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TRANSCRIPT
“Critical Events”
Applying Continuous Improvement to
Incident Reporting
Nigel CannGeneral Manager
Australian Vinyls
Buncefield
Texas City
Flixborough1 June 1974
•Modification Control
•Use suitably trained, educated and responsible people
•Know what you don’t know
SevesoJuly 1976
• Understanding safe state to leave reactions
• Multiple layers of protection
• Automated Reaction stop systems for exothermic systems
Piper Alpha6 July 1988
•Good functioning Permit to Work System including monitoring
•Never defeat Safety Systems
•Understand the hazards, their consequences and fit appropriate control measures
Longford25 September 1998
Sale
Barry BeachMarine Terminal
Long Island PointFractionation Plant,Crude Oil Tank Farmand Liquids Jetty
LongfordGas & Oil Processing
PortPhillipBay
c
Melbourne
Altona
Monotower
Sub-sea Well Oil Platform
Gas Platform
Concrete Structure
Barracouta Marlin
Snapper
GoodingCompression (GTC)
c
c
• “cold temperatures” • Training needs to impart and refresh knowledge.• Must identify other hazards and provide relevant training.•Corporate knowledge must be captured and kept alive
All of these introduced Major Hazards Legislation
• In Victoria, Australia– Occupational Health and Safety (Major
Hazard Facilities) Regulations 2000– Victoria giving effect to the National Code
of Practice for Major Hazard Facilities
Occupational Health and Safety (Major Hazard Facilities) Regulations 2000
• 302 Identification of major incidents and hazards
• 303 (1) …must conduct a comprehensive and systematic safety assessment…
• 304 (1) … must adopt control measures which…
• 306 (1) … must review, and as necessary revise…
The Deming PDCA Model
PlanAct
DoCheck
What Major Incidents can occur?
What Major Incidents can occur?
PlanAct
DoCheck
What Hazards exist that can cause those Incidents?
What Major Incidents can occur?
What Hazards exist that can cause those Incidents?
PlanAct
DoCheck
What Control Measures can be used to manage and contain those hazards?
What Major Incidents can occur?
What Hazards exist that can cause those Incidents?
What Control Measures can be used to manage and contain those hazards?
PlanAct
DoCheck
What SafetyManagement
System (SMS)Maintains those
Controlmeasures?
What Major Incidents can occur?
What Hazards exist that can cause those Incidents?
What Control Measures can be used to manage and contain those hazards?
What Safety Management
System (SMS) maintains those
control measures?
The Deming PDCA Model
PlanAct
DoCheck
How does theOperator maintainSMS performance
by reviewing KPI’s and SOP’s?
Australian Vinyls
STRIPPINGCOLUMN
DEG ASSER
AUTOCLAVES
STEAM
ADDITIVES
VCM TANKER
CHARGE WATER
VCM GASHOLDER
LIQUID VCM STORAGE
VCM RECO VERYPLANT
BAGGING ANDPAL LET IZ ING
BULK SUPPL Y
SLURRYTANK
STORAGESIL O
FLUID BED DRYER
CENT RIFUGE
PACKAGED SUPPL Y
Plan
Government Level
Acts Regulations Codes of Practice and other guidance
Commonwealth 7 7 20
Victorian State 18 29 28
Local Laws 2
Plan
• Safety Management Systems should not exist!
• Identify a framework– ISO 9000 & 14000 series– API 9100– AS/NZS 4801– AS ISO/IEC 17025
Maintaining performance via a SMS
• Top Down� • Permit to Work System� • Induction procedures� • Control of Third Parties� • Auditing program� • Purchasing procedures� • Recruiting processes� • Personnel and
organisational change processes
� • Engineering Modification controls
� • Emergency Response Procedures
� • Incident Investigation processes
• Bottom up– Identified control
measures must be managed
– Set Performance Standards
– Put in place Monitoring Systems
– AUDIT– Draw conclusions and
take action to close the loop.
