The effectiveness of U.S. OSHA process safety management inspection – A preliminary quantitative evaluation

This study attempted to evaluate the inspection effectiveness of the U.S. OSHA process safety management (PSM) standard using statistical correlation test. A total of 6578 citations of past 1277 OSHA PSM inspections from 1992 to 2006 were quantitatively compared with the findings of the U.S. Chemical Safety and Hazard Investigation Board (CSB) investigations on root and contributing causes of 19 major chemical accidents. Nonparametric Spearman's coefficient of rank correlation tests showed a moderately strong agreement between OSHA PSM inspection citations and CSB findings at p < .01 significant level, and the degree of agreement increased with time. These results suggested that past OSHA PSM inspections had cited the problems that were the accident root causes, and the effectiveness of PSM citations has been improved as more inspections were conducted since the standard promulgation. However, factors such as standard coverage, inspection frequency, inspection resources allocation, and inspection strategy, were critical for effective PSM standard enforcement and implementation. Future studies should include more aspects of PSM citations and CSB accident investigation data for better evaluation of inspection effectiveness. The results may be valuable to the PSM enforcement policy makers.     

Migrating an incident reporting system to a CCPS process safety metrics model

A major chemical company established a formal incident investigation and reporting system several years ago. The original system focused heavily on worker-related injuries, illnesses, and near-misses and was used primarily to track statistics reportable to the Occupational Safety and Health Administration (OSHA). This Occupational Injury and Illness (OII) approach has been recognized to be an ineffective tool for measuring, predicting, and preventing process safety incidents. The Center for Chemical Process Safety (CCPS) recently published guidelines on how to establish safety metrics for the measurement and reduction of process safety incidents. The process safety metrics approach relies upon leading and lagging metrics to improve organization process safety. This paper is a case study of the analysis of one organization’s incident database, which represents approximately five years of data from over a dozen facilities. The aim of this investigation was to extract useful process safety metrics from the incident investigation and reporting system, which would be pertinent to the types of process units and process functions at these facilities. This paper will discuss the approach taken to extract process incident information from an OII-based database and present the difficulties of performing an analysis on such a database. This paper provides guidance on how to migrate an existing OII-based reporting system to a program that includes process safety metrics in accordance with industry best practices.     

Global process safety incidents in the pharmaceutical industry

The objective of this research is to analyse global process safety incidents within the pharmaceutical industry in terms of their consequences and factors contributing to the incidents. There were 73 process safety incidents leading to 108 fatalities found between 1985 and 2019. Trends between the number of incidents, number of fatalities, location, and contributing factors were identified and summarized. The most reported fatalities occurred in 2018 & 2019. 83% of fatalities occurred in China and India. Explosions were associated with 71% of incidents, which resulted in 89% of fatalities. For most of the international incidents, incident investigations were not available and thus insufficient details were available to determine the causes. Contributing factors were available or estimated from available data for about half of the incidents, with the following most common: hazard awareness & identification; operating procedures; design; safeguards, controls & layers of protection; safety culture; and preventive maintenance. These findings can be used as a basis to improve process safety performance in the pharmaceutical industry.     

Managing process chemicals,technology and equipment information for pilot plant based on Process Safety Management standard

Injuries, accidents or even fatalities while working in pilot plant are reported worldwide. The OSHA Laboratory Standard and Hazard Communication Standard have been used as a guideline to manage safety of laboratories and pilot plant. In spite of the implementation of these standards, incidents which result in injuries and property loss are continuously occurring. The implementation of OSHA Process Safety Management (PSM) Standard in pilot plant is expected to further reduce the risks of accidents. This paper presents a new system for managing process chemicals, technology and equipment information in pilot plant and the concept is developed based on Process Safety Information (PSI) element of PSM 29 CFR 1910.119(d). It provides organized strategies to manage documentations, communicate information, and written program for maintaining, revising and updating related information. Process and Instrumentation Diagram (P&ID) is used as a foundation for data management. Implementation of this system at the CO₂ Hydrocarbon Absorption System pilot plant as a case study is examined and discussed.     

