Learning's From Major Process Safety Incidents Learning's From Major Process Safety Incidents

Learning's from Major
Process Safety Incidents
Brian D. Rains
Global PSM Practice Leader
DuPont Sustainable Solutions
23 February 2012
Copyright 2010 DuPont. All rights reserved. The DuPont Oval Logo, DuPont, and The miracles of science are registered trademarks or trademarks of DuPont or its affiliates.
2
Objective
To share Learnings from Major Process

Safety Incidents and how the application
of a Operations Risk Management Model
can significantly reduce the probability of
and consequence from such an incident
Copyright 2010 DuPont. All rights reserved.

3
My background
I am a Chemical Engineer by training and an

experienced operations leader
I am currently the Global PSM Practice
Leader for DuPont Sustainable Solutions
I am committed to helping organizations and
facilities achieve zero process safety incidents
while improving viability and sustainability
We preach what we practice
4
Safety is a DuPont Core Value
Core values: Safety, ethics and

respect for people and the
environment
$32 Billion revenue, 13 business units
from electronics to plastics, paints
and agricultural chemicals.
Sustainable Solutions is the services
oriented business unit
Over 175 facilities around the world
Worldwide reputation for safety
DuPont applies a single Operational
Risk Management system worldwide

5
Major Industrial Incidents

1988: Piper Alpha (Occidental) 1998: Longford Gas 2005: Texas City
Explosion (Esso) Refinery (BP)
167 killed
8 killed, 69 injured 15 killed, 170 injured
Cost: US$1.2 billion
Cost: US$1 billion Cost: US$3.5 billion+
2001: P36 Sinking 2010: Oil Rig

Platform (Petrobras) Explosion, Gulf
1991: Sleipner A Platform
10 killed of Mexico (BP)
1984: Union Carbide, Collapse (Statoil)
Cost: US$515 million Cost: >US$12.5
Bhopal Cost: US$1.2 billion billion
Reported 3000 killed
Cost: Disappearance 2005: Bombay High
of Union Carbide North Platform (ONGC)
22 killed
1996: Gas Pipeline Explosion Cost :US$195 million
Enchova Central Platform (Enron)
(Petrobras) 33 killed, 69 injured
2006: Pipeline
1984: Explosion, 37 killed Explosion (Nigerian
1988: Gas Blowout 1995: Nigerian Oil Rig National Petroleum
Cost: US$461 million Explosion (Mobil) Corp)
13 killed, 25 injured 200 killed
1985 1990 1995 2000 2005 2010

6
Defining Risk
Risk is the potential for loss, calculated

by combining possible or foreseeable
consequences with realistic probability
(or frequency) of occurrence.
Operational risk is a portion of a
businesss total risk profile, specifically
the operations or process related
aspectspotential losses resulting
directly from the businesss operations.

7
Typical Operational Risks
Employee / Public Health Regulatory

and Safety Compliance
Environmental Damage Reputation, Public
Physical Assets Support and Right to
Operate
Business Interruption
Employee Retention /
Morale
Product Liability
Business Value /
Market Capitalization
Community Economic
Impact

8
Top Operational Risk Factors
Inadequate identification / evaluation of

operational risks
Integrity of facilities
Competing priorities, i.e., production,
quality, costs
Insufficient resources, both quantity and
capabilities
Inadequate management of change
Weak compliance-to-procedures culture
Failure to manage process safety risks
differently from workplace safety
Weak audit function
Ineffective leadership
9
What Is Operational Risk Management?
An integrated management system that identifies, evaluates,

and controls a manufacturing process operational risks in a
way that catastrophic incidents are prevented that could
impact:
People the public, employees and contractors
The Environment local community / work sites
Business lost assets, business opportunities, loss of
customers, loss of shareholders

10
DuPont Operational Risk Management Model

11
Why the Model Works for Successful Companies
Management leadership and commitment is in

the center of the wheel. Core Value
A robust Managing System that identifies,
evaluates and mitigates process risks at all
stages of a facility's life cycle
Operational Discipline encircles all the technical
elements
A single governance process
Integrated into all business processes
Flexible and adaptable to many industries
12
Learnings from Major PSIs
1. Every element of the Operational Risk Management

Model is important

13
A Typical Incident RCFA

PSM Elements Analysis Performance (vs. system) System deficient
Management Leadership and Commitment
Technology
Process Technology
Process Hazards Analysis
Operating Procedures and Safe Work Practices
Management of Change Technology
Facilities
Quality Assurance
Pre-Startup Safety Reviews (PSSRs)
Mechanical Integrity
Management of Change Facilities
Personnel
Training and Performance
Contractor Safety and Performance
Incident Investigation and Communication
Management of Change Personnel
Emergency Planning and Response
Auditing
14
DuPont 1H2011 PSM Trends PSM Elements

PSM Technical Elements
Mechanical Integrity 30%
Top 4 for
Operating Procedures/SWPs 18%
past 5+
Training and Performance 17% years
Process Technology 13%
Quality Assurance 5%
MOC- Technology 4%
1/12/2012
Most Frequent NEP PSM
Citations
1910.119(x)(x)
(f)(1) Operating procedures.49
(d)(3) PSI pertaining to equipment 47
(e)(3) PHA specific criteria...40
(j)(4) MI Inspection & Testing .32
(e)(5) PHA recommendation F/U ..16
(j)(5) Deficient Equipment16
(l)(1) MOC implementation .15
16

