Se ha denunciado esta presentación.
Se está descargando tu SlideShare. ×

Barrier Thinking - rev 2 May 15.pptx

Cargando en…3

Eche un vistazo a continuación

1 de 83 Anuncio

Más Contenido Relacionado

Similares a Barrier Thinking - rev 2 May 15.pptx (20)

Más reciente (20)


Barrier Thinking - rev 2 May 15.pptx

  1. 1. Confidential Design Integrity Technica l Integrity Operating Integrity Integrity Leadershi p Process Safety and Barrier Thinking Awareness Campaign By UIO/G/SHMP
  2. 2. Confidential Table of Content February 5, 2023 2 MBT Tank Overfill - briefing by Technologist AI – PSM Barrier Thinking SCE & Performance Standard Safety Critical Position & Safety Critical Activity Common Failures Swiss Cheese Model Conclusion Quiz Group activity
  3. 3. Confidential The Relationship 05 February 2023 3
  5. 5. Confidential AIPSM Structure : 4 main aspects Our Assets are safe and we know it. Design Integrity Technical Integrity Operating Integrity Integrity Leadership Maintain the hardware barriers Design and build so that AI-PS risks are ALARP Work within the operational envelopes Design HSE Case Design & Engineering Practices Ops. HSE Case Processes and Procedures  Assessment & assurance processes  Integrity Leadership engagement  Learning From Incidents  Competency assurance programme
  6. 6. Confidential 6 Requirements Handled by Workstream HSE Case #1 Identify and document PS hazards #2 Manage risks to ALARP #3 Manage competencies in HSSE Critical Positions #6 Supervision of HSE Critical Activities (Identify) #12 Process Safety Reviews (PSRs) Maintenance and Integrity Execution (MIE) #15 Technical Integrity of HSSE Critical Equipment #16 Maintain HSSE Critical Equipment Operating Integrity (OI) #7 SoF (restart of Existing Asset) #13 Work in Classified Areas #14 Operate within Operational Limits #17 Permit to Work Well Integrity All requirements covered via Well Integrity Management Manual (WIMM) Projects and Engineering Integrity (PEI) #7 SoF – Start-up of New Assets / Modes #8 Technical Integrity in Design / Construction #9 Use of DEM 1s #10 PSBR Requirements #11 Documentation for HSSE Critical Equipment Management of Change Integrity Leadership #22 Demonstrate Leadership in PS Requirements Handled by Workstream #4 Fitness to Work by employer #5 Contract Holders role in HSSE #6 Supervision of HSE Critical Activities (Execute) #18 Single Point Accountability for PS #18 Annual Review of PS Risks to the Business #20 Annual Review of PS risks to the Asset #21 Risks Managed to ALARP OUR ASSETS ARE SAFE AND WE KNOW IT Vision / Goal Integrity Leadership Technical Integrity Design Integrity Operating Integrity Workstreams and 22 AIPSM Manual Requirement
  7. 7. Confidential 05 February 2023 7 GOAL ZERO = NO HARM + NO LEAKS. How do you deliver goal zero?
  8. 8. Confidential 8 Footer: Title may be placed here or disclaimer if required. May sit up to two lines in depth. Because we want to prevent scenes like this ... Design Integrity Technical Integrity Operating Integrity Integrity Leadership Design Integrity Technical Integrity Operating Integrity Integrity Leadership Why are we focusing on Asset Integrity Process Safety?
  9. 9. Confidential Process Safety vs Personal Safety  What are the differences between Personal Safety and Process Safety?  Which one is more critical?