What can the trove of CSB incident investigations teach us? A detailed analysis of information characteristics among chemical process incidents investigated by the CSB

Understanding the commonalities among previous chemical process incidents can help mitigate recurring incidents in the chemical process industry and will be useful background knowledge for designers intending to foster inherent safety. The U.S. Chemical Safety and Hazard Investigation Board (CSB) reports provide detailed and vital incident information that can be used to identify possible commonalities. This study aims to develop a systematic approach for extracting data from the CSB reports with the objective of establishing these commonalities. Data were extracted based on three categories: attributed incident causes, scenarios, and consequences. Seventeen causal factors were classified as chemical indicators or process indicators. Twelve chemical indicators are associated with the hazards of the chemicals involved in the incidents, whereas five process indicators account for the hazards presented by process conditions at the time of the incident. Seven scenario factors represent incident sequences, equipment types, operating modes, process units, domino effects, detonation likelihood for explosion incidents, and population densities. Finally, three consequence factors were selected based on types of chemical incidents, casualties, population densities, and economic losses. Data from 87 CSB reports covering 94 incidents were extracted and analyzed according to the proposed approach. Based on these findings, the study proposes guidelines for future collection of information to provide valuable resources for prediction and risk reduction of future incidents.     

Pilot sample risk analysis for underground coal mine fires and explosions using MSHA citation data

After three decades of sustained continuous improvement of mine safety performances in the US, mine disasters in 2006 and 2007 compromised an excellent record and presented new challenges and vulnerabilities for the underground coal mining industry. In the aftermath of the incidents, formal investigations and new scrutiny of mine safety by the US Congress and expert study groups followed. The US Congress passed the Mine Improvement and New Emergency Response Act of 2006 (MINER Act), which mandated new laws to address the issues, including those related to mine fires and explosions from which miners must be protected. The National Mining Association-sponsored Mine Safety Technology and Training Commission report highlighted the role of risk analysis and management in identifying and controlling major hazards, such as fires and explosions. In this paper an approach is given for analyzing the risks for fires and explosions based on the Mine Safety and Health Administration citation database. Using 2006 citation data and focusing on subsystem failures, the methodology is applied to a database for a pilot sample of underground coal mines stratified by mine size and state.     

Insights into process safety incidents from an analysis of CSB investigations

Many incidents have helped to define and develop process safety. Each has provided valuable learning opportunities. However, it is even more important to identify insights that can be obtained from an analysis of a large set of incidents that represents those that typically occur. This larger picture illuminates trends and commonalities and provides learning opportunities that are even more important than the causes of any one individual incident.The Chemical Safety Board has published the results of over 60 investigations of process safety incidents. These data have been analyzed to identify commonalities and trends so that measures to help protect against future incidents can be developed. Recommendations are made to address key issues identified.     

Visibility-related fatalities related to construction equipment

The construction industry annually experiences one of the highest fatality rates among the industrial sectors in the United States. The factors that contribute to this reputation include the nature of the work, human behavior, the tools and equipment involved, and also the compact work zones. Industrial fatalities are investigated by the Occupational Safety and Health Administration (OSHA). While OSHA groups the causes of fatalities into a few general categories, too little information is gleaned to effectively target specific problem areas.To improve safety performance in the construction industry, it is necessary to understand the underlying causes of accidents. With targeted analysis, patterns emerge and causal factors can be identified. These findings may then be used to form the basis for recommendations that will help to improve construction worker safety. Little research has been conducted in this area.Research was conducted that isolated fatalities in which vision or lack of good visibility was the principle factor or contributing cause. The objective of examining the details surrounding these fatalities was to uncover the contributing factors and to identify the agents that compromised visibility. The study identified 659 fatality accidents from a data pool of 13511 OSHA-investigated cases. It was discovered that blind spots, obstructions and lighting conditions were the most common factors contributing to vision-related fatalities. This research also analyzed the specific conditions associated with particular pieces of construction equipment.     

