t of fluids, a mixture of hydrocarbons and water. The direct cost replacing and repairing damaged equipment was estimated over €300.000 and a worker was injured, needing medical treatment. Tier 1 Unplanned release causing fire and resulting in over €25.000 direct costs. The injury would result into Tier 2 but the higher consequence counts. The release of a hot steam from safety valve ignited wooden planks of scaffolding and damaged the scaffolding. Tier 2 The immediate damage was higher than 2.500€ but lower than 25.000€ Hydrocarbon fumes migrate into the QA/QC laboratory located within the facility and results in a fire with €5000 damage. The source of the hydrocarbon fumes is the oily water sewer system. Tier 2 This incident is a Tier 2 PSE since the LOPC was from the process and resulted in a Tier 2 consequence (a fire which results in a direct cost greater than €2500). 21 22 23 24 25 26 27 28 29 30 31
  • 75.
    79 | Has afire or explosion occurred by a release of a hazardous substance? Event Class Comment A pump seal fails and the resultant loss of containment catches on fire. The fire is put out quickly with no personal injuries. However, the fire resulted in the need to repair some damaged instrumentation and replace insulation. The cost of the repairs, replacement, cleanup and emergency response totaled €20.000. Tier 2 Only the costs for repair and replacement of the equipment damaged by the fire are to be considered. The cost for the repair of the equipment which led to the fire must not be considered. A vacuum truck outfitted with a carbon canister on the vent is loading a spill of hydrocarbons. The carbon canister catches fire which escalates to the point of creating more than €10,000 in damage to the vacuum truck. Tier 2 This is a Tier 2 PSE since the original spill of hydrocarbons constitutes the LOPC and the response to the LOPC results in one of the Tier 2 consequences. Product from a small flange leakage dropped on a hot steam pipe and started smoldering Tier 3 Negligible damage from a fire involving LOPC There is a tube rupture in a fired heater. The operator detects the tube cracking with only a small flame from the tube and subsequently shuts down the heater with no resultant damage from the tube flame. Tier 3 The LOPC did not result in any of the defined Tier 1 or 2 consequences. However, it was a fire resulting from an unplanned LOPC. During a hot work the sparkles ignited the vapor of an atmospheric slop inlet. The fire damaged insulation material. no PSE The fire does not involve an unplanned, uncontrolled LOPC. (see above) If the fire threatened the installation it may be reported as Tier 3 Critical Operational Deviation A vacuum truck caught fire while standing in the hangar for repair. no PSE Fire in offices, shops, warehouses, etc. are not related to PS A scaffold board is placed near a high pressure steam pipe and subsequently begins to burn, but is quickly extinguished with no further damage. The investigation finds that the board had been contaminated by some oil, but there is no indication of an oil leak in the area. no PSE no unplanned or uncontrolled LOPC if the burning scaffolding threatens the process installation and there is an increased risk of LOPC the event should be reported under Tier 3 Critical operational deviation (COD) An internal deflagration in a vessel causes equipment damage > €25,000, but there was no loss of containment. no Tier 1 or 2 PSE  Tier 3 COD Does not meet the definition of a Tier 1 or Tier 2 PSE because there was no LOPC involved. The deflagration had critical potential for a LOPC event and will thus reported under Tier 3 Critical operational deviation (COD) An electrical fire, loss of electricity, or any other loss of utility may occur that causes a plant shutdown and possibly incidental equipment damage greater than $25,000 (e.g. damage to equipment due to inadequate shutdown). no Tier 1 or 2 PSE  Tier 3 CTSS Does not meet the definition of a Tier 1 or Tier 2 PSE because there was no LOPC involved. The event needs to be reported under Tier 3 Challenge to Safety System (CTSS) There is a boiler fire at the Main Office complex, and direct cost damages totaled €75,000. no PSE Fire in offices, shops, warehouses, etc. are not related to PS 32 33 34 35 36 37 38 39 40 41
  • 76.