  10. 10. Confidential Personal vs. Process Safety 05 February 2023 10  Personal and Process Safety describe two different types of risk that can lead to injury and/or fatality. PERSONAL SAFETY INCIDENTS PROCESS SAFETY INCIDENTS Typically workplace accidents (slips/trips/falls) Typically major release of flammable or toxic material from process facilities. Typically unsafe work behaviors or unsafe working environment Typically failure in engineering or human controls/recovery Typically low impact (personnel, asset) Typically high impact (people, asset) High probability Low probability Can be Deadly Can be Deadly
  11. 11. Confidential Process Safety versus Personal Safety 05 February 2023 11
  12. 12. Confidential Design Integrity Technica l Integrity Operating Integrity Integrity Leadershi p Barrier Thinking Training 12
  13. 13. Confidential Video of EA Asset HSE Case Operationalisation 05 February 2023 13 VIDEO
  14. 14. Confidential Objectives  Understanding Risk.  Learn about the steps of Risk Assessment  Barrier thinking.  Learn what barriers are, how to support and maintain them, as well as what will weaken or remove them.  Threat Line and Bow Tie Analysis.  Learn how critical equipment barriers, critical human barriers, and critical activities link together to provide an effective barrier against threats.  Swiss Cheese Model of Risk Analysis.  Learn how multiple barriers are used to separate people form harm.
  15. 15. Confidential Hazard Effects Management Process 05 February 2023 15
  16. 16. Confidential Risk Assessment Matrix 05 February 2023 16
  17. 17. Confidential Control Hierarchy 05 February 2023 17
  18. 18. Confidential Asset Integrity – Process Safety AI-PS is about preventing process safety incidents resulting from the unintentional release of energy or hazardous substances. Keeping It In The Pipe (Control) Dealing With Releases (Recovery)
  19. 19. Confidential Bow Tie  A pictorial presentation of how a hazard can be hypothetically released and further developed into a number of consequences. 05 February 2023 19
  20. 20. Confidential The Concept  For risk to exist, four elements must be present:  Hazard  Threats  Top Event  Consequence  Threat release scenario are called ‘Initiating events’. 05 February 2023 20
  21. 21. Confidential Threats  Threats : a possible cause that will potentially release a hazard and produce an incident.  Identifying threats is an essential step in the prevention and mitigation of incidents. Eg : Consider a. the loss of a hydrocarbon (hazard) containment due to the corrosion of a pipe, b. the brittle fracture of a pipe c. a tank overfill. These are three different threats.  The barriers to be implemented to prevent the release of the hazard will be significantly different for these three threats.  A high level alarm may be essential to prevent tank overfills, but will not in any case help address corrosion.  Barriers are thus, often only valid for the threat being considered. 05 February 2023 21
  22. 22. Confidential 05 February 2023 22
  23. 23. Confidential What are Barriers ?  Measures to prevent threats from releasing a hazard or measures to limit the consequences arising from the top event.  Barriers need to be put in place to control risks, through the HEMP process. Within our business processes and activities, there are tasks which maintain these barriers.
  24. 24. Confidential Barrier Expectations 05 February 2023 24 To work, a barrier in itself must be able to:  Stop the threat from releasing the top event  Mitigate or reduce the consequences after the top event  Effective, Independent, Auditable
  25. 25. Confidential Barriers Failures 05 February 2023 25 Intentional removal for maintenance (MoC, PTW, replace by using operator)
  26. 26. Confidential Barrier Types  Equipment barriers (hardware) – eg, a pressure relief valve  Human barriers (human interventions) – eg, following a procedure  Combination of both – eg, a high level alarm & the operator responding
  27. 27. Confidential Equipment Barriers  Equipment Barriers – equipment/hardware/software/assets that are intended to prevent or reduce the harm from a hazard  Examples : High level alarm + Operator Action for a tank, a bund wall, a relief valve, an electrical grounding wire) 14
  28. 28. Confidential Equipment Barriers in our business…  High pressure trip system  Tank high level alarm systems + Operator Action  Automatic valve shutdown systems  Pressure relief valves  Fire & Gas Detection System  Fire deluge system  Corrosion injection system  Open hazardous drains  Control valves to control flow or pressure  Fences  Signs 26
  29. 29. Confidential Human Barriers  Human Barriers – a person performing an action that prevents or reduces the harm from a hazard.  Example: A person checking to make sure there is enough room in a tank prior to receipt. Note : a people barrier is not a barrier unless the person is performing some action! A manual is not a barrier because it does nothing by itself!) 16
  30. 30. Confidential Human Barriers in Our Business • Operator de-pressurising an equipment using a procedure • Operator following a tank inventory procedure before filing tank • Responding to a tank high level alarm • Completing a Permit to Work • Taking corrective action in abnormal situation • Closing manifold valves after a tank receipt • Communicating with third party prior to pipeline or vessel receipt to tankage • Shift change documentation and communication • An operator following an emergency response containment procedure • Site guard checking credentials before allowing entrance to site if there is no action being performed there is no barrier (a manual itself is not a barrier)! 28
  31. 31. Confidential Control Barrier (1) 05 February 2023 31 Barriers that prevent threats from releasing the hazard are called Control Barriers.
