Learn about process safety management

1. Process Safety Management
(PSM) Preparedness
changes to expect and how they
affect you
Kenneth P. Bloch
processreliability@gmail.com
Sr. HES Professional in Process Safety
Houston, Texas USA

2. Personal Background
• Kenneth Bloch
– BS Lamar University 1988
– 30 years experience investigating industrial
incidents and process / mechanical failures
• Specialty & commodity chemical processes
• Downstream oil & gas / petrochemical
– Reliability & maintenance, process safety, &
operations roles in 2 major petroleum refineries
– Lessons learned & hazard mitigation speaker
(API, AFPM, AIChE/CCPS)
– Author of Rethinking Bhopal (Elsevier, June
2016) ISBN 978-0128037782

3. Topic Overview
• The push for PSM reform
– Industry performance review
– The call for action
– Change overview
• Significant developments in PSM’s growth
– The Bhopal disaster (1984)
– The PSM standard (1992)
– Event order reversal analysis (2016)
• PSM’s future success
– What does it require of you?
– Application summary
– Questions & answers

4. What you will learn
• How to prevent future disasters and
minor precursor incidents.
• Why reputable organizations are more
likely to incur a catastrophic event.
• What must be done to maintain
effective PSM performance when
regulatory requirements change.
• How to achieve satisfactory PSM
performance before new regulations go
into effect.

5. Part 1
The push for PSM reform

6. March 23, 2015
A. The 20-year anniversary of industry’s
cooperative effort to eliminate
catastrophic process incidents?
B. A devastating fire and explosion
occurred at a major USA refinery?

7. A. CCPS’ 20-year Anniversary
2016 CCPS Annual Report - AIChE

8. B. BP Texas City Refinery
(March 23, 2005)
Photo: CSB

9. BP Texas City Refinery
Summary
• Catastrophic loss of primary
containment (LOPC)
• Raffinate (naphtha-range) Tower overfill
• 15 fatalities & 180 injuries
• Mechanical integrity, facility siting, and
organizational culture defects
• Mogford Report
• CSB Report
• Baker Panel Report

10. BP Deepwater Horizon
(April 20, 2010)
Photo: CSB

11. BP Deepwater Horizon
Summary
• Catastrophic loss of primary containment
(LOPC)
• Crude oil spill over 4 million barrels into the
Gulf of Mexico
• 11 fatalities, 17 injuries, and serious
environmental damage
• Economic damage to multiple adjunct
industries
• Mechanical integrity, human error, and
organizational culture issues
• Presidential-appointed committee report
• CSB Report

12. PDVSA Amuay Refinery
(August 25, 2012)
Photo: REUTERS/Hector Silva

13. PDVSA Amuay Refinery
Summary
• Catastrophic loss of primary
containment (LOPC)
• Propane leak from process pump
• 48 fatalities, 151 injuries
• Mechanical integrity, hazard
awareness, and facility siting defects

14. West Fertilizer Company
(April 17, 2013)
Photo: Reuters

15. West Fertilizer Company
Summary
• Fire and explosion
• Detonation of 40 to 60 tons of ammonium
nitrate
• 15 fatalities & more than 260 injuries
• Property damage to more than 150 offsite
buildings
• Loss of operating license (the company
went out of business)
• Hazard awareness, emergency response
and planning, and facility siting defects
• CSB Report

16. DuPont Mercaptan Release
(November 15, 2014)
Photo: CSB

17. DuPont Mercaptan Release
Summary
• Catastrophic loss of primary
containment (LOPC)
• 24,000 pounds of toxic gas released
• 4 fatalities due to asphyxia and acute
exposure to toxic chemicals
• Process shut down permanently [1]
• Mechanical integrity, operating
procedures, and safety equipment
defects (CSB)
• Human error (DuPont Report) [1]

18. Pemex Petrochemical, Veracruz
(April 20, 2016)
Photo: Getty

19. Pemex Petrochemical, Veracruz
Summary
• Catastrophic loss of primary
containment (LOPC)
• Vinyl chloride (plastic) plant
• 32 fatalities & 160+ injuries
• More information expected in the future.

20. Performance Summary
• PSM events are a global concern
– Domestic (USA) and international incidents
– Major event frequency of 1.77 years in
manufacturing industry’s last 40 years [2]
• Major incidents have damaged the
reputation of companies once recognized
for PSM superiority (BP, DuPont [1]).
• Mechanical integrity (including
maintenance), facility siting, and cultural
defects are found in most tragic industrial
incidents.
• A bad enough incident can drive a
manufacturing enterprise out of business.

