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Why We Continue To Have Process Safety Accidents

Mark Paradies

President System Improvements, Inc. 238 S Peters Road Knoxville, TN 37923 865-539-2139 www.taproot.com

Not About This

Its About This

Continuing Accidents made me Think

Whats Wrong with Process Safety?

President, System Improvements


Seven Years in Admiral Rickovers Nuclear Navy Nuclear Navy Engineer Qualied (Navsea 08) MS Nuclear Eng with Emphasis on Human Factors Process Safety Work Started in 1985 at Du Pont Co-Developer of the TapRooT System Co-Author of the TapRooT Book 2 US & Foreign Patents for Root Cause Software IEEE Root Cause Analysis Standard Committee Co Author of CCPS book Guidelines for Investigating Chemical Process Incidents Editor of the Root Cause Network Newsletter Taught Root Cause Analysis Worldwide

Mark Paradies

Secrets of Process Safety from Admiral Rickover

Nuclear navy - The Original High Reliability Organization

Rickovers Process Safety Culture


(Total Concept - Must Work Together)

BIG THREE
1. TOTAL RESPONSIBILITY 2. Technical competence (outstanding people) 3. Facing the facts (do the right thing despite costs)
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Rickovers Process Safety Culture


And these too!

4. Conservatism of design 5. Designing the plant to avoid accidents to reduce the likelihood of the need to use emergency systems 6. Redundancy of equipment to avoid shutdowns or activation of emergency equipment

Rickovers Process Safety Culture


7. Inherently stable plant with simple, direct operator control 8. Full testing of the plant 9. Adhere to detailed maintenance schedules

Rickovers Process Safety Culture


10. Detailed operating procedures developed by the operators, improved with experience, and approved by the technical experts 11. Formal documentation of design and design changes and strict change control 12. Strict control of all vendor provided equipment with inspections prior to acceptance

Rickovers Process Safety Culture


13. Formal reporting of abnormal events (incidents) and the use of operating experience across all plants. 14. Frequent detailed audits / inspections of performance by independent, highly trained, experienced personnel that report to the top 15. Independent review of safety by governmental authorities 16. Personal selection of leaders (exceptional
technical knowledge and good judgment)

Rickovers Process Safety Culture


17. One year of specialized technical training and practical hands-on experience prior to first assignment 18. Advanced training and testing for more senior assignments (Engineer, CO) 19. Extensive continuing training and requalification

Rickovers Process Safety Culture


20. Strict enforcement of standards & disqualification of those who violate the standards 21. Internal, frequent self-assessments

Comparing Rickover to PSM & NRC Safety Culture


Nuclear Navy
Total responsibility Technical competence Facing the facts

OSHA PSM
No No No

CCPS PSM Accountability No Yes - Strong?

Comparison Continued
Nuclear Navy
Conservatism of design Design to avoid accidents Redundant equipment

OSHA PSM
d. Process safety information?
(not really)

CCPS PSM No No

e. Process hazard analysis? (not really) No

No

Comparison Continued
Nuclear Navy
Inherently stable plant Full testing Maintenance

OSHA PSM
No No j. Mechanical integrity

CCPS PSM No No Yes Requirements?

Comparison Continued
Nuclear Navy
Detailed operating procedures

OSHA PSM
f. Operating procedures
(doesnt address technical participation)

CCPS PSM Yes but minimal guidance or useage req. Yes

Design documentation & change control Inspection of vendor provided equipment

d. Process safety information & l. MOC i. Mechanical integrity

No

Comparison Continued
Nuclear Navy
Incident reports

OSHA PSM
m. Incident investigation
(no sharing f info required)

CCPS PSM Yes

Audits/inspections

O. Compliance audits (not independent


+ not frequent )

Yes
(not independent + not frequent )

Comparison Continued
Nuclear Navy
Independent review by government Personal selection of leaders Initial technical training + hands on training

OSHA PSM
No No g. Training
(but does not include initial technical training)

CCPS PSM No No Yes


(but not for management)

Comparison Continued
Nuclear Navy
Advanced training for senior mgmt jobs Extensive continuing training & requalication Strict enforcement of standards Self Assessments

OSHA PSM
No No

CCPS PSM No some

No O. Compliance audits (not frequent)

exceptions Only Audits


(not frequent)

Rickover didnt include these


OSHA PSM
Employee participation Contractors Hot work permits Trade secrets

CCPS PSM
Human Factors

Why Should Management Care?


Major Process Accidents Have Management Roots
BP Texas City Deepwater Horizon Shuttle I & II Davis-Besse Reactor Vessel Hole
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5 Things Management Should Know


(but they usually dont) 1. Managements effect on process safety improvement 2. How process safety improvement and root cause analysis work 3. How to change behavior effectively 4. How to move from reactive to proactive improvement 5. Effective trending
Lets Look at Each One
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Copyright 2007, Great Systems!

