Focus on mission success: Process safety for the Atychiphobist

Modern process plants are complex engineering systems. While thorough reviews of system safeguards are performed, catastrophic events continue to occur, often unfolding in unforeseen ways. Success in process safety demands safe processes, and understanding rare, high consequence events is central to the traditional process safety approach. This philosophy is common to all high-hazard industries, offering the potential for sharing approaches, experience, and lessons learned. The problem, however, is that people (and organizations and entire industries) who fear failure (atychiphobia) sometimes obsess about failure so much that they miss opportunities to succeed.This paper examines selected risk management practices in the power generation and aerospace industries and how those practices have led to improved performance. Risk informed decision making (RIDM) has had widespread application in the nuclear and aerospace industries, and is undergoing enhancements to become a key framework for risk management. Additionally, rather than focusing on avoidance of loss, there are emerging approaches supporting achievement of success. This approach provides a more direct link of risk to business and operational objectives, but does challenge conventional risk approaches founded in a loss prevention-centric view. The paper reflects upon risk informed decision making and success modeling, and suggests how these methods may be applied in the field of process safety. Specific examples are drawn from the defense in depth approach from the nuclear power industry and mission success concepts developed for NASA.     

企业系统化安全管理的主要问题及成因分析

针对系统化安全管理实践中存在着安全管理体系建立的模板化、安全管理体系运行的形式化、安全管理体系持续改进的无效化等问题,提出要提高安全管理绩效,首先纠正企业对系统化安全管理的认知偏差,统一企业不同管理层次的认识;其次是用正确的安全管理方法论作指导,开展系统化安全管理实践;三是匹配企业安全管理实践与系统化要求,发挥和协调不同管理主体的参与,对危险源进行动态化管理,有效实施绩效监测与改进。总之,企业系统化安全管理不能作为单纯的一项工作或任务来完成,必须以解决企业的具体安全生产问题为目标;系统化安全管理是一个持续优化的动态过程,既要把握安全管理系统化的要求,也要有效开展安全管理系统化实践。     

Risk indicators for major hazards on offshore installations

Major hazards risk indicators are proposed for offshore installations, based on what has been used by the Petroleum Safety Authority Norway for the Risk Level approach in the Norwegian offshore petroleum industry. Since 2002 also leading indicators are used, in the sense that indicators for barrier performance are included together with the lagging indicators. There are individual indicators for a number of barrier functions, including fire and gas detection, a number of safety valves, active fire protection and mustering of personnel. The performance of the leading indicators during several years of data collection as well as lessons learned from the project are discussed. This is followed by a review of how indicators may be used by individual companies, and how the lessons may be utilised by individual companies to develop risk indicators for individual installations as well as company wide indicators.     

Modeling of BP Texas City refinery incident

This paper presents detailed modeling results of the BP Texas City refinery incident. Three different approaches and explosion modeling tools were used to study the event. The results predicted by all three approaches are similar and all approaches identified a hazard potential comparable to what was witnessed on March 23, 2005. This confirms that quantitative risk assessment (QRA) has the ability to model a realistic scenario, and is therefore useful in safety measure design and emergency preparedness decision making to improve overall safety performance. Had QRA been conducted during a management of change (MOC) decision-making process, personnel trailers likely would not have been sited in such close proximity to the process units. The resulting severe consequences would then not have occurred. This work also aims to emphasize the importance of QRA in process safety management.

The paper presents the authors’ perception of the sequence of events involved in the incident based on the published literature available at the time of writing. It also assesses potential consequences for the perceived sequence of events using a variety of consequence assessment tools. In doing so, the analysis illustrates how this incident could have been prevented in spite of many operational difficulties. The observations and commentary presented in this paper are intended solely for the purpose of process safety enhancement on the basis of the lessons learned. BP has published its own detailed report; the incident is also the subject of a recent investigation by the US Chemical Safety and Hazard Investigation Board, with the CSB's final report being available at http://www.csb.gov/index.cfm?folder=completed_investigations&page=info&INV_ID=52 (as of April 2007).     

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.     

