PSM Implementation

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The DuPont Approach to
Achieve a Safety Culture

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Process Safety Management Model
• LOTO/LB
• Confined space
• Hot work
• Permit to work

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Expectation :
PSM is implemented and managed at each site as part of both
individual and group values and behaviors to enable sound
decision making and continuous improvement.

1. Build a Safety Culture

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“Safety is line management responsibility. If we can’t do it safely- we won’t do it at all”
E.I. DuPont (1817)

 Establish policy
 Leaders to be role model
 Commit resources
 Provide for encourage
 Employee involvement
 Establish clear accountability
 Verify compliance
2. Management Leadership  Participate personally
& commitment

1. Build a Safety Culture

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 3. Implement
PSM

2. Management Leadership
& commitment

1. Build a Safety Culture

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 OD Characteristics:
1. Leadership by example
2. Functioning capability & sufficient
resource
3. Employee involvement
Operational 4. Active line of communication
Discipline
4. OD 5. Strong teamwork
6. Common shared value
7. Up to date documentation
3. Implement 8. Practice consistent with procedure
9. Absence of shortcuts
PSM 10. Excellent housekeeping
11. Pride in the organization
2. Management Leadership
& commitment

1. Build a Safety Culture

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 PSM Structure Committee
Steering President K.Cholanat

MD TPC MD of each company DuPont

Corporate
VP SCG Chem. K.Somchai W.

MD TPC MD of each company

Company MD TPC K.Suchai

VCM Div. PVC Div. Indo. Vietnam Others II PSI/PHA SWP MOC PSSR OD

Task force Team

TFT Leader

Member 1 Member 2 Member 3 Member 4 Member 5 Member 6

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Basis for the 14 Element Approach

• The 14 elements cover all critical components that need

to be addressed to manage risk in any manufacturing
organisation with management commitment and
leadership as the core.
• DuPont has successfully used this approach in
managing the process safety worldwide in a wide range
of operations including chemicals, polymers,
electronics, mining, biotechnology, films and fibers.
• Implementing the system following these elements
meets or exceeds regulatory requirements.

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 12
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 PSM Elements
•Let’s take a look at the basic concepts
behind each of the 14 PSM elements.

Management
of Change – Facilities
(Subtle Changes)

Management
of Change – Facilities
(Subtle Changes)

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Element #1: Process Safety Information (PSI)

• Technology Elements:

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Element #1: Process Safety Information (PSI)
• The process safety information (PSI) package provides a
description of the process or operation. It provides the
foundation for identifying and understanding the hazards
involved—the first steps in the process safety management
effort.
• A definitive PSI package must be developed in written form and
maintained current by a system that reviews the information on
a regular basis and updates it.
• The PSI package generally consists of three parts:
• Hazards of materials
• Process design basis
• Equipment design basis

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Element #2: Process Hazards Analysis

• Technology Elements:

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Element #2: Process Hazards Analysis

• PHA is a critical element in PSM.

• Makeup of PHA team is crucial and must include people
experienced in the process under study as well as people
with expertise in the methodology.
• PHA assures that all process hazards have been
identified and adequately addressed through
administrative and engineering controls.
• There are many tools available to assess the process
hazards. 95% can be addressed using qualitative tools
coupled with critical analytical thinking.

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Element #3: Operating Procedures and Safe Practices

• Technology Elements:

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Element #3: Operating Procedures and Safe Practices

• Operating procedures provide a clear understanding of parameters

for safe operation for those who are operating the process. Operating
procedures must be written, accessible to the people that use them,
and updated whenever there are changes.
• Safe practices provide a carefully planned system of procedures
and/or permits involving checks and authorizations prior to doing non-
routine work in process areas.
• Everyone including operators, engineers and first line supervisors are
engaged in writing and implementing operating procedures and safe
practices.
• In addition to normal operation, written procedures should include
emergency operation, emergency shut down and temporary
operations and include assignment of emergency activities to qualified
personnel.

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Element #4: Management of Technology Change

• Technology Elements:

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Element #4: Management of Technology Change
• Process changes potentially invalidate prior hazard
assessments and create new hazards; accordingly, all
process changes to the Process Safety Information (PSI)
must be reviewed. Need to have a clear understanding by all
involved personnel of what constitutes change.
• All process changes should be reviewed by knowledgeable
personnel and authorized by responsible management.
• Many serious incidents occur within six months of some kind
of significant change.
• Changes to the operating procedures must be documented
and the personnel trained before the operational change is
implemented.

