ReducingMajor Accident Potential:

- Lessons From The Refining

Industries
Graham Bennett
Downstream Director
DNV Energy
Objectives of this presentation
To review process safety related accidents that have
occurred within the recent history of the refining industry, and
share the experiences
To examine lessons to be learned
To challenge some existing paradigms
To identify opportunities for the future
Process Safety Challenges
Buncefield, UK
1976 Seveso (?/?)
1974 Flixborough (28/36)
P36 (10/2) 2001
Humber Oil Refinery (0/0)
2001
Norco, Louisiana (4/42) 1988
Grangemouth (0 /0)
2000
Skikda (27/56) 2004
Piper Alpha (167/?)
1988
2005
Texas City (15/170)
Toulouse (29/650)
2001
2005
Pasadena, Texas (23/232)
1989
Bhopal (20,000/50,000)
1984
/
)
Longford (2 numerous 1998
Henderson, Nevada (2/350) 1988
Alon (0/0)
2008
(0 /40)
Texaco Pembroke - J uly 1994
Inadequate maintenance of plant & instrumentation
Control valve closed when monitoring system indicated it was open
Poor management of change
Control room graphics did not provide sufficient process overview
Poor alarm management
Attempting to keep the unit running when it should have been shutdown
Incorrect assumptions on corrosion allowances
Failure to incorporate lessons learned from previous incidents
BP Grangemouth - J une 2000
Inadequate Maintenance of pipework integrity
Not following risk assessment procedures for start-up
Poor organisational structure
Poor alarm management
A safety report that did not reflect operating realities
Plant unreliability not adequately assessed - short term focus problem
Not learning from previous similar incidents
Not acting on previous reports
ConocoPhillips Humber - April 2001
Poor management of pipework inspection
Poor management of change
Poor corrosion management
Communication failings
Insufficient attention paid to process safety
Emergency response improvements necessary
Gaps in safety management system coverage
Failure to act on previous incidents/reports
But major accidents are rare events?
In J anuary 2005, as part of an internal R&D project, DNV developed a
new internal database system to record major incidents and accidents in
the refining & petrochemical industry.
Since its inception, the database has recorded over 1800 incidents,
which have been classified as follows
Environmental release
Explosion
Fire
Loss of containment
Number Incident Type
Production Downtime
Regulatory Fines
Site Evacuation
Injury
Loss of life
Number Consequence
745
538
369
44
163
276
114
674
219
How are things in Europe?
Trends in occupational safety
0
1
2
3
4
5
1
9
9
3
1
9
9
5
1
9
9
7
1
9
9
9
2
0
0
1
2
0
0
3
2
0
0
5
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h
o
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r
s
API
Bayer
BP
Chevron Texaco
Concawe
ConocoPhillips
Dow
DuPont
ExxonMobil
OMV
Shell
Trend Line
Trends in refinery material damage costs
Incident costs - $ per 1000bbls refinery capacity corrected to 2000 prices
0.00
5.00
10.00
15.00
20.00
25.00
30.00
1
9
6
4
1
9
6
6
1
9
6
8
1
9
7
0
1
9
7
2
1
9
7
4
1
9
7
6
1
9
7
8
1
9
8
0
1
9
8
2
1
9
8
4
1
9
8
6
1
9
8
8
1
9
9
0
1
9
9
2
1
9
9
4
1
9
9
6
1
9
9
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Raw data
5-year average
Linear (5-year
average)
The Idea
There is a fixed ratio
of accident
severities
The Hope
If we address the
smaller events, the big
ones will also improve
The Reality
If we address the
smaller events, we
improve smaller
events
The hope . . .
. . . The reality ?
major injury
minor injury
property damage
1
10
30
600
1
10
30
600
no visible loss
1
8
20
300
1
8
20
300
0.5
5
15
300
0.5
5
15
300
Occupational incidents improve
faster than major accidents
Process Safety Incident Ratio Pyramid
PS Incidents
Loss of Containment
Fires
Explosions
Production Downtime
Injury
Fatality
1
2
1.5
2.5
3.5
5
11
Process Defects?
DNV Experience Globally
DNV has observed and participated in many regulatory and engineering
approaches aimed at reducing major accident risks
What we have seen in the downstream process industry
- Process industry in EU
- Very good personnel safety improvements
- Some basic process safety initiatives now implemented, but the trend in
major accidents is steady (from EU MAR dataset)
- But - worst process accident in 20+ years at Toulouse in 2001, other
serious accidents at Buncefield, Humber, and Grangemouth
- Process industry in USA
- Very good personnel safety improvements
- Some basic process safety now implemented via OSHA 1910, but no
trend showing decline in major accidents (EPA RMP dataset)
- But - worst accident in 16 years at Texas City
- In 2007 CCPS commits to a major series of initiatives on PSM
Major Accident Trends: Offshore North Sea
Two major accidents in 1980s
- Alexander Kjelland 1980 (123 dead) and Piper Alpha 1988 (167 dead)
Since then
- No major accidents, intensive safety case program in UK sector
- This shows significant reduction in major leaks precursor to serious accidents
This graph from the UK HSE
shows that major leaks have
decreased consistently, by
over 70 % in the last 9 years
A recent DNV review of
international offshore leak
frequencies for QRA purposes
shows leak frequencies have
reduced by 71-84% since
1995
What are the key lessons?
The Baker and CSB reports into the Texas City event implied that
improvements in SMS and culture alone might be sufficient means to
manage major accident risks
Our experience suggests that a more integrated approach to HSE and
Asset Management is needed in order to achieve the necessary process
safety improvements.
Management systems that are designed primarily for occupational safety
issues rarely perform well in managing major accident hazard potential. A
detailed risk-based process safety management program is a necessary
foundation to prevent major accidents
New initiatives to define critical barriers, establish performance
standards, and manage these throughout the plant lifetime, are required
Greater use of leading rather than lagging indicators of major accident
potential needs to be made.
Key Lessons
Major accident hazard industries must ensure that lessons learned both internally
and externally are incorporated into their management systems
Disruptions in utility systems on major hazard potential sites can have significant
implications for process safety and should not be underestimated.
Greater organisational connectivityis needed for major hazard issues and asset
management
Greater care needs to be taken to manage the risk portfolio (projects plus normal
operations)
Transferring functions to contractors does not transfer the risk responsibility.
Maintain close control of contractor activities.
Always adhere to inherent safety principles, dont place too much reliance on
instrumented safety systems, alarms etc to solve problems if they can be avoided
in the basic process design.
Maintain improved awareness of process safety competency issues
Recognise that short term business KPIs can negatively impact PSM
performance
Remember!
Companies with the best
performance in major
accident risk management
do not necessarily have
better systems than those
with poorer performance,
they are just much more
diligent in doing what they
say they do