Leading indicators of system safety – Monitoring and driving the organizational safety potential

An indicator can be considered any measure – quantitative or qualitative – that seeks to produce information on an issue of interest. Safety indicators can play a key role in providing information on organizational performance, motivating people to work on safety and increasing organizational potential for safety. We will describe the challenges of monitoring and driving system safety. Currently, the same lead indicators are used – explicitly or implicitly – for both purposes. The fact that the selection and use of safety performance indicators is always based on a certain understanding (a model) of the sociotechnical system and safety is often forgotten. We present a theoretical framework for utilizing safety performance indicators in safety–critical organizations that incorporates three types of safety performance indicators – outcome, monitor and drive indicators. We provide examples of each type of indicator and discuss the application of the framework in organizational safety management. We argue that outcome indicators are lag indicators since outcomes always follow something; they are the consequences arising from multiple other situational and contextual factors. Monitor and drive indicators are lead indicators. The main function of the drive indicators is to direct the sociotechnical activity in the organization by motivating certain safety-related activities. Monitor indicators provide a view on the dynamics of the organization: the practices, abilities, skills and motivation of the personnel – the organizational potential for safety. We conclude that organizations should better acknowledge the significance of monitor and drive indicators in safety management.     

Organisational learning and continuous improvement of health and safety in certified manufacturers

Certified management systems have increasingly been applied by firms in recent decades and now cover the management of health and safety, principally through the OHSAS 18001 standard. In order to become certified, firms must not only observe the relevant legislation, but also improve performance and raise goals within health and safety on a continuous basis. The article examines how certified occupational and health management systems influence this process to evaluate how far they hinder or support learning. It presents a model with which it is possible to identify and analyse improvement processes. The model is applied to five cases from a qualitative study of Danish manufacturers with certified health and safety management systems. The cases illustrate the wide variation in health and safety management among certified firms.Certification is found to support lower levels of continuous improvement performance in handling health and safety issues. However, more advanced improvement practices are shown to be connected to the integration of health and safety in other managerial areas, as well as to the employment of similar advanced improvement processes within firms. The article argues that certified health and safety management does not obstruct learning, and can support advanced learning. Improvement practices with regard to health and safety are mainly dependent upon the firm’s overall organisational processes and do not automatically arise from the standard alone.     

Framework for creating a Best-in-Class safety culture

To answer the question, “What are the practical attributes of Best-in-Class safety management,” consensus principles have been identified and lessons learned harvested from a broad spectrum of organizations with exemplary safety programs. Through years of studying the underpinnings of a strong safety culture, the authors have identified ten attributes that are important to create a Best-in-Class safety culture. Instead of expecting one organization to possess all of the attributes or employ all of the techniques identified, the authors suggest these principles be treated as guidelines that can be used to improve the safety culture in organizations.     

职业健康安全管理体系运行中若干问题的探讨

通过解读OHSMS标准相关术语,分析OHSMS运行中对危险源的管控机制与常规安全管理强调的事故隐患排查治理机制的关系。基于企业现有风险评价方法的缺陷建议,宜采取定性和定量相结合的评价手段,提出针对不同风险性质的危险源策划控制措施应依据的原则和思路。从运行控制、绩效监控机制等方面分析职业健康安全管理体系与企业常规安全生产管理活动的对应关系。在OHSMS运行中应强调对危险源的管控,合理策划控制措施,通过实施管理方案和引入绩效监控机制实现持续改进。     

Examining the asymptote in safety progress: a literature review

Many industries are confronted by plateauing safety performance as measured by the absence of negative events – particularly lower-consequence incidents or injuries. At the same time, these industries are sometimes surprised by large fatal accidents that seem to have no connection with their understanding of the risks they faced; or with how they were measuring safety. This article reviews the safety literature to examine how both these surprises and the asymptote are linked to the very structures and practices organizations have in place to manage safety. The article finds that safety practices associated with compliance, control and quantification could be partly responsible. These can create a sense of invulnerability through safety performance close to zero; organizational resources can get deflected into unproductive or counterproductive initiatives; obsolete practices for keeping human performance within a pre-specified bandwidth are sustained; and accountability relationships can encourage suppression of the ‘bad news’ necessary to learn and improve.     