    80 | Was therean unplanned release of hazardous substances? Event Class Comment A gas pipe broke and ~300m3 natural gas with 10% H2S was released Tier 1 For mixtures the highest category counts. From given data ~45kg H2S have been released. The amount of natural gas would classify as a Tier 2 event. Ten bbl of gasoline (1400 kg) leak from piping onto concrete and the gasoline doesn't reach soil or water. Site personnel estimate that the leak occurred within one hour. Tier 1 LOPC of 7 bbl (1000 kg) or more of liquid with a flash point < 23 °C in any one-hour period. If the spill had been less than 1000kg, but equal to or greater than 100kg, it would be a Tier 2 PSE. A faulty tank gauge results in the overfilling of a product tank containing liquid with a flash point < 23 °C. Approximately 50 bbl (7000 kg) of liquid overflows into the tank’s diked area. This incident is a Tier 1 PSE since it is a Tier 1 Release of 1000kg or more within any one-hour period, regardless of secondary containment. An operator is draining water off a flammable crude oil tank with a flash point of 60 °C or less into a drainage system designed for that purpose. The operator leaves the site and forgets to close the valve. Twenty bbl of crude oil are released into the drainage system within an hour. Tier 1 Release of crude oil is unplanned or uncontrolled and it is greater than the release criteria of 14 bbl. If the drainage system goes to an API separator and the oil is recovered (secondary containment), this would still be a Tier 1 event because the crude oil was released from primary containment. A process vessel low level cutout fails to close a valve allowing 550kg of a flammable gas to a floating roof tank resulting in a minor damage to the tank roof. Tier 1 Unplanned release above the Tier 1 threshold. An operator discovers an approximate 10 bbl liquid spill of aromatic solvent (e.g. benzene, toluene) near a process exchanger that was not there during his last inspection round two hours earlier. Tier 1 Since the actual release duration is unknown, a best estimate should be used to determine if the TQ rate has been exceeded (it is preferred to err on the side of inclusion rather than exclusion). This incident is a Tier 1 PSE because the solvents involved are Packing Group II materials and the threshold quantity of 7 bbl is exceeded if the time period is estimated to be less than one hour. A leak on a high pressure hydrochloric acid line results in a spill of 860kg of hydrochloric acid. Flash calculations indicate that greater than 100kg of hydrogen chloride would be released as a vapor. Tier 1 The 860kg release of hydrochloric acid would not a reportable Tier 1 PSE since this liquid is categorized as a “Packing Group II” corrosive liquid with a 1000kg reporting threshold. However, since the liquid flashed or was sprayed out as an aerosol, producing more than 100kg of hydrogen chloride, the event is be a reportable Tier 1 PSE due to exceeding the 100kg or more of toxic chemical within 1 hour. A pipe fitting in a specialty chemicals plant fails, releasing 1800kg of a mixture of 30% formaldehyde, 45% methanol, and 25% water in less than one hour. Calculations show that 450kg formaldehyde and 850kg methanol is released. Tier 1 This mixture is not classified by the UN Dangerous Goods/U.S. DOT protocols; therefore, the threshold quantity mixture calculation is applied. The pure component reporting threshold of formaldehyde is 2000kg and methanol is 1000kg. For the current release formaldehyde is 27% of the Tier 1 threshold and methanol corresponds 85% of the Tier 1 threshold. In total 112% of Tier 1 is achieved 42 43 44 45 46 47 48 49
  • 77.