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Element #5: Quality Assurance

Facilities Elements:

Management of
Change—Facilities
(Subtle Change)

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Element #5: Quality Assurance

• Quality assurance efforts focus on ensuring that process

equipment is fabricated in accordance with design specifications
and assembled and installed properly.
• Steps in an Effective QA Program, include:
1. Identifying equipment “Critical to Process Safety”.
2. Using current and correct specifications.
3. Using qualified inspectors.
4. Using QA standards.
5. Using QA procedure to prepare QA checklists.
6. Using QA checklist to do inspections.

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Element #6: Pre-Startup Safety Reviews

Facilities Elements:

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Element #6: Pre-Startup Safety Reviews

• The Prestart-Up Safety Review (PSSR) provides a final check of

new and modified equipment to confirm that all appropriate
elements of process safety have been addressed satisfactorily
and the facility is safe to operate.
• PSSRs ensure that all the management systems necessary for
safe operation of the process are in place before introduction of
material into the process.
• PSSRs are performed on new or modified facilities when the
modification is significant enough to require a change in the PSI.
• The PSSRs shall be conducted by multidisciplinary teams
consisting of manufacturing (including operator), technical,
design, maintenance, and appropriate safety representatives on
an as-needed basis.

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 Element #7: Mechanical Integrity

Facilities Elements:

Management of
Change—Facilities
(Subtle Change)

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Element #7: Mechanical Integrity

• Focuses on maintaining and continuously improving a system’s

integrity to contain hazardous substances and control the
mechanical hazards throughout the life of the facility.
• Line Organisation is accountable and responsible for Mechanical
Integrity.
• In addition to process safety, mechanical integrity of equipment is a
foundation for asset productivity.
• Inspection frequency depends on a number of factors:
• Failure rate data
• Criticality of control device
• Consequences of failure
• Redundant devices present

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Element #8: Management of Change – Facilities (Subtle
Change)

• Facilities Elements:

Management of
Change—Facilities
(Subtle Change)

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Element #8: Management of Change – Facilities (Subtle
Change)
• A facilities change is defined as all modifications to the facility which
may or may not involve large revisions or capital expenditures (any
change other than replacement in kind).
• Changes, even though small, can and have caused serious
incidents.
• Change must address impact on safety, health, and environmental
and consider the impact on following PSM elements:
• Management of Technology Change
• Operating Procedures/PHA
• Training and Communication
• PSSR/Field Inspection
• Levels of review and authorisation consistent with the nature /
magnitude of the change.

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Element #9: Training and Performance

• Personnel Elements:

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Element #9: Training and Performance

• Properly trained and performing personnel are a requirement for

keeping process equipment and machinery operating safely.
• All other elements of PSM can be in place—but without properly
trained and performing personnel, the chances of safe process
operation are greatly diminished.
• Initial training - employees must be trained in an overview of the
process and in specific safety and health hazards, operating
procedures (including emergency operation and shutdown) and
safe practices before working in a process.
• Refresher training must be provided at an appropriate frequency,
not to exceed three years.
• Operations should be audited to verify adequate training and
documentation.

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Element #10: Contractors

• Personnel Elements:

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Element #10: Contractors

• Assure that compliance with site safety requirements is an

integral part of the contract. The site is responsible for
evaluating contractor’s safety performance in selection
process and periodically thereafter.
• All tasks must be completed safely and performed in
accordance with established procedures and/or safe work
practices, consistent with the principles of good PSM,
whether the tasks are completed by site personnel or by
contract personnel.
• Efforts must be made to ensure that contractor employees
are properly trained and informed as to hazards and
proper methods of operation.

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Element #11: Incident Investigation

• Personnel Elements:

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Element #11: Incident Investigation

• Aggressive and persistent investigation of all serious and

serious potential incidents is necessary to continuously improve
safety performance.
• Incident investigation is important to prevent recurrence, share
findings with others, identify related problems, identify
weaknesses in safety systems, and guide development of
standards.
• An incident investigation team must be organised promptly by
line management. Team members should be assembled from
shift personnel and other relevant site and non-site personnel,
including contractors if involved.

