Incidents Continue to Happen
Washington DC, November 23, 2016 – A three-person investigative team from the U.S. Chemical Safety Board (CSB) is deploying to the scene of an incident that injured six workers – including four critically – on Tuesday, November 22 at the ExxonMobil Refinery in Baton Rouge, Louisiana.
According to initial inquiries, flammable vapors were released during unplanned maintenance around a pump. Although there was no explosion, the release ignited and caused a large fire.
– U.S. Chemical Safety Board, 2016
On February 23, 1999, 4 people were killed and 1 injured during maintenance work on a naphtha line. U.S. Chemical Safety Board concluded in their investigation report:
“…..job planning procedures did not require a formal evaluation of the hazards of replacing the naphtha piping. The pipe repair work was classified as low risk maintenance. Despite serious hazards caused by the inability to drain and isolate the line – known to supervisors and workers during the week prior to the incident – the low risk classification was not reevaluated nor did management formulate a plan to control the known hazards.”
– U.S. Chemical Safety Board, 2001
A sulfuric acid spill on February 12, 2014, burned two workers in the refinery’s alkylation unit, who were transported to the nearest hospital burn unit by life flight. The incident occurred when the operators opened a block valve to return an acid sampling system back to service. Very shortly after this block valve had been fully opened, the tubing directly downstream of the valve came apart, spraying two operators with acid.
– U.S. Chemical Safety Board, 2016
An explosion/fire occurred when opening a valve in the line between a quench vessel and the Phosphorus acid storage tank. The cause is due to the decomposition of Phosphorus acid in the line and exposure to air when the valve was opened. We were not aware of the chemistry related to phosphorus acid and the MSDS did not give enough detail as to the hazards associated with degradation.
– Health and Safety Executive (HSE), 2005
During the mechanical isolation of an Acetic Acid final product storage tank in readiness for internal inspection a release of between 0.9 and 1.5tes of Acetic Acid occurred.
– Health and Safety Executive (HSE), 2005
Release of gases from refinery slop system header occurred due to inadequate isolation of a section of line that was removed to enable a heat exchanger to be dismantled. At the time of removal, the line had become plugged with heavy oil residues and no release occurred. The plug melted when the steam tracing was reinstated later in the shutdown and the release occurred.
– Health and Safety Executive (HSE), 2005
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)?
- Do you combat organizational overconfidence that can be stimulated by past good performance?
- Do discussions on potential vulnerabilities take place between operations and senior leadership?
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 this 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 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 persons 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? For example:
- Opening a line to unplug it without a safe work permit?
- Not installing a blind flange when equipment in hazardous service such as a pump is taken out of service for maintenance?
- Not using a line opening permit when working on steam lines?
- Are all employees empowered to stop work for any situation deemed unsafe?
Evaluate Your Program
Do you audit your Line/Equipment Opening program to ensure the program is yielding the intended results?
Do you review the following items:
- Written Line/Equipment Opening procedure?
- Line/Equipment Opening permits?
- Roles and responsibilities of persons involved in Line/Equipment Opening activities?
- Training and competency provided to persons involved in Line/equipment Opening activities?
- Hazard assessments performed before Line/Equipment Opening activities are conducted?
- Job observations performed on Line/Equipment Opening activities?
- Personal protective equipment requirements for Line/Equipment Opening?
- Proper isolation techniques including double valves or blinds?
- Proper draining and cleaning of lines or equipment before opening?
- Verification procedure that the line or equipment is empty?
- Line/Equipment properly locked out?
- Is there a program in place that elevates the authorization level of the Line/Equipment Opening permit based on the assessed risk of the activity?
Have you audited your Line/Equipment Opening permits and discussed the results of the audits? Was there evidence that:
- Permits were not completely filled out (i.e. last hazardous material contained in the line not identified)?
- Permits were not signed?
- Proper PPE requirements were not identified?
- The permit writer was not trained?
- Line/equipment not properly cleaned or drained?
- Line or equipment not properly isolated?
- Lockout/Tagout (LOTO) procedure not followed?
- Permit conditions were not communicated to and within the affected work team(s)?
- Work was not coordinated between work groups (permit writing group vs. group(s) that perform the work?
- Work extended beyond the authorized period of time?
- Area was not inspected for possible ignition sources if flammables were being handled?
- Location of closest safety shower(s) not identified?
- Isolation valves not locked out properly to prevent operation?
Have you evaluated your Line/equipment Opening audit program?
- To ensure the quality of the audit process (i.e., protocols, sampling strategies, etc.)?
- To ensure the competency levels of the auditors?
- Does your Line/Equipment Opening procedure reflect the desired intent and is this intent adequately detailed in procedural instruction?
- Is the “goal” of your program to complete the permit or to use the permit as a tool to facilitate the execution of safe work?
- Does the execution of the procedure yield the intended results? Are you evaluating your program for:
- Procedural Compliance – are actions and tasks in compliance with procedural requirements? (Paper Control), and
- Program Health – is your system providing the intended results? (Actual Execution)
- Do you know of any site or company incidents related to Line or Equipment Opening?
- Have you discussed the results and causes within your organization?
- Do you know of any site or company near misses related to Line or Equipment Opening?
- Have you discussed the results and causes within your organization?
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 CSB, Process Safety Beacon and other relevant incident communication having learning potential with all members of the organization?
- Do you track specific line or equipment-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 line opening activity?
- 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 Line/Equipment Opening program depends on the actions of individuals within the organization. Do the values and behaviors of your organization determine the manner in which your Line Opening 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 Line/equipment Opening performance clearly established?
- Is open and effective communication encouraged and supported?
- Has management established safety as a core value?
- Does management and supervision provide strong leadership?
- Has management formalized the safety culture emphasis and approach?
- Does management work to ensure employees maintain a sense of vulnerability?
- Are individuals empowered to successfully fulfill their safety responsibilities?
- Does management ensure open and effective communication exists?
- Does management support and foster mutual trust?
- 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?