    81 | Was therean unplanned release of hazardous substances? Event Class Comment A pipeline leaks and releases 900kg of flammable vapor above ground within one hour; however, the release occurred in a remote location outside the facility fence. Tier 1 Remoteness is not a consideration and it exceeds a Tier 1 threshold quantity. For R&M operated pipelines the PSE will not be included in external reporting (see Chapter ‎ IV). A pipeline leaks and releases 900kg of flammable vapor above ground within 1 hour. A public road bisects the main facility and its marine docks. This pipeline originates in the facility and goes to the docks. The leak site happens to be off the site’s property in the short segment of piping that runs over the public road. Tier 1 Although the leak technically occurs off-site, this is a Tier 1 PSE since the facility owns and operates the entire segment of pipeline. A DOT covered pipeline that is owned, operated, and maintained by Company A crosses through Company B’s property. The DOT covered line has a 700kg release within an hour from primary containment of flammable gas and causes a fire resulting in greater than €25,000 damage to Company A’s equipment. Tier 1 This is not a PSE for Company B since the pipeline is not owned, operated or maintained by Company B. This would be a transportation incident for Company A. A third-party barge is being pushed by a tug and hits the Company dock. A barge compartment is breached and releases 50 bbl of diesel to the water. Tier 1 The event is not included in external reporting since the barge was not connected to the process for the purpose of feedstock or product transfer. A third-party truck/trailer on Company Premises has a spill of gasoline greater than 7 bbl in less than an hour while loading. Tier 1 The incident is included in external reporting since the truck was connected to the process for the purpose of feedstock or product transfer. A pipe containing CO2 and 10,000 vppm H2S (1 % by volume) leaks and 7000 kg of the gas is released within an hour. Calculations show that the release involved about 55 kg of H2S (TIH Zone B chemical). The release is a Tier 1 PSE because it exceeded the threshold quantity. Tier 1 If the H2S concentration is 50 vppm, then the calculated release quantity would be 0.3 kg of H2S and would be counted as Tier 3. A drilling subsurface blow-out comes to surface (along the casing path to the surface) resulting in release of over 10t of flammable gas to atmosphere Tier 1 During and extended well test at slug of liquid extinguished the flare flame resulting in a release of combusted natural gas as 250.000 SCF per hour until the flare was reignited 10 min later. Tier 1 Uncontrolled release because the flare failed to operate as designed after the flame out. The released amount is above 500kg within one hour. While drilling a well, a shallow gas pocket was stuck, causing a loss of well control. Mud, cuttings, and 100 barrels of oil wer released to the environment and over 64.000kg of gas were discharged to atmosphere. Tier 1 50 51 52 53 54 55 56 57 58
  • 78.
    82 | Was therean unplanned release of hazardous substances? Event Class Comment A bleeder valve is left open after a plant turnaround. On start-up, an estimated 15 bbl of fuel oil, a liquid with a flashpoint above 60 °C, is released at 38 °C (below its flashpoint) onto the ground within an hour and into the plant’s drainage system before the bleeder is found and closed. This is a Tier 2 PSE. Tier 2 Unplanned or uncontrolled release If the release temperature would be above the flashpoint; thus, it would be a Tier 1 PSE An operator opens a quality control sample point to collect a routine sample of product and material splashes on him. The operator runs to a safety shower leaving the sample point open and a Tier 2 threshold quantity is released. Tier 2 Unplanned or uncontrolled release A Company railcar derails and spills more than 7 bbl of gasoline while in transit. Tier 2 The incident is not included in external reporting since it is not connected to the process for the purpose of feedstock or product transfer. During loading a truck was overfilled and 150l heating oil spilled on the paving. Tier 2 Unplanned release of a category 7 substance (see Table 2) regardless whether the release is mitigated by secondary containment. A valve leak occurred in a gas turbine acoustic enclosure. The quantity of gas released was 40kg. Tier 2 The quantity released exceeds the threshold quantity for an indoor release of flammable gases. While troubleshooting a higher-than-expected natural gas flow rate, operating personnel find an open block valve on the natural gas line releasing to an elevated vent location. Upon further investigation, it is determined that a total of 1 million lb of natural gas was relieved at a steady rate over a 6 month period. Tier 2 This is not a Tier 1 PSE as the release rate (~100 kg per hour) did not exceed the threshold quantity of 500 kg or more within one hour); however, it is a Tier 2 PSE because it did exceed the threshold of 50 kg or more within 1 hour. An underground pipeline operated by the facility leaks and releases 450kg of diesel (flash point > 60 °C) at a temperature below its flash point within the facility over a period of three days (6.5kg/hr). Tier 2 The spill results in contaminated soil that is subsequently remediated. This is a Tier 2 PSE since the leak rate was greater than the Tier 2 threshold quantity. A Company operated Marine Transport Vessel that had just disconnected from the process has an onboard 10 bbl spill of material with a flash point > 60 °C released at a temperature below its flash point. Tier 2 The event will not be included in external reporting since Marine Transport Vessel incidents are specifically excluded, except when the vessel is connected to the process for the purposes of feedstock or product transfer. A third-party survey boat is pulling a tube screen for seismic survey and a shark bites into the tube releasing 7 bbl of hydraulic fluid into the water. Tier 2 The event will not be included in external reporting because exploration activities are not in the scope. 59 60 61 62 63 64 65 66 67
  • 79.