  32. 32. Confidential Control Barrier (2)  Controls Barriers Examples :  Design: Guards, shields, threat elimination, or automatic process shutdown  Operations: The people and equipment that allow you to operate within the operation envelope, or operations intervention activities.  Management System Processes /Control (Eg, MOC or Technical Integrity Management)  Management System Processes are not barriers  Critical Business Processes in HSE MS  Are supporting Activities /Processes to a design/operations barrier on the bowtie. Following these processes can be a barrier. 05 February 2023 32
  33. 33. Confidential Recovery Barrier (1) 05 February 2023 33  Barriers that limit or mitigate the consequences arising from the top event are called Recovery Barriers.  They sit between the top event and the possible consequences.
  34. 34. Confidential Recovery Barrier (2)  Recovery Barrier Examples :  Design: Spill containment, dikes, automatic water spray, or ignition control  Operations: Operations intervention, rescue team response.  Management System Processes / Control (Eg, Emergency Response Mgt)  Management System Processes are not barriers  Critical Business Processes in HSE MS  Are supporting Activities /Processes to a design/operations barrier on the bowtie. Following these processes can be a barrier. 05 February 2023 34
  35. 35. Confidential 10 MINUTES Break 05 February 2023 35
  36. 36. Confidential Barrier Effectiveness (1)  Effective – The barrier prevents the consequence when it functions as designed (ie, big enough, fast enough, strong enough).  An effective barrier shall have the following three elements: I. A detector- detects the condition that requires action II. A logic solver- decides action is to be taken III. An actuator – action taken to address the condition 5 February, 2023 36
  37. 37. Confidential Barrier Effectiveness (2) 5 February, 2023 37
  38. 38. Confidential Barrier Independency  Independent  Independent of the initiating event (threat) and the components if any other barrier already validated for the same condition.  The barrier can not be considered independent from one another if there is a common cause failure.  Example of dependence: Threat: Instrument air failure, all barriers that need instrument air are dependent and thus not valid. 5 February, 2023 38
  39. 39. Confidential Barrier Auditability  Auditable - The barrier can be evaluated to assure that it can operate correctly when it is called upon.  A critical activity shall be available to maintain the barrier. This links to accountability, responsibility & competence assurance .  The barrier shall reduce the risks by a factor at least 10, the Probability of Failure on Demand (PFD) is maintained at no greater than10 %. This link to requirements for maintenance & inspection in maintenance system (like SAP). 5 February, 2023 39
  40. 40. Confidential Maintaining Effective Barriers Hazard/ Risk Undesirable Outcome Barriers must be healthy and effective to avoid incidents (“Swiss cheese”) Process Safety Risks are managed with Barriers Hardware Barrier (8 SCE systems) Human Barrier Safety critical Roles & positions Safety critical tasks
  41. 41. Confidential SCE Hardware barriers categories 19-Nov-14 The Safety Critical Equipment (SCE) hardware barriers are divided in 8 (eight categories). 41
  42. 42. Confidential Equipment Barriers : SCE 15
  43. 43. Confidential Safety Critical Element SCE (1)  SCE : An item of equipment or structure whose failure could lead to the release of a Major Hazard or whose purpose is to prevent or limit the consequences of a major incident, excluding business loss.  Performance standard (PS) : A statement, which can be expressed in qualitative or quantitative terms, of the functional performance required of a system or item of equipment, and which is used as the basis for managing the risk from the Major Hazards. 05 February 2023 43
  44. 44. Confidential Safety Critical Element SCE (2) SCE Features  Reliable / Robust : SIL, Redundancy  Availability : Spares stock, stringent assurance requirements (PMs, CMs) more frequent maintenance  Standardization : Inter changeability SCE Management tools  CMMS - for managing the tasks and results recording.  Total Reliability (TR) Measures dashboard - for performance indicator reporting and trending.  Facilities Status Reporting (FSR) tool - for status reporting and deviation management. 05 February 2023 44
