Reducing Major Accident Potential: - Lessons From The Refining

Industries

Graham BennettDownstream Director

DNV Energy

Objectives of this presentation

To review process safety related accidents that have occurred within the recent history of the refining industry, andshare the experiences

To examine lessons to be learned

To challenge some existing paradigms

To identify opportunities for the future

Process Safety Challenges

Buncefield, UK

1976Seveso (?†/?) 1974Flixborough (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

2005Texas City (15†/170)

Toulouse (29†/650) 20012005

Pasadena, Texas (23†/232) 1989

Bhopal (20,000†/50,000)1984

/ )Longford (2† numerous1998

Henderson, Nevada (2†/350) 1988

Alon (0 †/0) 2008

(0 /40)†

Texaco Pembroke - July 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 - June 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 January 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

NumberIncident Type

Production Downtime

Regulatory Fines

Site Evacuation

Injury

Loss of life

NumberConsequence

745538

369

44

163276

114

674

219

How are things in Europe?

Trends in occupational safety

0

1

2

3

4

5

1993

1995

1997

1999

2001

2003

2005

Inci

dent

s pe

r 200

,000

wor

k ho

urs

APIBayerBPChevron TexacoConcaweConocoPhillipsDowDuPontExxonMobilOMVShellTrend Line

Trends in refinery material damage costsIncident costs - $ per 1000bbls refinery capacity corrected to 2000 prices

0.00

5.00

10.00

15.00

20.00

25.00

30.00

1964

1966

1968

1970

1972

1974

1976

1978

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

Dam

age

$/10

00 b

bl re

finer

y pr

oduc

tion

at 2

000

pric

es

Raw data

5-year average

Linear (5-yearaverage)

The IdeaThere is a fixed ratio

of accident severities

The HopeIf we address the

smaller events, the big ones will also improve

The RealityIf 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 1980’s- 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 thatimprovements 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 LessonsMajor 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 “connectivity” is 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, don’t 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 KPI’s 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”