Book: Process Risk and Reliability Management

Book: Process Risk and Reliability Management
2nd Edition



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Book: Process Risk and Reliability Management

This book provides comprehensive and practical guidance for the development and implementation of process safety management (PSM), operational integrity and operational excellence programs. It covers design and operations, and shows how to improve not only safety but also reliability, environmental performance, quality and profitability. Techniques and principles are illustrated with numerous examples, chemical plants, refineries, transportation, pipelines, and offshore oil and gas.

The information provided will help executives, managers and technical professionals achieve not only their current PSM goals but also to make the transition to a broader operational integrity strategy. The book focuses on the energy and process industries - from refineries to pipelines, chemical plants, transportation, energy and offshore facilities. The techniques described in the book can also be applied to a wide range of non-process industries.

The book is both thorough and practical. It discusses theoretical principles in a wide variety of areas such as management of change, risk analysis, and incident investigation, and then goes on to show how these principles work in practice, either in the design office or in an operating facility.

The second edition has been expanded, revised and updated and many new sections have been added including: the impact of resource limitations, a review of some recent major incidents, the value of story-telling as a means of conveying process safety values and principles, and the impact of the proposed changes to the OSHA PSM standard. 

Ordering Information

This book can be ordered directly from the publisher, Elsevier, or from Amazon and Barnes & Noble. It is also available in ebook form at ScienceDirect.

Book: Process Risk and Reliability Management

Reviews

Book: Process Risk and Reliability Management . . . Sutton says, "the best way of ensuring that a facility is safe and productive is to design it correctly in the first place, but, regardless of the quality of the design, it has to be operated by real people. This book," he goes on, "seeks to help both designers and operators."

And so it does. There's a wealth of very practical advice in this book, and if you implement the strategies Sutton suggests, you will have a safe, productive, and sustainable plant.


Walter Boyes, Editor in Chief Control Global

This unique book is to safety what Perry's is to Chemical Engineering. Fully of practical facts and advice and invaluable to the novice or seasoned professional; and a comprehensive reference. Since acquiring my copy I have used it frequently and it has provided the answers I needed. I highly recommend it.

Clive Wilby

In my opinion, the author has produced an excellent book, replete with much useful and practical information, figures, and tables. Many of the references are also very recent (some as late as 2009 and 2010). It is a practical guide and roadmap to making the shift from Process Safety Management programs to Operational Integrity regimes that focus on increasing performance not just in safety, but also in environmental compliance, quality control, and overall profitability.

Stanley Grossel

Ian provides comprehensive guidance on the development, implementation and evaluation of process risk and process safety programs.

Charles Gillard

Ebooks and Videos

The following ebook/video combinations provide material that complements the content of this book.

Contents

The book has 20 chapters. The Tables of Contents for each chapter are listed below; follow the bookmark link to learn more.