    83 | Was therean unplanned release of hazardous substances? Event Class Comment 100kg of diesel spills within an enclosed area during a period of 30min while transferring fuel to a drilling platform while in-hole. Tier 2 The spill exceeds the indoor threshold and occurred during transfer of fuel to a MODU (e.g., jack-up or drill ship). An underground gasoil pipe was found leaking over several months. Soil was contaminated and the loss was calculated 10l per hour. Tier 3 Here the amount released in any one-hour period is below the Tier 2 threshold even though the total loss is higher. A rupture of a flow line created a spill of 1000 l saltwater (oil fraction negligible) Tier 3 Unplanned release of saltwater shall be recorded as Tier 3 PSE if the exceeded 100l. There is a 10 bbl spill of gasoline that steadily leaks from piping onto soil over a two week time period. Simple calculations show the spill rate was approximately 0.03 bbl per hour. Tier 3 This is not a Tier 1 or Tier 2 PSE since the spill event did not exceed the threshold quantity in any one-hour period. A Company may choose to count this as a Tier 3 other LOPC event. Infrared scans identified that the separator floatation treater was leaking 10.000 SCFD (standard cubic feet per day) from an agitator seal. The separator continued to operate for 10 days until the treater was taken out of service and its seals replaced Tier 3 unplanned release below the thresholds for Tier 1 and 2 in any one hour period After collecting a load from an adjacent unit, a vacuum truck is parked at the wastewater treatment facility awaiting operator approval to discharge. While waiting the vacuum truck malfunctions and vents a small amount of process material to the atmosphere. Tier 3 This event will not be reported externally since vacuum truck operations are excluded unless loading, discharging, or using the truck’s transfer pump. A low pressure steam pipe broke in winter and freezing condensate caused icing of the pathway no PSE Steam is considered as LOPC of hazardous substance unless there is injury caused by the release. An operator purposely drains 20 bbl of material with a flash point > 60 °C (140 °F) at a temperature below its flash point into an oily water collection system within one hour as part of a vessel cleaning operation. no PSE The drainage is planned and controlled and the collection system is designed for such service, this is not a reportable Tier 1 or 2 PSE. Routine monitoring of waste water indicates increased load of H2S but below maximum allowable tolerance. no PSE Emission within the allowable permits are not PSE 68 69 70 71 72 73 74 75 76
  • 80.
    84 | Was therea release of a pressure relief device to atmosphere? Event Class Comment There is a unit upset and the PRD fails to open, resulting in overpressure of the equipment and a 10-minute release of 900kg of butane from a leaking flange before it can be blocked in. Tier 1 A relief valve operates and vents 250kg of a flammable gas directly to atmosphere with a small liquid carry over estimated at 10kg hydrocarbons Tier 1 The total mass exceeded the thresholds and there was a small liquid carryover The flare system is not functioning properly due to inactive pilots on the flare tip. During this time, a vapor load is sent to the flare due to an overpressure in a process unit. Tier 1 The volume of the vapor through the PRD is greater than the Tier 1 threshold and it results in the formation of a flammable mixture at grade to be considered as unsafe release. A PRD activates resulting a substantial release exceeding Tier 1 thresholds on an offshore platform causing precautionary down- manning or platform abandonment. Tier 1 This is equivalent to an onshore situation resulting in an onsite shelter in place. 100 bbl of naphtha liquid are inadvertently routed to the flare system through a PRD. The flare knockout drum contains most of the release; however, there is minimal naphtha rainout from the flare. Tier 1 This is a Tier 1 PSE since the volume released from the PRD to a downstream destructive device does exceed the threshold quantity in Table 1 and resulted in one of the four listed consequences (i.e. liquid carryover). During a routine procedure of bleeding off of casing pressure the well operators accidentally fully opened the valves. The bleeding off release was estimated higher than 500kg. Tier 2 Unplanned release of a category 5 substance (see Table 2) There is a unit upset and the PRD opens to an atmospheric vent that has been designed for that scenario, resulting in a release of 150 of propane to the atmosphere requiring on-site shelter in place. Tier 2 This is a Tier 2 PSE because it both exceeded