  45. 45. Confidential Performance Standard 05 February 2023 45  Describes the minimum performance criteria for a Safety Critical Element  is used as the basis for verification throughout the lifecycle of the facility  is a statement, which can be expressed in qualitative or quantitative terms, of the performance required of a system, item of equipment, person or procedure  used as the basis for managing the Hazard according to the HSSE Case (e.g. planning, measuring, control or audit through the lifecycle of the installation).  Each SCE has a Performance Standard  The Technical Authorities shall own Performance Standards
  46. 46. Confidential Safety Critical Positions An HSSE Critical Position is :  a position that can impact significantly on the execution of HSSE Critical Activities at the operational level or management level,  or at both levels, because the position has responsibility for performing Level 1 or Level 2 HSSE Critical Tasks or a combination of Level 1 and Level 2 HSSE Critical Tasks, as documented in the Business Unit HSE-MS or HSE Cases. 05 February 2023 46
  47. 47. Confidential Safety Critical Activities 05 February 2023 47  HSSE critical activity :activity that can impact significantly on the control of the hazards & risks. Necessary to provide or maintain barriers and recovery measures to assure that HSSE risk objectives are continuously met.  An HSSE critical task : action required for the execution of an HSSE critical activity. Critical activities maintain barriers to keep them from deteriorating.
  48. 48. Confidential HSSE critical tasks are divided into two types :  Level 1 : Tasks are ones where a mistake can directly cause an accident. Operational tasks required for the execution of HSSE Critical Activities, where actions (or inactions) taken while performing such tasks could lead directly to a significant incident. associated with the Control or Recovery elements of HEMP.  Level 2 : Tasks where a mistake can make an accident more likely. Tasks required for the execution of HSSE Critical Activities, where action (or inaction) while performing such tasks could lead indirectly to a significant incident. 05 February 2023 48
  49. 49. Confidential Examples  Level 1 : HSSE Critical Tasks performed by plant operators, technicians, vehicle drivers, aircraft pilots, ship’s captains, emergency response, and recovery from emergency.  Level 2 : Normally supervisory-related, such as identifying /assessing staffing requirements to implement processes, and the Control and Recovery elements of HEMP. Refer to the appropriate HSE-MS and HSE Cases to identify these tasks.  Competence requirements for these tasks have to be defined in the Job Competence Profiles. These will be loaded into the Shell People competence system. 05 February 2023 49
  50. 50. Confidential Re-cap: Bow Tie BACK UP 05 February 2023 50
  51. 51. Confidential Bow-tie link to Critical Activities, Process & Equipment  Each barrier has to be assigned to a critical activity to ensure it will work when the situation needs it. P:5B A:5C Unrefined Hydrocarbon Material selection of piping LOPC Internal corrosion (piping) Fire Chemica l injection system Emergency Response Design & operation in compliance with DEP Critical Process (RBI) Critical Eq – Piping Critical activity – carry out the maintenance Chemical Injection program Critical Process (Operation) Critical Eq – injection skid Critical activity – monitoring injection rate, chemical consumption Emergency Response Critical Process (ER) Critical Eq – F&G detectors, fire fighting equipment Critical activity – PIP review, training for response team
  52. 52. Confidential Some Common Failures Where we usually go wrong?  Poor line of sight,  Assignment to incompetent / inappropriate workforce  Susceptibility : Maintenance overrides/bypass, malfunction, overdue PMs/CMs, obsolescence, Spare and availability, destruction in incidences, use under excessive/beyond design/operating envelopes  delegation without considerations (sit ins, turnovers, resignations, manpower, vacations substitutes, etc) 05 February 2023 52
  53. 53. Confidential Swiss Cheese Model If the holes in the barrier walls (holes in the slices of Swiss cheese) line up, and the hazard “escapes”, an incident may occur. This is why we have multiple barriers and why we maintain the barriers. Swiss Cheese has holes; barriers can have “holes” or deficiencies 19
  54. 54. Confidential Swiss Cheese Model “Barrier thinking” includes addressing small holes at each level. This keeps a series of small holes from lining up and leading to an incident. 20 The “Swiss Cheese Model” is a visual way to think about making sure barrier holes are prevented