  1.  Risk Management
  2.  Compliance and Standards
  3.  Culture and Participation
  4. Technical Information
  5.  Hazard Identification
  6. Operating Procedures
  7. Training and Competence
  8. Prestartup Reviews
  9. Asset Integrity
  10. Management of Change
  11. Incident Investigation and Root Cause Analysis
  12. Emergency Management
  13.  Audits and Assessments
  14. Consequence Analysis
  15. Frequency Analysis
  16. Reliability, Availailability and Maintainability
  17. Managing a Risk and Reliability Program
  18. Project Management
  19. Contractors
  20. The Risk Management Professional
    Citations
Chapter 1 - Risk Management
top of page
Introduction
Technical, Process and Occupational Safety
Historical Development
   1. Safety as a Value
   2. Codes and Standards
   3. Workers' Compensation
   4. Occupational Safety
   5. Systems Analysis
   6. Regulations
   7. Management Systems
   8. Behavior-Based Safety
   9. Safety Culture
Major Events
Health, Safety & Environmental Programs
   Environmental / Sustainability
   Health
   Safety
Prescriptive / Non-Prescriptive
   Safety Management Programs
   Regulations
   The Regulator's Dilemma
Process Safety Management
   Definition of Process Safety Management
   Safe Limits
   Set Point Values
   Operating, Safe and Emergency Limits
   Measurement Strategies
   Involvement
   Thoroughness
   Holistic
Environment
Quality Management
   Statistical Process Control
   ISO 9000 / 14001
   Six Sigma
Risk
Components of Risk
   Hazards
   Consequence
   Predicted Frequency
   Safeguards
   Presence of Persons
   Single Contingency Events
   Economies of Scale
Common Cause Events
   Fukushima-Daiichi
   Examples
      Utility Failure
      Instruments on Manual
      Instrument Pluggage
      Vibration
      External Events
      Maintenance Availability
      Human Error / Untrained Personnel
Subjective Nature of Risk
   Degree of Control
   Familiarity with the Hazard
   Direct Benefit
   Personal Impact
   Natural vs. Man-Made Risks
   Recency of Events
   Perception of the Consequence Term
   Comprehension Time
   Randomness
   Regression to the Mean
   Bias toward Positive Evidence / Prior Beliefs
   Availability
Quantification of Risk
   Mathematical Terms
      Frequency
      Predicted Frequency
      Probability
      Likelihood and Failure Rate
      Error / Statistical Significance Confidence
      Failure / Fault
      Independence and Randomness
   FN Curves
   Limitations
Acceptable Risk
   The Third Law
   Perfection as a Slogan
   As Low as Reasonably Practical - ALARP
   De Minimis Risk
   Citations / 'Case Law'
   RAGAGEP
   Indexing Methods
Risk Matrices
   Consequence Matrix
      Worker Safety
      Public Safety and Health
      Environmental Impact
      Economic Loss
   Frequency Matrix
   Risk Matrix
      A - (Red) Very High
      B - (Orange) High
      C - (Yellow) Moderate
      D - (Green) Low
      Other Categories
   Limitations of Risk Matrices
      Low-Hanging Fruit
      Prepare for the Worst Case
      Expensive Good Ideas
Black Swan Events
Different Industries
   Oil Refineries
   Offshore Oil and Gas
      Lack of Escape Routes
      Persons on Board (POB)
      Cyclones / Hurricanes
      Downers and Leaners
      Blowouts
      Hydrogen Sulfide
      Dropped Objects
      Helicopters
      Ship Collision / Mooring Failure
      Spill Response
   Pipelines
Examples
   Example 1 - Facility Design
   Example 2 - Process Flow
   Example 3 - Heat Exchanger
   Example 4 - Risk Management Workflow
      External Standard
      Guidance
      Risk Analysis Plan and Implement
      Audit / Deltas
Success / Continuous Improvement
   Example 5 - Significant Potential Incident

Chapter 2 - Compliance and Standards
top of page
Introduction
Regulations
   Rule-Based Approach
   Goal-Driven Approach
   Process Safety Regulations
Codes and Standards
   Development of a Standard
   Standards Organizations
      American Chemistry Council / Responsible Care®
      American National Standards Institute (ANSI)
      American Petroleum Institute (API)
      American Society of Mechanical Engineers (ASME)
      International Organization for Standardization (ISO)
      National Fire Protection Association (NFPA)
   Other Industry Sources
      Center for Chemical Process Safety
      Center for Offshore Safety
      Chemical Safety and Hazard Investigation Board
Company Standards
Industry Information
   Regulatory Guidance
   Open Literature
Commercial Information
Analysis
United States Federal Regulations
   The Regulatory Process
   Code of Federal Regulations
   General Duty Clauses
   The Tenth Amendment to the United States Constitution
   The Environmental Protection Agency (EPA)
The Occupational Safety & Health Administration (OSHA)
   OSHA Inspections
      Variances
      Enforcement
   The Entry Process
Fatality / Catastrophe
      Programmed Inspections
      Complaints
   Citations
      Willful
      Serious
      Other-than-Serious
      Repeat and Failure-to-Abate
   OSHA Standards
      Part 29
      Subparts of Part 29
      Sections of Subparts
   Interpretations and Guidance
The OSHA PSM Standard
   Covered Processes
   Other Standards
   Audit Guidelines
   National Emphasis Programs
   Proposed Update
      1. Atmospheric Storage Tanks
      2. Oil- and Gas-Well Drilling and Servicing
      3. Oil- and Gas-Production Facilities
      4. Reactivity Hazards
      5. Highly Hazardous Chemicals
      6. Management System Elements
      7. RAGAGEP
      8. Definition of RAGAGEP
      9. Safety-Critical Equipment
      10. Organizational Changes
      11. Emergency Planning
      12. Third-Party Compliance Audits
      13. Explosives, Blasting Agents and Pyrotechnics
      14. Flammable Liquids and Spray Finishing
      15. Ammonium Nitrate
      16. Retail Facilities
      17. Concentrations of Highly Hazardous Chemicals
The Environmental Protection Agency (EPA)
The EPA Risk Management Program - 40 CFR 68
   Tiering / Program Levels
   Covered Chemicals
   Formal Management System
   Worst Case Release
   Emergency Plan
   Five-Year Accident History
BSEE
State Regulations
   New Jersey Toxic Catastrophe Prevention Act
   Delaware/Nevada
The Safety Case Regime
   Elements of a Safety Case
      Duty-Holder Responsibility
      Responsibility of the Auditor / Assessor
      Risk Management System
      Management Systems
      Living Document
   Structure of a Safety Case
      1. Facility Description
      2. Safety Management System
      3. Formal Safety Assessment
   Preparation and Implementation
   Assessment
   Performance Measurement
International Agencies
Elements of PSM
   1. Employee Participation
      Written Plan of Action
      Consultation
      Access to Information
   2. Process Safety Information
   3. Process Hazards Analysis
      Initial Hazard Analysis
      Methodology
      Issues to Address
      Team
      Revalidation
   4. Operating Procedures
      Written Down
      Initial Start-Up
      Temporary and Emergency Operations
      Certification
   5. Training
   6. Contractors
      Application
      Employer Responsibilities
   7. Prestartup Safety Review (PSSR)
      Process Safety Information
      Construction and Equipment
      Procedures
      New / Modified Facilities
   8. Mechanical Integrity
      Application
      Written Procedures
      Training
      Inspection and Testing
      Deficiencies
      Quality Assurance
   9. Hot Work
   10. Management of Change
      Employer Responsibility
      Written Down
      Replacement In-Kind
      Factors that Affect Change
      Training and Participation / Accountability
      Information Base
      Operating Procedures
      Making the Change
      Training / PSI / Operating Procedures
   11. Incident Investigation
      Investigation
      Timing
      Team
      Report
      Follow Up
      Participation
   12. Emergency Planning and Response
   13. Compliance Audits
      Certification
      Technical Qualifications
      Report
      Response
      Retention of Reports