21. Executive Order (EO) 13650

22. CSB “Most Wanted”

23. Timeline

24. Significant Changes Underway
(Cal/OSHA) [3]
• Process Hazard Analysis (PHA) / Safeguard
Protection Analysis (SPA)
– SPA is a new element used to gauge the
independence and effectiveness of safeguards
against failure scenarios evaluated during a PHA.
• Management of Change (MOC)
– New requirement to apply a Hazard Control Analysis
(HCA) prior to implementing a major change.
• Process Safety Management Program (PSMP)
– An entirely new PSM element directed at stop work
authorization and criteria for rejecting
recommendations.

25. Significant Changes Underway
(Cal/OSHA) cont’d [3]
• Mechanical Integrity (MI) / Damage
Mechanism Review (DMR)
– DMR is a new element that utilizes a broad team to
identify any deficiencies associated with damage
mechanisms that could degrade equipment or
material performance.
• Inherently Safer Technology (IST), Hierarchy
of Hazard Control Analysis (HCA), and Safer
Technology and Alternatives Analysis (STAA)
– New processes for prioritizing hazard mitigation with
the preferred practice of eliminating or minimizing
the hazard before resorting to less effective, more
human-dependent measures.

26. Significant Changes Underway
(Cal/OSHA) cont’d [3]
• Process Safety Culture Assessment
(PSCA)
– A new PSM element related to assessing
cultural safety practices at a production site.
• Human Factors (HF)
– A new PSM element that requires assessing
how the complexity of tasks, employee training
and skills requirement, human-machine
interface design, physical process demands,
and the impact of shift work will affect human
performance.

27. Changes also apply to . . . [3]
• Process safety information (PSI)
• Training
• Contractors
• Pre-startup safety review (PSSR)
• Hot work
• Employee participation
• Operating procedures
• Incident investigation – root cause analysis
• Emergency planning & response
• Management of organizational change
(MOOC)

28. More Widespread Action is
Expected

29. What to Expect
• Mandatory PSM/RMP changes (USA)
based on changes in progress (Cal/OSHA)
• Indoctrination of similar practices by EU
and APAC, due to networking of best
practices by NGOs (CCPS, IChemE, API,
AFPM, etc.)
• Additional regulatory requirements without
de-emphasizing standing requirements.
• More complex Safety Management
Systems (SMS)
– Prescriptive tasks
– Reporting commitments
– Industrial accountability

30. Balancing
compliance with complexity
“. . . a complex SMS Regulatory
Environment can create implementation
challenges for not only industry, but also
for regulators providing oversight. It is an
important objective for regulators to
always minimize unnecessary complexity,
because unnecessary complexity can
erode some of the safety benefits desired
from the promulgation of Modernized
PSM/RMP regulations.” [3]

31. Regulatory Growth
Relevant questions
• How can I prevent
counterproductive
results from the
impending
regulatory
changes?
• What must I do to
reduce the potential
for a process
release where I
work?
[4]

32. Part 2
Significant developments in
PSM’s growth

33. The PSM Movement’s
Development
• Catastrophic loss of primary containment (LOPC)
• 28 tons of toxic gas emitted into the atmosphere
• > 3000 fatalities; > 200,000 injuries
• Residual mortality and environmental impact
• Mechanical integrity, hazard awareness, emergency
response and planning, and facility siting defects
• Organizational culture defects
• Destruction of a successful manufacturing
enterprise

34. Event order reversal analysis
December 1984 – Catastrophic LOPC incident, Union Carbide India Limited
February 1992 – 29 CFR 1910.119 (PSM Standard USA)
What should we
be doing?

35. Part 3
PSM’s future success

36. 1. Make no distinction between
internal and external compliance
REGULATORY, VISIBLE TO ALL
• MOC, deviation process, waivers & exceptions, deferrals
• Specifications
• Standards
• Procedures
• Policies
• Asset reliability
• Action items
• Operating limits
• Site auditing
• Disciplinary program
• Management systems
• Administrative controls
?
External Compliance
(Mandatory)
Internal Compliance
(Discretionary)

37. 2. Expand your definition of
mechanical integrity
• Establish and insist on meeting asset
performance targets
– Reliability limits (pressure, temperature, flow, level,
composition, etc.)
– Failure performance (MTBF & life expectancy)
– Investigate deviations
• Understand the concept behind “Inherently
Safer Technology.”
– “Safety is built into the process or product, not
added on. Hazards are eliminated or significantly
reduced, not controlled, and the way they are
eliminated or reduced is fundamental to the design
that it cannot be changed or defeated without
changing the process. In many cases this will result
in simpler and cheaper plants.” [5]

38. 3. Understand what “double
jeopardy” means
• Most failure scenarios are much less
rare than you think.
• All simultaneous failures must be
revealed for double jeopardy to apply.
• Common-cause failures tend to be
hidden and make double jeopardy
scenarios highly probable.