the threshold quantity and resulted in one of the defined negative consequences. A process upset caused a low pressure safety valve to open to atmosphere no PSE blow off is on a safe location, steam not considered as hazardous substance unless nobody is injured A sour gas vessel has a PRD that was identified in a recent PHA to be undersized. In the process of making a transfer, the vessel overpressures. A release of 30kg sour gas (TIH Zone B material) occurs through this PRD to a safe location over a period of 25 minutes. no PSE This would not be a Tier 1 or Tier 2, regardless of the HAZOP finding, so long as it did not result in a liquid carryover, on-site shelter-in-place, public protective measure or other indication of discharge to an unsafe location. It is not counted as a Tier 1 LOPC since the system the overpressure opening is included in normal operations design (although it is not a recommended design). 77 78 79 80 81 82 83 84 85
  • 81.
    85 | Was therea need of community evacuation or shelter in place due to the release of hazardous substances? Event Class Comment A leakage of a gas system which contains up to 10% H2S requires evacuation of neighbors. Tier 1 Unplanned release of a category 2 substance requiring evacuation A PRD discharges to a srubber that vents to atmosphere. The scrubber is overwhelmed by a flow rate greater the its design resulting in a discharge that is detected by fence-line monitoring system and a publich shelter in place order is issued Tier 1 The release quantity is estimated less than the Tier 1 threshold. However, the need for shelter in place classifies to Tier 1 PSE A small quantity of very odorous material enters a cooling water system via tube leak. The material is dispersed into the atmosphere at the cooling tower. An elementary school teacher decides not to conduct recess outside due to a noticeable odor even though officials deemed no shelter-in-place was necessary. no PSE This is not a Tier 1 or Tier 2 PSE because of no official declared shelter in place. Less than 0.5kg of Hydrogen Sulphide gas is released while unloading a truck at a refinery. The release is detected by a local analyzer and triggers a unit response alarm. An off-duty police officer living in a nearby home advises his neighbors to evacuate because “an alarm like that means there’s a problem at the refinery.” no Tier 1 PSE  Tier 3 LOPC This is not an officially declared evacuation or shelter-in-place because in this situation the officer is acting as a private citizen suggesting a precautionary measure; therefore this is not a Tier 1 or Tier 2 PSE. Evacuation because of bomb threat or other crime act no PSE Robbery, assault, crime acts (if not associated with hazardous substance) are not PS related. 86 87 88 89 90
  • 82.
    86 | Have thesafe operations limit of a process installation exceeded? Event Class Comment A sealing of the pump was damaged after the pump pressure increased due to a blocked valve downstream of the pump Tier 3 The shut off head of the pump is obviously higher than the design pressure of the sealing A nozzle rated 16bar was accidentally installed at a 60bar pipeline. It was found out during testing. No release created. Tier 3 The 60bar is well above the safe operating limit of the nozzle. Overfilling of a fuel tank but not creating a spill. Tier 3 In the overhead section of a process installation product stared to freeze because of very cold winter. Tier 3 A faulty pump bearing was identified by a temperature high alarm. The system was shut down to avoid further damage to pump and process. Tier 3 If the operation could have been continued with a spare pump it will not be counted as PSE. While drilling a well there was a loss of hydraulic overbalance resulted in a well kick. The standard procedure to reestablish the well resulted in a planned venting of the kick through the rig's choke and kill system and de-gasser. Tier 3 The release is planned and does not count under LOPC PSE. The event counts under demand of safety system. The car wash needs to be stopped because of lack of cleaning substance. no PSE Not relevant for safe process. Have been inspection or testing results of primary containment found outside acceptable limits? Event Class Comment Routine inspection of fuel tank yield critical degradation of the wall thickness. Tier 3 A moving truck squeezes the fuel hose which suffers cracks. Tier 3 During routine testing of a flow line a leaking flange has been identified Tier 3 The leak is considered as fugitive emission and does not count under LOPC Parts of the metal cover of control cabinet loosened. no PSE Not relevant for safe process. 91 92 93 94 95 96 97 98 99 100 101
  • 83.