Lessons after Bhopal: CSB a catalyst for change

The Bhopal tragedy was a defining moment in the history of the chemical industry. On December 3, 1984, a runaway reaction within a methyl isocyanate storage tank at the Union Carbide India Limited pesticide plant released a toxic gas cloud that killed thousands and injured hundreds of thousands. After Bhopal, industrial chemical plants became a major public concern. Both the public and the chemical industry realized the necessity of improving chemical process safety.

Bhopal served as a wake-up call. To prevent the same event from occurring in the United States, many legislative and industrial changes were invoked—one of which was formation of the U.S. Chemical Safety and Hazard Investigation Board (CSB). The ultimate goal of CSB is to use the lessons learned and recommendations from its investigations to achieve positive change within the chemical industry—preventing incidents and saving lives.

Although it seems clear that the lessons learned at Bhopal have improved chemical plant safety, CSB investigations indicate that the systemic problems identified at Bhopal remain the underlying causes of many incidents. These include:

• Lack of awareness of reactive hazards.

• Lack of management of change.

• Inadequate plant design and maintenance.

• Ineffective employee training.

• Ineffective emergency preparedness and community notification.

• Lack of root cause incident investigations and communication of lessons learned.

The aim of this paper is to present common themes from recent cases investigated by CSB and to discuss how these issues might be best addressed in the future.

This paper has not been independently approved by the Board and is published for general informational purposes only. Any material in the paper that did not originate in a Board-approved report is solely the responsibility of the authors and does not represent an official finding, conclusion, or position of the Board.     

Motor vehicle towing: An analysis of injuries in a high-risk yet understudied industry

Objectives: National fatality rates for commercial tow truck operators exceed those of other first responders who also perform traffic incident management services. The objectives of the current study are to (1) characterize causal factors associated with injuries among commercial tow truck operators engaged in roadside assistance through analysis of coded and free text data obtained from U.S. Occupational Safety and Health Administration (OSHA) investigation files, and (2) utilize supplemental data sources to analyze environmental factors for injuries in which commercial tow truck operators were struck by roadway traffic. Methods: Searches of OSHA’s online IMIS database were performed to identify investigations of incidents in which tow truck operators were injured while performing roadside assistance duties. Freedom of Information Act (FOIA) requests were submitted to obtain full investigation files for each case. Coded and narrative text analyses were performed to identify causal themes across the identified cases. Results: One-hundred and six cases of tow truck operators being killed or severely injured were identified in IMIS; 41 FOIA requests for related investigation documents were fulfilled. Two major event type themes were identified which accounted for 9 in 10 of the cases identified. These were (1) ‘struck-by’ incidents, which were primarily injuries resulting from contact with roadway traffic, rolling vehicles and equipment or other non-motorized objects; and (2) ‘caught-in or -between’ incidents, which were primarily injuries resulting from being pinned beneath and between vehicles and being caught in moving parts. Conclusions: The towing industry should provide initial and refresher safety training on vehicle loading and unloading, defensive techniques when exposed to traffic on roadways, and proper wheel chocking and braking procedures. States should include tow trucks as a first responder vehicle type in their “Move Over” laws and implement public awareness campaigns to protect all first responders, including tow truck operators.     

Communicating costs and benefits of the chemical industry and chemical technology to society

Risk Communication is increasingly important to the chemical and manufacturing industries in the wake of a wave of major incidents in recent years. However, risk communication strategies as they are currently implemented tend to place the chemical industry on the defensive. Renewed attempts should be made to place the life-saving benefits of the chemical industry back in the public eye and counter-balance the popular political view that the chemical industry is often responsible for loss of life. In truth, while the chemical industry suffers on the job fatalities like many industries, the frequency is much less than many common industries and the chemical industry provides benefits to society that ultimately save far more lives.     

The legacy of Bhopal: The impact over the last 20 years and future direction

Chemical process safety was not a major public concern prior to 1984. As far as chemical hazards were concerned, public fears focused on disease (cancer) and environmental degradation. Even a series of major process incident tragedies did not translate into widespread public concerns about major incidents in chemical plants that might disastrously affect the public. This situation changed completely after the December 1984 disaster at the Union Carbide plant in Bhopal. Not only was the public's confidence in the chemical industry shaken, the chemical industry itself questioned whether its provisions for protection against major incidents were adequate.