39. 4. Do not replace an incident
investigation with an MOC
• Reject workaround solutions.
• Generate recommendations that
preserve the process’ original design
basis.
• Investigate production constraints as
process safety defects.
• Avoid using consequence thresholds as
investigation triggers.

40. 5. Know what your line
organization is doing.
• How is the work getting done?
• Is tribal knowledge creating the false
impression of a reliable process?
• Does “employee participation” focus
around hazard awareness & control or
employee relations?

41. What is wrong with this picture?
How many people did it take
for this to happen?

42. 6. Clarify Teamwork
Expectations
Stop Work Authorization (card, policy, etc.)
?Internal
(Hidden)
• Line organization’s
courage and PSM
commitment
• Supervision’s visibility
& consistency
External
(Visible)
Teamwork requires going
against the team.

43. Get the Book
(ISBN 9780128037782)
• Discuss its contents with the line
organization.
• How do they respond under similar
circumstances?
• What they say might surprise you.
• Your success depends on what you know.
• Take steps now to stabilize PSM.
• On sale now for preorder at Elsevier
bookstore and Amazon.
• Expected release date June 6, 2016.
• All royalties go to the “Process Safety
Heritage Trust” science and engineering
scholarship

44. Application Summary
Action Step: 1 2 3 4 5 6
Process Hazard Analysis (PHA) / Safeguard Protection Analysis (SPA) X X
Management of Change (MOC) X X X X X
Process Safety Management Program (PSMP) X X X X
Mechanical Integrity (MI) / Damage Mechanism Review (DMR) X X X X X
Inherently Safer Technology (IST), Hierarchy of Hazard Control Analysis
(HCA), and Safer Technology and Alternatives Analysis (STAA)
X X X
Process Safety Culture Assessment (PSCA) X X X X X
Human Factors (HF) X X X X X X

45. For More Information
1. Kenneth Bloch, Rethinking Bhopal: a definitive guide to investigating,
preventing, and learning from industrial disasters, 2016.
2. Steven Maher, Aleksandar Metulev, PSM/RMP Modernization
Programs in California (New Developments and Correlation to
Evolution at the Federal Level), 2016 Spring Meeting and 12th Global
Congress on Process Safety, Houston, Texas (USA), April 10-14,
2016. http://www.rmpcorp.com/sms_regulatory_updates/
3. J. Wayne Chastain, Stanley Urbanik, Robert Johnson, John Murphy,
New CCPS Guideline Book: Guidelines for Enabling Conditions and
Conditional Modifiers in LOPA, 2013 Spring Meeting and 9th Global
Congress on Process Safety, San Antonio, TX, April 28 – May 1, 2013.
4. Dennis Hendershot, Inherently Safer Design: The Fundamentals,
Chemical Engineering Progress, 108 (1), 40, 2012.
5. Trish Kerin, Improving learning through interactive case studies, 2016
Spring Meeting and 12th Global Congress on Process Safety,
Houston, Texas (USA), April 10-14, 2016.

46. References
Mark Collette, DuPont's La Porte plant, site of worker
deaths, won't reopen, Houston Chronicle, March 31, 2016.
Chason Coelho, Addressing Human Factors in Process
Safety – Corporate and Plant Practices, 2016 Spring
Meeting and 12th Global Congress on Process Safety,
Houston, Texas (USA), April 10-14, 2016.
Steven Maher, Aleksandar Metulev, PSM/RMP
Modernization Programs in California (New Developments
and Correlation to Evolution at the Federal Level), 2016
Spring Meeting and 12th Global Congress on Process
Safety, Houston, Texas (USA), April 10-14, 2016.
Daniel Crowl, Joseph Louvar, Chemical Process Safety:
Fundamentals with Applications, Second Edition, 69,
2002.
Dennis Hendershot, Inherently Safer Design: The
Fundamentals, Chemical Engineering Progress, 108 (1),
40, 2012.
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