Chapter 3 - Culture and Employee Involvement
top of page
Introduction
Regulations and Standards
   BSEE Standard for Culture
   inherent-safety and Culture
   National Energy Board
   Survey
Warning Flags over Your Organization
   Flag One - Unrealistic Stretch Goals
      Production Creep
      Production Records
      Initiative Overload
   Flag Two - Excessive Cost Reduction
      Reduction of "Non-Essentials"
      Reductions in Work Force
      The "Big Crew Change"
      Flattened Organizations
      Aging Infrastructure
      Out-Sourcing
      Not Enough Time for Detailed Work
      Project Cutbacks
      Organizational Spread
   Flag Three - Belief That "It Cannot Happen Here"
      Lack of Direct Experience
      Good Occupational Safety Performance
      Lack of Imaginative Thinking
      Failure to Learn from Near-Misses
      Failure to Draw on Experience Elsewhere
   Flag Four - Excessive Belief in Rule Compliance
   Flag Five - Ineffective Information Flow
      Critical Safety Information Is Buried, Lost or Diluted
      Team Player Culture
      Fear of Litigation
      Mergers, Acquisitions and Divestitures
   Flag Six - Ineffective Audit Process
      Softened News to Senior Managers
      Failure to Identify Root Causes
      Inadequate Follow Up
Thinking Backwards
Imagination
Culture Matrices
   Elements of Culture
      On-Going and Consistent
      Actions and Words
      External Evaluation
      Learning from Incidents
      Attention to Basics / Housekeeping
   Mergers and Acquisitions
   Generational Differences
Measurement
Key Performance Indicators
Lagging and Leading Indicators
   Lagging Indicators
      OSHA Recordable Rate
      Process Safety
   Leading Indicators
      Near Misses
      Unplanned Maintenance
      Process Safety Incident
   KPI Limitations
      Activity and Quality
      Quality of Reporting
      Management Elements
API RP 754
   Tiers
      Tier 1 - Process Safety Event
      Tier 2 - Process Safety Event
      Tier 3 - Challenge to Safety Systems
      Tier 4 - Operating Discipline and Management System Performance
   Data Submission
Selection of KPIs
Surveys
Creating a Strong Culture
   Mission Statement
   Guiding Tenets
   Detailed Program
Behavior Based Safety
   Observed Hazard Card
   Five by Five Policy
   Off-the-Job Safety
   Pointless Activities
Employee Participation
   Developing Employee Participation
      Safety Committees
      Involvement in PSM Elements
   Difficulties with Workforce Involvement
      Inefficiencies
      Unwillingness to Accept Change
      Labor / Management Relations
Stakeholder Outreach

Chapter 4 - Technical Information
top of page
Introduction
Table of Contents
Process Description
Flowsheets
   Block Flow Diagrams
   Process Flow Diagrams
   Piping & Instrument Diagrams
      Design Phases
      Equipment and Line Designations
      Instrument Designations
      Updating P&IDs
   Editing Engineering Information
Materials of Construction Table
Material Safety Data Sheet or Safety Data Sheet
Global Harmonization System
   Materials of Construction Table
Material Safety Data Sheets (MSDS)
The Safety Diamond

