Incidents Continue to Happen
“High risk operations, like the delivery and handling of hazardous chemicals, require strict adherence to safety protocols. An inadvertent mixture can result in a chemical reaction with extremely dangerous consequences. Our findings reaffirm the need for facilities to pay careful attention to the design and operation of chemical transfer equipment to prevent similar events.”
– CSB Chairperson Vanessa Allen Sutherland
Maintain a Sense of Vulnerability
A Sense of Vulnerability Is Healthy – Just because it has not happened yet (or here) does not mean it will not happen in the future!
- Is a sense of vulnerability a critical part of the mindset of every employee and contractor?
- Do you require consistency in practice from everyone in the organization?
- Do you have systems in place to determine if inconsistencies exist?
- Do people believe that “yes, it can happen here”?
- Do people believe that “yes, we have similar vulnerabilities”?
- Have you experienced similar incidents but without consequences (i.e., near misses)?
Prevent Normalization of Deviation
Normalization of deviation is defined as…..
The gradual process through which unacceptable practice or standards become acceptable. As the deviant behavior is repeated without catastrophic results, it becomes the social norm for the organization.
– Sociologist Dr. Diane Vaughan (The Challenger Launch Decision, 1996)
A gradual erosion of standards of performance as a result of increased tolerance of nonconformance.
– CCPS Glossary (iPhone Application)
Signs of Normalization of Deviations – Does any of these describe your organization?
- If a deviation is absolutely necessary, are there defined steps that must be taken (i.e., a written variance procedure)?
- Do these defined steps (or variance procedure) require a detailed risk assessment and approval from multiple levels within the organization?
- Are your the expectations clear that no one individual alone is permitted to determine whether a deviation is permissible?
- Do you allow operations outside established safe operating limits without a detailed risk assessment?
- Are willful, conscious, violations of established procedures tolerated without investigation or without consequences for the person(s) involved?
- Can employees be counted on to strictly adhere to safety policies and practices when supervision is not around to monitor compliance?
- Are you tolerating practices, or conditions that would have been deemed unacceptable a year or two ago?
- Are all employees empowered to stop work for any situation deemed unsafe?
Evaluate Your Program
Do you audit your equipment filling and mixing practices and procedures to ensure they are yielding the intended results?
Do you review the following items?
- Hazardous reactions which can occur if materials in your plant are accidentally mixed?
- Unloading pipe connections are clearly labeled, including the use of a code or numbering system to avoid confusion of materials with similar names?
- Roles and responsibilities of persons involved in hazard identification activities?
- Training and competency provided to persons involved in chemicals handling activities?
- Hazard assessments performed before de-commissioning activities are conducted?
- Location of chemicals stored?
- Availability of appropriate emergency response equipment?
Continually Improve Your Program
Are you considering improvements to prevent future incidents? Here are some ideas you may want to consider:
- How frequently do you review Chemical Safety Board (CSB) reports, CCPS Process Safety Beacons, and other relevant incident communication having learning potential with all members of the organization?
- Do you track specific process safety incidents due to mixing of incompatible fluids-related metrics that can be used to determine program effectiveness and improve performance?
- Have you benchmarked your program against other programs in your industry?
- How often do your senior managers visit the field to watch filling and mixing operations in action?
- Do you have a requirement to periodically update your program?
- Do your workers (those closest to the work), have an easy method to suggest improvements to your program?
Organizational Culture
A successful equipment filling and mixing program depends on the actions of individuals within the organization. Do the values and behaviors of your organization determine the manner in which your equipment filling and mixing program is managed and executed?
- Does management and supervision reinforce desired behaviors to ensure they become integrated into the group’s values?
- Are high standards of equipment filling and mixing performance clearly established?
- Does management establish and enforce high standards of performance?
- Does management defer to expertise?
- Has management established a questioning/learning environment?
- Does management require timely responses provided to safety issues and concerns?
- Does management provide continuous monitoring of performance?