  55. 55. Confidential Conclusion  Barrier thinking is a way of thinking that helps us:  Identify hazards  Put appropriate controls in place to prevent and contain incidents  Ask what hazards we face and what controls can be initiated.  Encourage mind-sets that will:  Make sure effective barriers are in place.  Ask the right questions to put safety first.  Check effective barriers are in place.  Don’t assume it will be OK (based on previous experience) 05 February 2023 55
  56. 56. Confidential Recap  What are barriers ?  Types of barriers  When are SCEs compromised :  How do we assure the SCEs are healthy :  Common Failures : Where we usually go wrong?  Ask yourself : What role do you play ? 05 February 2023 56 Critical Equipment Barrier, Critical Human Barrier, or combination of both Measures to prevent threats from releasing a hazard or measures to limit the consequences arising from the top event Maintenance overrides/bypass, malfunction, overdue PMs/CMs, obsolescence, SPIRs unavailability, destruction in incidences, use under excessive/beyond design/operating envelopes PM/CM : Assigning the task to a competent person – SCE positions (Level 1 / 2 ) Line of sight, delegation without considerations (sit ins, turnovers, resignations, manpower, vacations substitutes, etc)
  57. 57. Confidential Questions?
  58. 58. Confidential Quiz QUIZ 05 February 2023 58
  59. 59. Confidential Question 1  What is Process Safety? (Choose the correct answer.) a. Process Safety involves things that happen only outside the boundary of the plant. b. Process Safety includes things that happen at home c. Process Safety is about protecting you, your co- worker, the plant and the community d. Process Safety is mostly about protecting the individual 
  60. 60. Confidential Question 2  What is Personal Safety? (Choose the correct answer) a. Personal Safety involves things that happen only outside the boundary of the plant b. Personal Safety includes things that happen at home c. Personal Safety is about protecting you, your co- worker, the plant and the community d. Personal Safety is mostly about protecting the individual 
  61. 61. Confidential Question 3  Which of these activities is predominantly related to Process Safety? Select all correct answer. a. Putting on a safety harness b. Conducting operator rounds c. Responding to alarms d. Selecting appropriate PPE e. Selecting proper gasket f. Following Emergency procedures g. Function test of a shutdown device h. Proper foot placement i. Wearing a seatbelt     
  62. 62. Confidential Question 4  What is the purpose of Understanding Risk? a. To protect the individual against slips, trips, and falls b. To distinguish between critical equipment and human barriers c. To provide a structured approach to managing hazards in the workplace d. To establish healthy and safety procedures 
  63. 63. Confidential Question 5  What is the proper order of the components for Understanding Risk? a. Assess, Recover, Control, Identify b. Control, Recover, Assess, Identify c. Identify, Assess, Control, Recover d. Recover, Assess, Identify, Control 
  64. 64. Confidential Question 6  Which of the following accurately describes a barrier? a. Process safety barriers prevent hazards from being released or minimize the effect b. Barriers never have weaknesses c. Process safety barriers make my job more dangerous d. A barrier often causes fire or explosion 
  65. 65. Confidential Question 7  There are two main types of barriers : Critical _____ Barriers and Critical Human Barriers a. Process b. Equipment c. Hazard 
  66. 66. Confidential Question 8  The Swiss Cheese model demonstrates how holes or weaknesses in barriers line up to allow undesirable events to occur a. True b. False 
  67. 67. Confidential Question 9  Compliance creates holes in our barriers a. True b. False 
  68. 68. Confidential Question 10  Preventing Abnormal Situations includes : (Please select all appropriate answers) a. Reporting or fixing small things before they become bigger b. Listening to your intuitions, sights, sounds and smells c. Proactively communicating d. Constant vigilance    
  69. 69. Confidential Question 11  The Bow Tie model is a tool used to analyse how we manage hazards and potential consequences. a. True b. False 
  70. 70. Confidential Question 12  When multiple threat lines for a hazard are shown, they appear in the shape of a ____ a. Brick wall b. Swiss Cheese c. Bow Tie d. Triangle 
  71. 71. Confidential EXERCISES 05 February 2023 71