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Element #12: Management of Personnel Change

• Personnel Elements:

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Element #12: Management of Personnel Change

• Safe operations require well trained and experienced

personnel, including operating, maintenance, and contractor
personnel.
• Site and higher levels of management are responsible for
developing and implementing criteria and guidelines regarding
management of personnel change so that a minimum level of
skills is maintained.
• Management of Change Concepts are applied in the event of:
• Promotions/transfers
• Resignations
• Illnesses/deaths
• Force reductions

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Element #13: Emergency Planning and Response

• Personnel Elements:

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Element #13: Emergency Planning and Response

• In-depth planning for potential emergencies is required so

that timely and effective response by the site along with the
community can mitigate the impact on people, the
environment, and facilities.
• Establish appropriate response procedures for the entire
spectrum of emergencies.
• Responsible positions and personnel for EP must be defined.

• Training and periodic drills are a vital part of EP.

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Element #14: Auditing

• Personnel Elements:

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Element #14: Auditing
• Auditing provides a measurement of compliance with the
established PSM program.
• An effective auditing approach is twofold:
• The line organisation must audit, and
• An outside group, independent from the line organisation, must audit.
• Area audits of individual elements in the PSM program by the
line organisation should be conducted such that all elements are
covered within a 36 month period.
• Second party audits of the site system and overview of area
performance. Suggested frequency is once every three years.
• A third party audit conducted by outside resources to determine
overall compliance with corporate program. Suggested
frequency: Once every three years.

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PSM Excellence and Operational Discipline

•PSM Excellence: •Operational Discipline (OD):

• PSM excellence results • Dedication and commitment
when an organisation by every member of the
establishes Operational organisation to carry out each
task the right way every time.
Discipline (OD) and
completes all tasks
properly, thus contributing
to the organisation’s goal of
achieving business
excellence.

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Operational Discipline
1. Leadership by example
2. Sufficient resources to support safety programs
3. Employee involvement
4. Active lines of communication
5. Strong teamwork
6. Shared values
7. Up-to-date documentation (procedures, records, etc.)
8. Practice consistent with procedures
9. Absence of shortcuts
10. Excellent housekeeping
11. Pride in the organisation
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THANK YOU
Q&A
45
The Swiss Cheese
Piper Alpha on July 6, 1988
The next
morning

Hazard
Risks

Disaster

SWP PHA MOC(F)Emergency respond plan

46 Copyright © 2013 SCG Chemicals. All Right Reserved
Incident Investigation
Introduction

By… TPC
December 2015
Process Safety Management Model

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Incident investigation is base on our Safety
Principles and Key element of safety culture
Safety Vision
“Zero Tolerance to injury and incident is our safe work culture”
Safety Principles
1. All Injuries and incident can be prevented.
2. All Management and Supervision are responsible for safety
3. Employee involvement is a must
4. All Operating exposures are safeguarded through
uncompromising of safety standards
5. Training employees to work safely is essential.
6. Working safely is a condition of employment.
7. Audits and Observations must be conducted
8. All deficiencies must be corrected promptly.
9. Off the Job safety is an important part of the corporate policy.

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ICEBERG
Fatality
DAWC
Major Injury
First Aid
Near Miss

Near Miss
Unsafe Act
Unsafe Condition

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 TABLE TIME EXERCISE

1. Group Brainstorm
2. List past Incident cases
happened in Company
3. Identify 3 accidents which
are the most recurrent
4. Analyst why those cases
were recurrent 10 min
5. Each group present
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 Benefits of Investigation
1. Prevent recurrence.
– Identify and implement action
– Communicate lesson learned
2. Spot deficiencies in safety management.
– Identify conditions that could cause other incident
– Input to the development and improvement of SHE policies,
procedures, guidelines and standards
3. Demonstrate your commitment to safety.
– Increase employees’ confidence in workplace safety.
4. Promote an atmosphere of openness
– Involve employee in analysis and decision making process
– Improve communications and understanding of incidents

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What is a good incident investigation?

It is NOT
● a quick fix on defects of equipment
● a fault finding process on people
● about focusing on just short term fix of defects / symptoms
● about your opinions and prejudices but facts of what has happened

Who: Line management, starting with first-line supervisor

What: All incidents, especially those with injury potential
When: As soon as possible

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 Incident Investigation Standard Scope

Provides requirements and guidance on:

• Responsibilities
• Investigation team Selection
• Investigation process, facts and key factors
• Corrective and Preventive recommendations
• Findings Communication
• Findings Follow-up
• Management systems

Local regulations may impose requirements not reflected in this

standard.
The most stringent requirement shall apply .

