1. Process Safety Management: Some Lessons from Recent Incidents Presentation to the Introduction to Environmental, Health & Safety Workshop CSChE 2008 Conference Ottawa, ON, October 21, 2008
Graham Creedy, P.Eng, FCIC, FEIC
Senior Manager, Responsible Care®
Canadian Chemical Producers’ Association
(613) ,

2. Origins of this Workshop
Why Process Safety Management?
Knowing (and meeting) the regulations is important; but is not enough – especially in Canada
Need to Know:
How to spot the hazards
Why and How defences fail
How to communicate

3. Personal safety hazards can sometimes be easy to spot; but major hazards are often not obvious
Keep an open mind about hazards – do not assume that if it is important, someone else would have noted it
Know the basic hazard identification & risk assessment techniques and when to use them
If using a contractor for this, know enough to watch for competence

4. Why and How Defences Fail
People often assume systems work as intended, despite warning signs
Examples of good performance are cited as representing the whole, while poor ones are overlooked or soon forgotten
Failure modes and effects analysis (FMEA) should include human and organizational aspects as well as equipment, physical and IT systems

5. Avonmouth, UK 1996
Although not recent, it is a classic example of a latent failure
Hazard of material known, but lack of awareness of potential system failure mode leads to defective procedure design

6. Ghent, WV 2007
Hazards well-known and supposedly covered by equipment and procedure design
Latent errors in procedure execution allow actual practice to deviate from assumed

7. Danvers, MA 2006
Hazards known, but defences compromised by apparently benign change
Latent error in procedure design creates vulnerability to likely execution error

8. Port Wentworth, GA 2007
Hazard of material not obvious (despite history)
Latent error allowed dust to accumulate, creating conditions for subsequent events

9. James Reason’s “Cheese Model”
shows how the layers of protection intended to control hazards are not perfect, but are subject to holes that can increase over time if not monitored carefully. Eventually the holes are such that enough defences fail, leading to a major incident

10. The Process Safety Management Guide
Summarizes CCPS approach in handy, short booklet
Available as free download from CSChE’s PSM division website, in English and French (or as booklet, for nominal fee)
Website:

11. A page from the “HISAT” Site Self-Assessment Tool, available on the PSM Division website

12. Understanding and sizing up the hazards
The US Chemical Safety Board website has case studies and videos – great for understanding and “Could it happen here?”
Center for Chemical Process Safety (CCPS) guide
Easy to use
Describes hazard evaluation procedures
Explains when and how to use them

13. When communicating, remember the New Product Introduction Curve
Innovators
Early Adopters
Early Majority
Laggards
Late Majority
Percent adoption
Categories differ by ability and more importantly, motivation
Where is your org, and your boss, on this curve?

14. Dealing with a Safety (or Engineering) Problem
Finding out who you’re dealing with
Where is the organization on the curve? (generally, and re the specific issue or problem)
Where are the people you’re dealing with on the curve? (generally, and re the issue or problem)
Finding out what to do
“Benchmark” – don’t try to reinvent the wheel unless you’re sure there isn’t one already (or you’ve time and it’s fun to do so)
Find out what others are doing about it
Read the instructions
Identify/define the issue
If it’s likely to be regulated, check with government agencies, trade associations, web, internet
If not regulated but likely good industry practice, check suppliers, other users of same material or item, other users of similar items, other industry contacts – but test the info!!! (cross-check, ask if it makes sense)
Check standard reference works,(Lees, CCPS, etc)
Doing it
Try to think of all situations that are likely to occur (process, eqpt, people)
“KISS”, keep it user-friendly, show basis for decisions if practical to do so
Follow up afterwards to see how it’s working

15. Questions?