Safety & Loss Prevention Special Interest Group Launch Learning from Past Accidents

Presented by

Dr. Christina Phang Environmental Resources Management

The worlds leading sustainability Delivering sustainable solutions in a more consultancy competitive world

ERM

Presentation Outline

Some lessons from past accidents Three Causes of major accidents Four Practical Initiatives

ERM
Slide 2

Past Major Disaster

Piper Alpha (1986) Esso Longford (1998) Texas City (2005)

ERM
Slide 3

Piper Alpha - Lessons

Engineering Integrity
Platform not designed to withstand prolonged fire

Communication & Information

Lack of feed forward and feedback communication Inadequate display and access of information Inadequate emergency control centre Emergency procedures manual inadequate

Operator Performance
Insufficient training to ensure effective operation of the PTW system Contractors lack offshore experience

Working Environment
Inadequate flow of labour Inadequate working programme Pressure to maintain production at whatever cost

Procedures & Practices

Maintenance procedures were inadequate Emergency Procedures were inadequate

ERM
Slide 4

Piper Alpha - Lessons

Management Control
Inadequate performance measurements Failure to manage change as rig processes were extended Inadequate co-ordination and definition of responsibilities Unclear assignment of safety responsibilities Poor emergency planning

Organization & Management

Inadequate methods for setting work priorities Lack of commitment to safe working environment Inadequate PTW system and fire safety Poor organization between operations and maintenance Inadequate shift changeover procedures Inspectors and auditors failed to identify hazards System Climate Company subjected to production pressures Risks from other rigs not realized

Site & Plant Facilities

Operating outside the design envelope Lack of isolation of gas pipelines from other rigs

ERM
Slide 5

Esso Longford, 1998

Brittle fracture of vessel 2 fatalities 8 injuries 25 tonnes released causing an explosion followed by
Jet fire which burned for 2 days

Loss of gas supply to Victoria for 2 weeks with

substantial disruption to the local economy

ERM
Slide 6

Learning from Esso Longford

No Process Hazard Analysis completed (eg

HAZOP)

No assessment of Major Accident Hazards Ineffective management procedures Staff competency

Reliance on lost time injury data in major hazard industries is itself a major hazard - Hopkins

ERM
Slide 7

BP Texas City, 2005

Vapour Cloud Explosion 15 People killed 180 Injuries Isomeriser Tower overfilled Blowdown vessel and associated stack overfilled formed flammable vapour cloud

Liquid hydrocarbon released and

ERM
Slide 8

Key findings
Cost cutting and production pressure impaired safety
performance

No responsibility for assessing & verifying MAH prevention Reliance on low personal injury rate as safety indicator Mechanical integrity programme - equipment was run-to-failure Lack of reporting and learning culture Safety campaigns were aimed at personal safety Deep seated problems identified but management action was too little too late

ERM
Slide 9

Baker Panel Recommendations

Effective leadership from senior management Implement an integrated and comprehensive
Process Safety Management (PSM) system

Ensure employees and contractors have

appropriate process safety knowledge

Develop positive process safety culture Implement leading and lagging indicators Implement an effective audit process

ERM
Slide 10

What Can We Learn from Past Incidents?

Challenges in having design, technical and
operations integrity What safety barriers/ controls/ mitigation measures were missing or failed? Information sharing new hazards, understanding of risk levels, etc.

Identification of Performance Indicators

that might have given an indication that an major accident/ incident was imminent

ERM
Slide 11

Three Causes of Accidents (There are only three!!)

Poor procedures or people not following procedures

Poor design and Poor Equipment

Incompetent and ill-disciplined people

ERM
Slide 12

Problem 1:

If everything is important then nothing is important.

ERM
Slide 13

Typical decline in process safety

Safety Performance

Learning Phase

Ageing plant Loss of memory Creeping Change

Time

ERM
Slide 14

Where do I start?
ERM
Slide 15

Solution 1:

Understand what is Critical

ERM
Slide 16

Bow Tie Analysis

ERM
Slide 17

Define Performance

System definition and role Function Reliability and availability Survivability

ERM
Slide 18

What can Bow Ties do for me?

Overview: understand the major accident events:

causes, consequences, hazards and safety barriers

Focus: what is CRITICAL Understand Communicate Act

ERM
Slide 19

Problem 2:

Poor or Non-existent Procedures

ERM
Slide 20

Solution 2:

Statement of Operational Boundaries (SOOB)

ERM
Slide 21

Follow Critical Rules - SOOB

ERM
Slide 22

Scope of a SOOB
Barrier-defeating factors

Concurrent operations (aka SIMOPs) Non-routine operations Abnormal process conditions Equipment that is not fit-for-purpose Systems unavailable due to maintenance or damage Poor environmental conditions Key personnel unavailable

ERM
Slide 23

Problem 3:

People cause accidents most of the time

ERM
Slide 24

Incompetent ill-disciplined people

ERM
Slide 25

Solution 3:

Employ competent and disciplined people

ERM
Slide 26

All Outcomes Arise from Behaviors

Behaviour = Thought + Action
Management whether they know it or not
creates an environment that yields a body of operator behaviours

The front line behaviours which arise will

yield good and bad HSE (and operational) outcomes Acceptable / Unacceptable impacts Compliance / Non-compliance Controlled Risks / Accidents

There is no improvement in performance

without a change in behaviour

ERM
Slide 27

Improve Safety Culture

Make sure: the way we do things around here, is the safe way

ERM
Slide 28

Problem 4:

Inability to respond to a major accident

ERM
Slide 29

Solution 4:

Be prepared for the worst case scenarios

ERM
Slide 30

Understanding Accident Scenarios

ERM
Slide 31

Be Detailed & Verify

Plan Equipment Consumables Command and control Interfaces Training, drills, combined exercises

ERM
Slide 32

Four Initiatives tied to Accidents Prevention

Use the BTD to show how they fit

What is critical applies to all green boxes

Manual of permitted operations poor procedures and people

not following procedures - Prevention

Hire competent disciplined people covers both sides of BTD Prepare for worst case scenario RHS of BTD
ERM
Slide 33