    87 | Was therean unplanned shutdown of a process installation or of its subsystems? Event Class Comment A technical failure of the LNG compressor causes the unit to shut- down. Tier 3 Customer forgot the fuel hose in the car after filling and drove away. The hose broke and the dispenser shut down automatically. Tier 3 T3 Challenge to safety system: demands on safety systems designed to prevent or mitigate a LOPC event. A propane tank over-pressures through a PRD to the flare system. The pilots on the flare system are not working properly, and the flare does not combust the vapors. The event transpires over a period of 45 minutes. The volume of propane release was estimated to be 600kg and the release dissipated into the atmosphere above grade and above any working platforms. Tier 3 Even though the PRD release exceeded the Tier 1 threshold quantity, this is not a Tier 1 PSE since the discharge was routed to a downstream destructive device with no consequence listed under Tier 1 PRD. An upset causes a PRD to open and release fuel gas to the facility flare system. The flare system works properly and combusts the vapor release which came from the PRD. Tier 3 This is not a Tier 1 or Tier 2 PSE since the PRD release was routed to a downstream destructive device that functioned as intended (i.e. did not cause one of the four listed consequences). A short circuit stopped power supply of the station. no PSE The shut-down is not cause for safety reasons. A faulty flame detector triggered fire alarm. Firefighting checked the situation and confirmed faulty alarm. no PSE No shut-down of the system. Was there an event within the process area which has no immediate PS consequence but had critical potential for a PS event? Event Class Comment On a hot, dry summer day bushes close to a well site caught fire. Firefighting services could prevent flash over to the installation. Tier 3 The fire threatened the installation and had thus the potential for a severe process accident. While refueling a customer car caught fire. Tier 3 The fire threatened the retail station. A sewer pit exploded due to electrostatic ignition of the hydro-carbons contained in the waste water. The sewer cover flew several meters and damaged windows. Tier 3 The explosion does not involve an unplanned, uncontrolled LOPC. Acc. definition Tier 1 & 2 explosions and fires need to result from LOPC. A theft was stealing cables from the cathodic protection system. Tier 3 A truck damaged the support structure of a pipe rack. Tier 3 An internal leakage of a water cooler was identified by increased HC in backflow cooling water. The unit had to shut down for repair. Tier 3 Marginal release. The unmanaged leak could have ended in more severe consequences. A car crashed into the shop window. not PS No risk to end up in a PS event. 102 103 104 105 106 107 111 108 109 110 112 113 114
  • 84.
    88 | Does thefinding or hazard indicate an increased likelihood of a PS event? Event Class Comment Earthing cables found loosened / degraded / missing during inspection. Tier 4 Critical operating parameters changed without proper management of change (e.g. increased H2S content) Tier 4 Slippery / icy paving. not PS Not relevant for PS Are Process Safety relevant barriers missing or failing? Event Class Comment PS related docs not up to date (e.g. emergency plan for LOPC, explosion protection documentation) Tier 4 Design data for equipment not available. Tier 4 A subcontractor entered the site using the access card of his colleague. not PS Event Class Comment Missing emergency response devices (e.g. firefighting, oil spill, emergency numbers) Tier 4 A safety instrumented function is bypassed without appropriate compensation measures and communication Tier 4 A safety valve did not pop at the set pressure at the test bench. Tier 4 Missing first-aid box not PS First-aid box and PPE have only limited PS relevancy. Is there a deficiency of a management procedure related to PS 115 116 118 119 121 122 120 123 124 117
  • 85.
  • 86.