Model is important
2. Every element requires a managing system
Ownership and accountability (who)
Standard of expectations / subject matter expertise (what, when,

where)
Metrics, Audits and Continuous Improvement (how and why)
Data management (how)

17

Model is important
where)
Metrics, Audits and Continuous Improvement (why)
3. Every element is dependent on other elements, creating
the need for a holistic, interdependent and integrated
complete managing system

18
Baker Panel Recommendations

The Panel was charged with making recommendations
to improve BPs corporate safety culture, corporate
oversight of process safety, and process safety
management systems.
RECOMMENDATION #2 INTEGRATED AND COMPREHENSIVE

PROCESS SAFETY MANAGEMENT SYSTEM
BP should establish and implement an integrated and
comprehensive process safety management system that
systematically and continuously identifies, reduces, and
manages process safety risks at its U.S. refineries.
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Baker Panel Recommendation #2
RECOMMENDATION #2 INTEGRATED AND COMPREHENSIVE

PROCESS SAFETY MANAGEMENT SYSTEM
From the Commentary on Recommendations:
(1) integrated and comprehensive management systemIn order
to be effective, a management system for process safety must be
comprehensive; a weak or fragmented system will not address all
of the numerous process safety risks that exist in BPs U.S.
refineries. Among other things, this comprehensive management
system should
(b) utilize an integrated set of leading and lagging performance
indicators for process safety as described in Recommendation #7
Example. A minor incident
investigation
21
DuPont Process Safety Management Model
22
23
24
25
26
27
28
29

Model is important
where)
Metrics, Audits and Continuous Improvement (why)
3. Every element is dependent on other elements, creating
the need for a holistic, interdependent and integrated
overall managing system
4. Process Safety Management must be applied from early
conceptual design through mothballing/shutdown if all
Major PSIs are to be prevented
Confidential 30
Risk Management from Beginning to End
PSI & PSM Emergency

Critical Revalidation Planning &
Equipment PHAs Response
Continuous
Screening Improvement /
PHA PSSR MOC-
T&F Contractors Metrics
FEL-1 Shutdown /
Mothballed
Incident PSM
Quality
Investigation Systems
Assurance
Auditing Final PHA
Procedure
s&
Training
Mechanical MOC-Personnel
Integrity
START-UP
31
Risk Management Program Benefits
Avoidance of catastrophic events that injure

people, facilities, business and the environment
Improved sustainability performance
Improved productivity and reduced costs
through reduced downtime; fewer incidents
Sustained right to operate, as granted by the
community, governments and other
stakeholders
Improved employee morale
Improved credibility in the investment
community
32
Conclusion
Successful leaders identify, evaluate and mitigate

operational risks by:
Implementing comprehensive, integrated
management systems
Fostering a positive, trusting and open culture
Pursuing and achieving the goal of zero
significant operational incidents
It is imperative that leadership set the tone at the top
of the organization and establish appropriate expectations
regarding process safety performance.
Baker Panel Report (January 2007)

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Learning's from Major

Process Safety Incidents

DuPont Sustainable Solutions

To share Learnings from Major Process

Copyright 2010 DuPont. All rights reserved.

I am a Chemical Engineer by training and an

We preach what we practice

Safety is a DuPont Core Value

Core values: Safety, ethics and

Copyright 2010 DuPont. All rights reserved.

Major Industrial Incidents

2001: P36 Sinking 2010: Oil Rig

1985 1990 1995 2000 2005 2010

Risk is the potential for loss, calculated

Copyright 2010 DuPont. All rights reserved.

Typical Operational Risks

Employee / Public Health Regulatory

Copyright 2010 DuPont. All rights reserved.

Top Operational Risk Factors

Inadequate identification / evaluation of

What Is Operational Risk Management?

An integrated management system that identifies, evaluates,

Copyright 2010 DuPont. All rights reserved.

DuPont Operational Risk Management Model

Copyright 2010 DuPont. All rights reserved.

Why the Model Works for Successful Companies

Management leadership and commitment is in

Learnings from Major PSIs

1. Every element of the Operational Risk Management

Copyright 2010 DuPont. All rights reserved.

A Typical Incident RCFA

DuPont 1H2011 PSM Trends PSM Elements

Learnings from Major PSIs

1. Every element of the Operational Risk Management

Standard of expectations / subject matter expertise (what, when,

Metrics, Audits and Continuous Improvement (how and why)

Data management (how)

Copyright 2010 DuPont. All rights reserved.

Learnings from Major PSIs

1. Every element of the Operational Risk Management

Copyright 2010 DuPont. All rights reserved.

Baker Panel Recommendations

RECOMMENDATION #2 INTEGRATED AND COMPREHENSIVE

Baker Panel Recommendation #2

RECOMMENDATION #2 INTEGRATED AND COMPREHENSIVE

DuPont Process Safety Management Model

DuPont Process Safety Management Model

DuPont Process Safety Management Model

DuPont Process Safety Management Model

DuPont Process Safety Management Model

DuPont Process Safety Management Model

DuPont Process Safety Management Model

DuPont Process Safety Management Model

Learnings from Major PSIs

1. Every element of the Operational Risk Management

Risk Management from Beginning to End

PSI & PSM Emergency

Risk Management Program Benefits

Avoidance of catastrophic events that injure