Dynamic management of human error to reduce total risk

Safety management in companies at the limit of risk criteria must be implemented in order to survive in the very aggressive and competitive environment of modern society. It implies that the risk in process industries is crossing the limit of safe practices. Most major accidents consist of human errors and mechanical component failures, and cannot be explained by a stochastic coincidence of independent events. This work focuses on the coincidence of human error and mechanical failure to introduce a concept of dynamic management of human error. By the dynamic management of human error during a short period, when a mechanical component is temporarily unavailable during periodic testing or maintenance, the probability of a major accident may be reduced significantly without additional investment on improving safety. For the periodically-tested standby component, the majority of total average unavailability of the component may be recognized by operators or workers as well as maintenance mechanics. During this short period, an appropriate dynamic management of human error for improving human performance temporarily may be very effective in reducing total risk in industries. The dynamic management of human error may be a useful method to prevent loss effectively in the process industries     

航空安全文化运行模式研究

依据安全文化基本原理,对航空安全文化模式进行系统化设计。将安全精神文化、制度文化、行为文化和物态文化4个子系统置于安全文化模式的大系统中,综合分析各子系统之间的互动关系及其对管理模式变革的影响。结合航空安全管理的特点,设计安全文化运行机制的结构框架。通过分析安全文化模式的运行过程和运行功能模块,实现航空安全文化模式的动态管理,使零散的安全文化模式得以系统化。航空安全文化模式的构建为航空运输企业建立了一个程序化、系统化、动态循环的管理过程,并以持续改进的思想指导企业系统地实现其安全目标。     

The role of standardization in safety management – A case study of a major oil & gas company

This article discusses the strengths and weaknesses of various kinds of standardization, when applied to the field of safety management. Recently, there are signs that organizations operating in high risk environments take further steps towards standardization. On the positive side, standardization has the potential to enhance the predictability of normal operations as well as facilitating the transfer of lessons learnt across organizational contexts. On the negative side, standardization is by definition a strategy for dealing with known hazards and accident scenarios. We discuss how too strong an emphasis on standardization can involve unintended negative consequences for organizations’ crisis-handling capabilities.     

Work-related road safety: A case study of Roche Australia

Fleet, work-related or occupational road safety has the potential to make a major contribution to reducing both human harm and asset damage. To date, however, there would appear to be a dearth of well researched and evaluated case studies in the public domain in this area.This paper provides an on-going, documented, real-world case study of work-related road safety within an Australian company that has sought to manage, monitor and improve its road safety performance over the last 5 years through a range of proactive, fleet manager, insurance and risk-led initiatives.Roche Australia has successfully implemented a Company Motor Vehicle Safety Program with support from its fleet insurers and risk management advisors. Four key initiatives are set out covering: (1) Driver risk assessment, monitoring and improvement. (2) Policy development and communications. (3) Process and outcomes evaluation. (4) Continuous review and refinement of policies, processes, programs and future developments.The program has led to a range of process and performance-based outcomes. Typical barriers to success in work-related road safety have been identified and overcome. Almost 100% risk assessment and improvement process compliance by drivers has been achieved. A predictive relationship between risk assessment outcomes and collision history has been identified. Reductions in insurance claims, collision costs and claims ratio have been sustained. A detailed project plan is in place to continue the program for the next 3 years.The paper concludes that with effective management, a well developed work-related road safety program can result in performance improvements within the initiating organisation. Several limitations in the case study methodology, as well as areas for further work and lessons for policy makers, researchers and practitioners are also identified.     

How can process safety and a risk management approach guide pandemic risk management?