    90 |  TheOffshore regime is based around the Safety Case Regulations (2005) which requires operators to have a safety case for fixed and mobile installations accepted by the Health and Safety Executive (for UK operators)  The safety cases need to be maintained and submitted to the HSE at various times throughout the life cycle of the installation. Offshore regulatory regime
  • 87.
    91 | Offshore regulatoryregime The contents of a safety case are detailed in the Safety Case Regulations (2005) and should include:  Description of installation (with drawings)  Location plan of installation  Operational parameters  Maximum number of persons on installation  Well control arrangements  Description of pipelines including contents, dimensions and layout
  • 88.
    92 | Offshore regulatoryregime  Description of compliance with PFEER regulations which include description of risk assessments and the performance standards for safety critical elements.  Arrangements for protection against toxic gas  Measures or arrangements for protection from hazards of explosion, heat, smoke, toxic gas or fumes including provision for temporary refuge.  Specification for design of installation/plant and description of suitability of safety critical elements.
  • 89.
    93 | HAZARD A situationwhich poses a threat to life, health, property or environment RISK The probability that an hazard will cause a given damage under given circumstances Hazard and Risk High Risk Low Risk
  • 90.
  • 91.
    95 | Risk Assessment– General Tolerability Criteria
  • 92.
    96 | Risk Assessment– Individual Risk
  • 93.
    97 | Safety Case– Hazard Identification The Safety Case has to consider the hazards that can occur in the field, from both external and internal origin: Internal  Loss of Containment: • Fire, Explosion • Gas and Smoke Dispersion  Process Hazards (HAZOP Review)  Workplace hazards  Transportation hazards (Helicopter) External  Marine Hazard (impacts)  Dropped Objects
  • 94.
    98 | Safety Case– Study Structure QRA Performance Standards HAZID Escape, Evacuation and Rescue Analysis Fire & Explosion Analysis Gas & Smoke Dispersion Analysis Emergency Systems Survivability Analysis Marine Hazard Analysis Dropped Object Study SIL Analysis MAE  SCEs HAZOP
  • 95.
    99 | Safety CaseActivities As part of the Safety Case the following studies have to be developed.  HAZOP Review  Safety Integrity Level (SIL) Review  Marine Hazard Analysis  Dropped Object Study  Fire and Explosion Analysis  Gas and Smoke Dispersion Analysis  Emergency Systems Survivability Analysis (ESSA)  Escape, Evacuation and Rescue (EER) Study  Performance Standards & Verification Scheme for SCE  QRA Report  HSE Management System Review Report  Operational Safety Case
  • 96.
    100 | Safety Case– Engineering studies – Marine Hazards Purpose: to assess quantitatively the incidental collision frequencies between ships passing in the vicinity of the field facilities, shuttle tankers visiting the field, supply vessels and fishing vessels in the area. Collision Scenarios:  Passing vessels (commercial, passenger, recreational boat) powered and drifting;  Shuttle tankers;  Supply vessels (powered and drifting);  Fishing ships. The parameters considered to assess the impact frequency are:  Ship breakdown frequency;  Probability of human error;  Emergency response.
  • 97.
    101 | Safety Case– Engineering studies – Marine Hazards
  • 98.
    102 | Damage: Ships withtonnage higher than 5000 DWT are considered to cause major damage to the impacted installation Results Total frequency of collision Frequency of collision causing major damage Safety Case – Engineering studies – Marine Hazards
  • 99.
    103 | DWT >5000 DWT>15000 DWT > 1500 DWT <1500 Safety Case – Engineering studies – Marine Hazards
  • 100.
    104 | It isrecommended that the supply vessel approaches the platform away from the risers and to create a limitation zone around the risers. • Exclusion area of 7.1 km around the facilities; • Signalisation and inscription on the maritime maps of the field facilities; • Marine radar system; Safety Case – Engineering studies – Marine Hazards • Navigational aid systems on the platforms; • Installation of an AIS (Automatic Identification System); • Installation of a Radar anti-collision; • Fog horn installed on each platform; • Visual signals; • Presence of supply vessel warning vessels entering the exclusion area; • Supply vessel are forbidden to approach the facilities in case of bad weather; • Shuttle tankers approach assisted by tug boat and only during the day.