  72. 72. Confidential Barrier Exercise: “LINE OF FIRE” : Mobile Heavy Equipment What happened? Worker run over by truck and injured, leads to fatality. The Injured Party (IP) was walking on a road in sand quarry adjacent to the accommodation site.  The IP stopped in the middle of the road behind a truck with his back to it.  At the same time the truck started to reverse in preparation for sand loading and knocked over and crushed the IP under its wheels.  The medics were on site immediately to apply first aid but were unable to save the IP’s life. 05 February 2023 72
  73. 73. Confidential Why did it happen ? (1) Underlying causes :  Unclear accountability for managing (sand storage) site access and sand loading activities.  Failures in applying safe worksite practices like segregation of pedestrians and heavy goods vehicles on project sites.  Allowing lower standards for visitors into the field area, for the purpose of goods 05 February 2023 73
  74. 74. Confidential Why did it happen ? (2) Immediate causes  IP neither saw nor heard the project truck reversing.  The truck had a faulty reversing alarm; the driver had not completed defensive driver training (which includes the requirement to check behind/under the vehicle before reversing).  On the day of the incident there were significantly more heavy transport activities in the quarry than normally and therefore higher noise levels.  Pedestrians and vehicles used the same road at the same time (no segregation). 05 February 2023 74
  75. 75. Confidential Barrier Exercise: “LINE OF FIRE” “LINE OF FIRE” situation : Mobile Heavy Equipment Review the incident below  Which hardware barriers are missing?  Which human barriers are missing?  Which process barriers are missing? Class divide into 3 groups, each take one question. 5 mins for discussion 05 February 2023 75
  76. 76. Confidential HARDWARE Barrier failures Barrier : Site Planning & Design Layout  No formal risk assessment was performed, which would have revealed that the sand storage area was occasionally used heavily, as on the day of the incident. Barrier: Equipment  The truck was fitted with an automatic reversing alarm but this was not working.  Having delivered goods to site, the truck was requested to do an extra job. The normal and compliant sand truck was broken, hence the request. Barrier: Equipment Monitoring Systems  A system such as Collision Avoidance Devices, was not present. Barrier: Physical Barriers  Physical Barriers such as Exclusion Zones, Boundary Markers, Hard and/or Soft Barriers or Berms were not present at the time of the incident. 05 February 2023 76
  77. 77. Confidential HUMAN Barrier failures Barrier : Hazard awareness  Not all involved were aware of the hazards behind the vehicle and no checks were done before reversing. Barrier: Following Procedures/Rules  The driver was also delivering goods to a contractor working at another site. On that site he had been instructed to use the horn when reversing. Local requirements were not known. Barrier: Supervision  The nominated construction contractor supervisor was not seen on the site, even on a day of heavy use.  While each site in the large area has an owner there is no overall owner who takes accountability for coordinating and planning across the various sites. 05 February 2023 77
  78. 78. Confidential CRITICAL PROCESS Barrier failure Barrier: Training & Competency  The driver had not passed the required defensive driving training, he was on waiting list for training in September. Barrier: Contractor Management  There was no contract holder review/audit or enforcement of supervision on site. Barrier: Company Standards – & Operating Procedures  The truck was allowed on to the site after inspection, on a temporary visitor pass.  Failure to ensure that heavy machinery operating at construction worksites met company standards. While there was a traffic flow plan for the sand storage site and this was in the working instructions, there were no signs at the site showing the planned traffic flow or any other warnings, e.g.: no signs barring pedestrian access or parking. 05 February 2023 78
  79. 79. Confidential
  80. 80. Confidential Team Activity: Identifying Barriers Can you identify at least six specific barriers in the diagram? 23
  81. 81. Confidential Team Activity: Identifying Barriers Some of the barriers include:  pressure reliefs  pressure indicators  level transmitters  low level trip  site glasses  piping and valves  temperature and pressure gauges  inspection points  fire detection system  coupling guard  vibration measuring points  breaker  start/stop switch  asset integrity  various maintenance/inspection tasks As you can see, there are a lot of barriers out there protecting us! 24
  82. 82. Shell Refining Company (FOM) Confidential Q & A Feedback/comments? February 5, 2023 82
  83. 83. Confidential THANK YOU END 05 February 2023 83