The coronavirus disease (COVID-19) brought the world to a halt in March 2020. Various prediction and risk management approaches are being explored worldwide for decision making. This work adopts an advanced mechanistic model and utilizes tools for process safety to propose a framework for risk management for the current pandemic. A parameter tweaking and an artificial neural network-based parameter learning model have been developed for effective forecasting of the dynamic risk. Monte Carlo simulation was used to capture the randomness of the model parameters. A comparative analysis of the proposed methodologies has been carried out by using the susceptible, exposed, infected, quarantined, recovered, deceased (SEIQRD) model. A SEIQRD model was developed for four distinct locations: Italy, Germany, Ontario, and British Columbia. The learning-based approach resulted in better outcomes among the models tested in the present study. The layer of protection analysis is a useful framework to analyze the effect of different safety measures. This framework is used in this work to study the effect of non-pharmaceutical interventions on pandemic risk. The risk profiles suggest that a stage-wise releasing scenario is the most suitable approach with negligible resurgence. The case study provides valuable insights to practitioners in both the health sector and the process industries to implement advanced strategies for risk assessment and management. Both sectors can benefit from each other by using the mathematical models and the management tools used in each, and, more importantly, the lessons learned from crises.     

Accident data for the Semantic Web

This paper describes concerns about the documentation, dissemination and use of lessons learned from mishap investigations, impediments posed by current practices, and opportunities for improvement. Lessons are presently developed, documented and stored primarily in narrative form and relational databases, and disseminated in many forms and media, including the Internet. Current practices pose many impediments to maximized development, dissemination and use. Investigation process research and new data concepts behind the Semantic Web, exploited elsewhere, offer potential opportunities to overcome these impediments. To exploit these opportunities, formation of a working group to develop an improved Semantic Web-friendly mishap investigation lessons learning system is proposed. An example illustrating an alternative approach is described to support a reasonable expectation that an alternative lessons learning system could be developed.     

Human resource management practices and organizational injury rates

Introduction: This study investigated the extent to which five human resource management (HRM) practices—systematic selection, extensive training, performance appraisal, high relative compensation, and empowerment—simultaneously predicted later organizational-level injury rates. Methods: Specifically, the association between these HRM practices (assessed via on-site audits by independent observers) with organizational injury rates collected by a national regulatory agency one and two years later were modeled. Results: Results from 49 single-site UK organizations indicated that, after controlling for industry-level risk, organization size, and the other four HRM practices, only empowerment predicted lower subsequent organizational-level injury rates. Practical Applications: Findings from the current study have important implications for the design of HRM systems and for organizational-level policies and practices associated with better employee safety.     

Trends in chemical hazards in Japan

In the past, the chemical industry in Japan has been the cause of a number of major industrial accidents. Subsequent to each accident, specific lessons have been learned. These lessons learned have been implemented in terms of safety education of the employees and/or safety measures of the equipment and facilities resulting in a rapid decrease of corresponding accident frequencies. In this paper, we summarized both recent and past major accidents caused by chemical substances in fixed installations in Japan. Case studies show that runaway reactions are among the main causes of major accident occurrences in the chemical process industry in Japan. A recent fatal poisoning accident caused by H₂S gas generated during maintenance work again highlights the necessity of adequate safety management in a chemical factory. Therefore, even if hazard evaluation of chemical substances and chemical processes is necessary to prevent runaway reactions, human error is also an important factor contributing to reaction hazards [Wakakura, M. (1997) Human factor in chemical accidents, J. Safety Eng. High Press. Gas. Safety Inst. Japan, 34, 846].     

An adaptive management system for hazardous technology organizations

This paper introduces a management system suitable for hazardous technology organizations which has been developed based on the assumptions that in these organizations safety is a critical strategic factor, the existence of an enhanced safety culture is a crucial condition for safety and that safety culture enhancement implies in organizational changes. The management system was theoretically developed and then implemented at a Brazilian nuclear research and development installation, as a case study, in order to validate the theoretical propositions assumed in the system development. The developed management system comprises a day-to-day based organizational framework which treats safety as one of the organization strategic perspectives and provides a continuous adaptation of the complex causal inter-relationships which occur between the implementation of new management practices – designed and implemented according to the requirements of the criteria of excellence of the Brazilian quality award management assessment model – and the organization safety culture. The results achieved in the case study permitted to demonstrate the validness of all the system theoretical propositions and to conclude that the continuous and systematic operation of the management system makes an effective safety culture enhancement possible and simultaneously facilitates that the new management practices be effectively implemented, thus making continuous organizational improvement possible.