The recognition of the need for technical advances and implementation of management systems led to a number of initiatives by various stakeholders throughout the world. Governments and local authorities throughout the world initiated regulatory regimes. Has all that has resulted from the legacy of Bhopal reduced the frequency and severity of incidents? How can we answer this question? As we move into more and more globalization and other complexities what are the challenges we must address? According to the authors, some of these challenges are widespread dissemination and sharing of lessons learned, risk migration because of globalization, changing workforce, and breakthroughs in emerging areas in process safety.     

Issues with using police citations to assign responsibility in quasi-induced exposure

Crash fault determination is one of the most critical issues in applications of quasi-induced exposure. Traditionally, the driver citation issued by the investigating police officer is the primary source to assign responsibility for motor vehicle crashes. Such citations are based on the “evidence” or observation of a moving violation (such as engaged hazardous actions) in combination with non-moving violations (such as suspended driver license) prior to the crash. The objective here is to identify the contributing factors that may lead to driver citations in two-vehicle crashes in addition to the hazardous action. Multivariate binary logistic regression modeling is employed to explore the behavior of the investigating police officer in terms of issuing citation at the crash scene. A series of explanatory parameters including roadway characteristics, environmental factors, and driver and vehicle attributes is assessed. The results show that whether the crash type was a hit-and-run, alcohol and illegal drug use, driver gender, driver age, and injury severity all appear to have significant impacts on the investigating officer’s decision-making. Specific examples are given to demonstrate how two factors hit-and-run and drinking status can skew the exposure estimates in the context of quasi-induced exposure. The findings will help to serve as a basis to select appropriate parameters in assigning crash responsibility in quasi-induced exposure applications; and we make recommendations to modify existing crash database for better safety research in the future.     

A rising tide raises all boats: Regional promotion of process safety through joint government/industry management

With the development of increasingly complex processes and technologies in chemical and manufacturing industries, Process Safety Management (PSM) has been globally recognized as the primary tool for operating companies to reduce process accidents on their industrial sites and the risks posed to their employees and surrounding communities. Yet, industrial facilities are often interdependent and collocated with others. Recognizing this, regional authorities are also applying PSM principles to reduce the cumulative incidents associated with high density industrial areas and the multiplicative risks posed to broader communities. This paper compares Strathcona County Emergency Service (SCES) in Alberta, Contra Costa County Health Service Hazard Material Programs (CCCHSHMP) in California, and Technical Standards & Safety Authority (TSSA) in Ontario and their PSM systems to provide practical recommendations to improve SCES's system. Four aspects of PSM are considered: regulation and guidance, auditing and inspection, annual performance indicators, and public participation. Based on the results of this comparison, we recommend that SCES develop comprehensive PSM regulations based on CSA Z767-17 PSM including clear instructions for assessing technologies and methodologies for consequence analysis. Both worst-case scenarios and alternative scenarios need to be considered as well as the domino effect of primary accidents. Furthermore, regular audits and inspections will ensure compliance with PSM regulations while helping the design of planning, performing, and following-up strategies to ensure effectiveness. In addition, we suggest the use of lagging and leading performance indicators to evaluate the performance of the PSM program. Finally, we recommend using advisory councils or commissions to increase public participation and ensure the representation of stakeholders' perspectives with the PSM system.     

Evaluation of process safety indicators collected in conformance with ANSI/API Recommended Practice 754

At the request of the U.S. Chemical Safety and Hazard Investigation Board (CSB), we examined some of the possible uses of the process safety event metrics proposed by the American Petroleum Institute and published as ANSI/API Recommended Practice 754. We examined many sources to try to estimate what the likely number of Tier 1 and Tier 2 process safety events would be at refineries. Then we calculated the statistical power that would be available to compare rates, both over time and across facilities and firms. As Tier 1 and Tier 2 are defined, it appears that the event frequencies estimated for U.S. refineries (i.e., 0.12 per 100 employees for Tier 1 and 0.26 for Tier 2) would make it unlikely that even two-fold differences in the rates would be statistically significant, except at large refineries with several thousand workers.     