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Who Should Investigate Incidents?

We believe that
Line Management is Responsible
for investigating
All
incidents

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 Management Responsibilities

• Ensure that all incidents are reported.

• Create an atmosphere of trust and respect that leads to
openness
• Establish systems and procedures
• Communicate value of conducting incident investigation
• Provide resources and priority
• Implement follow-up systems to prevent recurrence
• Ensure system for communication is effective

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Role and Responsibility of all employees

1. Shall report when notice that incident happen or happen

to yourself
2. Support information for investigation
3. Involve in Investigation team (If needed)

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11 Steps for Investigating Incidents Process

1. Initial response 2. Initial Reporting 3. Management Review

4. Form a team 5. Gather information 6. Determine the key factors

7. Determine the 8. Recommend 9. Document and receive

systems to be corrective and approval
strengthened preventive actions

10. 11. Follow up

Communicate and verify

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 1. Initial Response

● Initial response plan

● Coordinate emergency
● Preserve incident scene
● Preserve potentially relevant evidence
● Document and Interview Key Personnel

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 2. Initial Reporting

● Report All incidents by end of shift

● Through Company Line & SHE Organization

● Initial Evaluation

● Incident Classification

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 3. Line Management Review

● Review for accurate facts, information &

Classification

● Assigns investigation Lead

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 4. Form Investigation Team
● Determine competent Investigation Leader & Team members
Table 1. Guidelines for incident investigation team formation

Incidents Team formation by Team leader

Level 1 Section Manager Supervisors/ Engineers and above
Level 2 Department Manager Department Manager and above
Level 3 Division Manager and above Division Manager and above

Note:
1. Team size should be 3 to 5 members
2. Why Tree trained person is a must in team.
3. Team should be formed within 24 hours of incident.
4. Prelim Investigation report to be released within 7 working days from the date of the incident.
5. Final Investigation report to be released within 14 working days from the date of the incident

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 5. Gather information
● Determine and organize the facts
● Identify sources of evidence – list of witnesses, photographs
etc.
● Testing physical evidence
● Planning for the interview
● Interviewer
● Location
● Witnesses
● Sequence of witnesses
● Topics and questions
● Documentation and recording of information
● Interview conclusions
● Finalizing the facts

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6. Determine the Key Factors

● Funneling information
● Develop chronology
● Root cause analysis
● Develop a why tree
● Develop hypotheses
● Verify hypotheses

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7. Determine systems to be strengthened

● Conclusions – arriving at, drawing, developing

● Review PSM and/or SHE management systems
1. Identify chronic system weakness
2. Identify Operational Discipline weakness

● Enable Trend Analysis

● Spot symptoms of “Repeated Failures”
● Continuous Improvement

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 8. Recommend corrective and preventive
actions

● Address key factors and include the following:

o Description of action
o Person responsible for implementation
o Completion date

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 Corrective and Preventive Actions
• Eliminate hazards

• Substitution

• Engineering Controls

• Add rules, procedures, and training

to protect people from hazards.
Handout #2

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 9. Document and Receive Approval

• Line Management for the location of incident of incident

reviews completeness & quality:
o Team Adequacy
o Facts, chronology, Key factors (System, Human, Physical)
o Recommendations specifics & Timing
o System to be strengthened (PSM / SHE)
o Accurate Incident Classification

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● Document Details & Findings :
o A description of events leading to the incident
o Correct identification & description of all causal factors
o Corrective actions already taken
o Recommendations for further corrective actions;
o Investigation Team details, and
o Review and sign-off by senior management

• SHE keeps Final Document

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 10. Communicate Findings
● [Within Company] - Incident should be communicated with all
company and contract employees who were involved in the
incident.
● [Within Corporate] - Share with other sites for min Level 2 and 3
Incidents
● [Government agency investigations] - get requests in writing and
review with Legal.
● Information to be shared
o Background information
o Account of the incident – what happened?
o Analysis of the incident (how and why)?
o Recommendations

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 11. Follow up and verify
There needs to be a robust system to ensure the following :

● Periodic update of incident / recommendations closure status

to management
● Recommendations are properly executed & described
● Proper closure of action items with quality documentation &
verified to meet intent
● Audit to verify completion of action items and that they are
effective

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THANK YOU
Q&A
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