• Need to develop robust system– Eg HAZOP keywords
• Be systematic in identifying Incidents– Recommend use of LOC
• Use of Databases and “Bow ties”
Hazard Identification and Safety Assessment
The Laverton Resin Plant
Hole > 150mm
in Storage Tank
HAZARDS
• Working wrong tank
•Corrosion
•Vehicle Hits it
•Flange breaks
•Overpressure
•Fire under tank
•Bullet Hole
•Overfilling
•Wrong Material
Tank Design
Control Measures
Control Measures
Hazard & Control Measure
Identification
•Permit to Work
•Barriers
•Speed Limit
•Signs
•Stand by
•Security
•Bunds
How does a Control Measure become CRITICAL?
Control Measure CRITICALITY
Hole > 150mm
in Storage Tank
HAZARDS
• Working wrong tank
•Corrosion
•Vehicle Hits it
•Flange breaks
•Overpressure
•Fire under tank
•Bullet Hole
•Overfilling
•Wrong Material
Tank Design
Control Measures
Control Measures
Hazard & Control Measure
Identification
•Permit to Work
•Barriers
•Speed Limit
•Signs
•Stand by
•Security
•Bunds
Hole > 150mm
in Storage Tank
HAZARDS
• Working wrong tank
•Corrosion
•Vehicle Hits it
•Flange breaks
•Overpressure
•Fire under tank
•Bullet Hole
•Overfilling
•Wrong Material
Tank Design
•Relief Valves
•Gasholder Venting Procedure
•High Pressure Alarms
•Return to Service Procedure
Control Measures
Control Measures
Hazard & Control Measure
Identification
Draw a “Bow-Tie”
Hole > 150mm in Storage
Tank
Tank Design
Vessel exceeds pressure
Relief Valves
Procedure for venting
to gasholder
High Pressure Alarms
Procedure for Return to Service
Vessel out for
Maintenance
Air in Vessel
Supports Earthquake designed
Vehicle impacts supports
Speed LimitRoad BarrierPTWVehicle
needs to access
area
Draw a “Bow-Tie”
Derive Performance Measures
– No failure on demand– No failure on testing.– As received from duty, pop test to
be within 10% of setting– Inspection and test to be no more
than 3 months overdue
Leading Indicator Monitoring
Latent Unsafe ConditionsDecision-Makers
Latent Unsafe ConditionsLineManagement
Latent Unsafe ConditionsPre-Conditions
Active FailuresProductiveActivities
Active FailuresandLatent Unsafe Conditions
Defences
The Reason “Swiss Cheese” Model: Stages to an Accident
Accident & InjuryAccident & Injury
Investigation of Critical Events
Operator failed to detect significant Reaction Temperature Deviation
Operator failed to detect significant Reaction Temperature Deviation
• 16 Actions that resulted1. Resolve persistent Panel Alarms that should not be there2. Generate list of Critical Alarms
1. Review list of Critical Alarms to see what is on DCS 2. Review list of Critical Alarms on DCS3. Review High Pressure Alarm Recipe settings
1. Set appropriate High Pressure Limits for S1 A/C’s2. Change High Pressure Limits for S1
4. Check S2 Agitator Motor Current settings in DCS
3. Review Trip 18 conditions on DCS4. Reinforce the importance of the Panel with CRO’s
Operator failed to detect significant Reaction Temperature Deviation
5. Specify Temperature Deviation alarm sensitivity at either end of phase 61. Change Temperature Deviation Alarm Sensitivity at either end of
phase 6
6. Check DCS for S2 Temperature Deviation Alarms1. Put Temperature Deviation Alarm on DCS
7. Alarm Controller Output of 09 Valves
8. Assess Effectiveness and Completeness of changes to DCS alarms
Suggestions for other Industries
• Flammable, Toxic or Radioactive Materials– LOC
Suggestions for other Industries
• Complex Machinery
– Catchpoints– Energy Sources– Access Points– Cleaning
Suggestions for other Industries
• Electricity
– Distribution– HV Switching– Working at Heights
Suggestions for other Industries
• Public Transport, Logistics, Port Operations– Third Party collisions– Single vehicle collisions– Derailing– Lifting operations etc
SUMMARY