  • 101.
    105 | Safety Case– Engineering studies– Dropped Objects Purpose: To evaluate quantitatively the dropped objects hit frequency on decks, jackets and on oil and gas sealines. The analysis covers the operation, drilling and work-over working phases performed on the platforms and the storage barge. Scenario:  dropped objects from monorails impacting on main deck;  dropped objects from cranes impacting on main deck;  dropped objects from cranes impacting on the jacket structure;  dropped objects from cranes impacting on the sealines. The parameters considered to assess the impact frequency are: • Drop frequency (from statistical data); • Excursion in water.
  • 102.
    106 | Calculation technique(examples) Assess the impact energies Safety Case – Engineering studies– Dropped Objects
  • 103.
    107 | Safety Case–EER Analysis Purpose: Objective of the Escape, Evacuation and Rescue (EER) study is to assess if successful evacuation from the manned facilities of the field can be achieved. Steps: The EER study is a qualitative assessment of the performance of the EER systems in response to the major accident events, which may or may not require personnel to evacuate the platform in an emergency. The analysis could be done by means of an “EER HAZOP”
  • 104.
    108 | Safety Case–Fire & Gas explosion
  • 105.
    109 | Safety Case–Fire & Gas explosion The analysis of the fire and explosion risks is performed in accordance with the following steps:  Identification of Credible Fire and Explosion Scenarios; (example) • Release diameter for Minor release: 7mm (1/4”); • Release diameter for Significant release: 25mm (1”); • Release diameter for Major release: 100mm (4”).  Evaluation of Random Rupture Frequencies; • Each identified section has been analysed in order to evaluate the expected rate of failure  Assessment of Consequences of Fire and Explosion Scenarios.
  • 106.
    110 | Safety Case–Fire & Gas explosion  Frequency result  Consequences result • Pool fire • Explosion Release diameter Initial event frequency Frequency consequences [event/year] [mm] [event/year] Jet Fire Explosion Flash-Fire Dispersion 7 5.90E-05 5.66E-08 0 2.36E-09 5.89E-05 25 8.86E-05 5.41E-07 0 2.98E-08 8.80E-05 100 2.95E-05 7.38E-07 1.33E-08 1.19E-07 2.86E-05 Location Equipment Hole diameter Pool diameter Distance to Heat Radiation [m] [mm] [m] 37.5 kW/m2 12.5 kW/m2 5 kW/m2 - - 7 3 3.5 5.4 7.8 25 6 5 11 15.6 100 Location Equipment Hole diameter Explosive mass Peak Overpressure distance [m] [mm] [Kg] 0.5bar 0.35bar 0.1bar - - 7 0 - - - 25 0 - - - 100 17 122 126 147
  • 107.
    111 | All thenumerical results of the engineering safety studies have to be summarized in a Quantified Risk Assessment report, to demonstrate if the Company Risk tolerability criteria are met. Targets  IRPA (Individual Risk Per Annum)  PLL (Potential Loss of Life)  TRIF (Temporary Refuge Impairment Frequency) The above values are calculated for the groups of people in the facilities: • Group 1: personnel in the living quarter / offices most of the time; • Group 2: personnel in the control rooms (or other technical rooms) most of the time; • Group 3: personnel in the process areas (maintenance, etc.). Safety Case –QRA
  • 108.
    112 | The QRASUMS all the risks deriving from each of the hazards assessed individually in the Engineering Safety Studies. In formula:     n i i i i Group p v f IRPA Frequency of one of the hazards assessed in the safety studies “Vulnerability”. The probability that an individual will die due to the consequence associated to the hazard Probability that an individual will be present in the location, at the moment of an accident All the hazards identified Safety Case –QRA
  • 109.
    113 | The calculationof risk requires an high number of calculations to be done: Safety Case –QRA
  • 110.
    114 | Total IRPA P1IRPA P2 IRPA P3 IRPA Safety Case –QRA
  • 111.
    115 | Potential Lossof Life: PLL Safety Case –QRA