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#1 Managements Effect
What They Say But Beyond That
Knowledge / Standards What They Ask For (Demand) Budget - What Gets Cut? Involvement/Attention/Tracking Who Is Assigned/Evaluations/Promotions Do They Insist Their Subordinates are Trained?
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Tale of Two Plant Managers


Both Say They Support Process Safety Improvement, but Good Example
Budget Approved Top People Assigned Monthly Reviews Tracking System - Mgmt Reacts Sr. Mgmt Trained Asks for Root Cause Analysis Sends Subordinates to Advanced Training

Bad Example
No Budget - No Travel Best of the Rest Skip Quarterly Meetings Big Backlog or No Tracking Heard a Talk Once Asks Who Did It & Fires Asks Why Would They Need Training?
Copyright 2007, Great Systems!

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BP Texas City Refinery Explosion


Say They Want Safety Improvement, but
25% Budget Cut After Merger In 2002, Flare Tie-In from ISOM Cut to Save $150,000 Big Backlog of Old Corrective Actions People Assigned Without Technical Background (Example: No PSM Training for HSE Manager) 3 Fatalities Think They Are Improving Cheap Trailers Save Money
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Management Needs To Know

#2 How Process Safety Improvement & Root Cause Analysis Work


Senior Manager Sponsors Process Safety Improvement
As Sponsor, Helps Design & Approves Program
(See Chapter 6 of 2008 TapRooT Book)

Understands Keys to Process Safety Improvement Understands Theory & Practice of Root Cause Analysis
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BP Texas City Refinery Explosion


How Was Senior Management Involved?
Plant Manager Did Sponsor Telos Report - BUT No Ownership from Above for Fixes Senior Management Didnt Know What Was Wrong with BP Root Cause Analysis Tools or Reports (Including Interim Report & Mogford Report) Senior Management Stuck in Blame Culture Didnt Understand Keys to Performance Improvement (Watch Mgmt response to Interim Report or read
the Mogford Report)
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INTERIM INVESTIGATION REPORT BP Press Statement (now retracted)


Had the six operators and one supervisor assigned to
the start-up of the refinery's isomerization unit been doing their jobs, the explosion would not have happened, 15 people would not have been killed and more than 170 would not have been injured, said Ross Pillari, President of BP Products North America. "The mistakes made during the start-up of this unit were surprising and deeply disturbing," Pillari said during a news conference in which BP released a 47page interim report on its investigation. The core issue here is people not following procedures," Pillari said. Immediate action: 5 operators and supervisors fired.
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Management Needs To Know

#3 How to Change Behavior Effectively


Effective Use of Discipline Soon - Certain - Positive Behavior Change Matrix

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What Happens if Management Doesnt Know Behavior / Attitude Problems


Broken Rules Shortcuts / Procedures Not Used Supervisors Look the other way Real way its done Bad Attitude Us vs. Them
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What Happens if Management Doesnt Know

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Management Needs To Know

#4 From Reactive to Proactive


Improve Before Incidents Happen
Improve Performance/Avoid Incidents Avoids Negatives From Incidents Continuous Improvement Very Lean Concept
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Investigations Based on Significance


Category 1 # of investigations: 1 - 5 Category 2: 30 - 100 Category 100 - 1000 Category 4: 1000 - 4000

Analysis Action Serious Incident Incident Near-Miss At-Risk Behaviors Latent Conditions
Good Root Cause Analysis Then Fix Fast Analysis Then Fix Very Little Analysis Then Fix No Analysis Maybe Fix?

Reactive Improvement Approach


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Reactive Investigations based on Significance

Analysis Action Serious Incident Incident Near-Miss At-Risk Behaviors Latent Conditions
Root Cause Analysis Then Fix Root Cause Analysis Then Fix Categorize Repair

Category 1: 1-5 Category 2: 30 - 100 Category 3: 100 - 1000 Category 4 & 5: 1000 - 4000

Fix Only If
Adverse Trend

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Lean Improvement Approach

Improve Before Waste!

Targeted Proactive Observations


Root Cause Analysis FIX
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What Happens if Management Doesnt Know Nuclear Industry Surprises


1. Big incidents analyzed well. 2. Minor incidents analyzed poorly. 3. Hundreds of poorly analyzed incidents drive corrective action program. 4. Result: Large backlog of dubious xes. 5. Regulators/Management focus on backlog. 6. Waste effort implementing dubious xes. 7. Trends dont help management manage. 8. Reactive approach whipsaws management with random events.
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Management Needs To Know

#5 Effective Trending
Measuring Performance Damage of Over-reacting

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LTI: What Months Are Abnormal?


12 10 8 6 4 2
Aug Oct Sep Nov Feb Jun Mar Apr May

11

12
Lost Time Injuries (L TI)

9 6 4 4 5 7 5 4 7 4 2
Dec Jul Jan Feb Jan Mar Apr

9 6

6 4 5 4 2 2
Aug May

Nov

Dec
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Oct

Sep

Jun

Jul

October 12 Month - Take Action!


Management Must Lead!
Fire Safety Manager & Guilty Parties! Hire Consultant Send Out Memo Safety is a Condition of Employment Hold People Accountable
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No Months Outside "Natural Variation"

Natural Variation

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What Did Reactive Approach & Over-Reacting Do? Davis-Besse Reactor Hole

What Did Reactive Approach & Over-Reacting Do? Davis-Besse Reactor Hole

What Do You Need To Do?


Rate Your Company
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r m mp our i I in y
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