Causes and consequences of thermal runaway incidents—Will they ever be avoided?

A study of runaway incidents involving thermal chemical reactions in the UK over the past 25 years (1988–2013) has been carried out. The objective of this study is to determine possible causes of thermal runaway incidents. A statistical analysis of the underlying problems that led to thermal runaway incidents has been provided. A comparison of the current study on thermal runaway incidents with those identified prior to 1988 has been carried out. This study clearly shows that lessons have not been learnt from thermal runaway incidents caused by operator errors, management failures and lack of organised operating procedures. These factors have been the possible causes of about 77% of all the thermal runaway incidents analysed in this study. The number of fatalities and injuries as a result of thermal runaway incidents has increased by ∼325% and ∼279%, respectively, in the last 25 years even though the number of incidents was significantly less. On the basis of this analysis, several recommendations have been proposed that could help to minimise the risks associated with any thermal runaway incidents in the future.     

A comparative analysis of process safety management (PSM) systems in the process industry

The root cause of most accidents in the process industry has been attributed to process safety issues ranging from poor safety culture, lack of communication, asset integrity issues, lack of management leadership and human factors. These accidents could have been prevented with adequate implementation of a robust process safety management (PSM) system. Therefore, the aim of this research is to develop a comparative framework which could aid in selecting an appropriate and suitable PSM system for specific industry sectors within the process industry. A total of 21 PSM systems are selected for this study and their theoretical frameworks, industry of application and deficiencies are explored. Next, a comparative framework is developed using eleven key factors that are applicable to the process industry such as framework and room for continuous improvement, design specification, industry adaptability and applicability, human factors, scope of application, usability in complex systems, safety culture, primary or secondary mode of application, regulatory enforcement, competency level, as well as inductive or deductive approach. After conducting the comparative analysis using these factors, the Integrated Process Safety Management System (IPSMS) model seems to be the most robust PSM system as it addressed almost every key area regarding process safety. However, inferences drawn from study findings suggest that there is still no one-size-fits-all PSM system for all sectors of the process industry.     

Lessons learned for process safety management in China

A number of chemical accidents have occurred in China over the past two decades with significant impact on humans and the environment. It is expected that lessons will have been learned from these accidents that will help industries to reduce the risk that catastrophic chemical accidents occur in future. In fact, to some extent there is evidence that lessons have been learned, to the extent that the Chinese government has substantially strengthened legislation and regulatory standards. Nonetheless, there remains a concern that much more still needs to be done to reduce chemical accidents risks in China. Important progress in this area requires not only government support but a commitment across all hazardous industries to learn from past accidents that may in many cases require establishment or considerable improvement of their safety management systems. To assist small and medium-sized enterprises (SMEs), in this effort, results of an analysis of common causes of the chemical accidents reported in the Major Accident Information (MAI) website of Chinese State Administration of Work Safety (SAWS) are presented in this paper In particular, inadequate process hazard analysis (PHA), training and emergency response planning (ERP) were identified as the top three process safety management (PSM) elements that contribute to most of the SMEs accidents in China. Seven recommendations are proposed in order to improve the effectiveness of lesson learning for government agencies and SMEs.     

Inherently safer design review and their timing during chemical process development and design

This paper discusses the enhancement of inherent safety review and its implementation in the chemical process development and design. The aim is to update and improve the existing inherently safer design review (ISDR) practices during design of chemical process plant by exploiting major accident cases from the U.S. Chemical Safety Board (CSB) and Failure Knowledge Database (FKD). Although the basic guidelines to conduct ISDR during design phase are available, however they are too general and incomplete. The review criteria and their best timing for application are still missing. This paper attempts to develop the accident-based ISDR for chemical process plant design. The proposed accident-based ISDR is supported with detail review criteria for each phase of process design. The timing of ISDR application is corresponding to the common design tasks and decisions made in the design project. Therefore, timely design review could be done at the specific design task and the findings help designer to make a correct decision making.