Chapter 5 - Hazard Identification
top of page
Introduction
Hazards Management Process
   Step 1. Identify the Hazards
      Creative / Imaginative Techniques
      Experience-Based
      Logical / Rational
   Step 2. Risk Rank
   Step 3. Eliminate or Substitute the Hazard
   Step 4. Remove the People
   Step 5. Reduce the Consequence
   Step 6. Reduce the Likelihood
   Step 7. Install Safeguards
Organization of a Hazards Analysis
   Charge / Scope Letter
      Objective
      Physical Scope
      Method(s) to be Used
      Assigned Personnel
      Risk Management Guidance
      Schedule and Reporting
   Abandoned Equipment
   Preparations
   Logistics
   Meeting Protocol
   Location of the Meeting
   Projection of Notes
   Documentation Requirements
   Security of the Information
   Time Required
   Kick-Off and Close-Out Meetings
HAZID / Major Hazards Screening
The Team
   Leader / Facilitator
      Process Knowledge
      Stimulate Thinking
      Creative Thinking
      Casual Remarks
      "If We Had Unlimited Money"
      Generalizations
      Team Management
      Knowledge of Actual Incidents
      Lawyer-Like Behavior
      Persona
      Personal Preparation
      Engineering Standards
   The Scribe
   Operations / Maintenance Expert
   Process and Instrument Experts
   Specialists
   Use of Sophisticated Language
   The One-Minute Engineering Department
Results of the Analysis
   Findings
   Recommendations
   Action Items
   Risk Register
      Finding Number and Date
      Hazard
      Source
      Consequence(s) / Likelihood / Risk
      Follow-Up
The Hazards Analysis Report
   Completeness of the Notes
   Cross-Reference
   Anonymity
      Findings Terminology
      Completeness
      "Non-Findings"
      Appearance
      Pictures
   Report Distribution
   Communication with the Public
   Table of Contents
      1. Disclaimer
      2. Executive Summary
      3. Objectives of the Analysis
      4. Summary of Findings
      5. Method Used
      6. Risk Ranking
      7. The Team
      8. Regulations
      9. Attachments
      10. Meeting Notes
   Development of the Report
      Step 1. Notes Clean-Up
      Step 2. Team Review
      Step 3. Draft Report
      Step 4. Client Review
      Step 5. Final Report
      Step 6. Risk Register
   Legal Issues
      Need to Act on Findings
      Informal Notes
      Internal Communication
Special Types of Hazards Analysis
   Temporary and Transient Operations
   Non-Process Applications
   Decommissioning / Demolition
Revalidation Hazards Analyses
Benefits and Limitations of Hazard Analyses
   Strengths
      Providing Time to Think
      Challenging Conventional Thinking
      Cross-Discipline Communication
      Education
      Development of Technical Information
      Economic Payoff
   Limitations and Concerns
      Imprecision in Defining Terms
      Multiple Contingencies
      Complexities and Subtle Interactions
      Dynamic Conditions
      Common Cause Events
      Knowledge of Safe Operating Limits
      Lack of Quantification
      Team Quality
      Personal Experience
      Boredom
      TRIZ
      Confusion with Design Reviews
      False Confidence
      Equipment Orientation
      Interfaces
      Human Error
The Hazard and Operability Method (HAZOP)
   Step 1. Node Selection and Purpose
      Selection of Nodes
      Pressure Breaks
   Step 2. Process Guideword / Safe Limits
   Step 3. Identification of Hazards and their Causes
   Step 4. "Announcement" of the Hazard
   Step 5. Consequences
   Step 6. Identification of Safeguards
   Step 7. Predicted Frequency of the Hazard
   Step 8. Risk Rank
   Step 9. Findings
   Step 10. Next Process Guideword / Node
   Effectiveness of HAZOPs
Checklists
   Checklist Categories and Guidewords
   Structure of a Checklist
The What-If Method
   Node / Functional Area Review
   Equipment and Function Review
   Ignition Source Controls
   Instrumentation and Control Systems
   Human Factors
   Process Upsets
   Siting
   Structured What-If
   Utility Systems
   Batch Processes
   Operating Procedures
   Layout Reviews
What-If / Checklist Method
Failure Modes & Effects Analysis
Bow Tie Analysis
Indexing Methods
Interface Hazards Analysis

Chapter 6 - Operating Procedures
top of page
Introduction
Definition of Operating Procedures
   Operations
   Written Instructions
   Design or Operating Intent
Definition of Maintenance Procedures
Terminology
Engineering the Solution
Quick Assessment of Operating Procedures
The Users
   Experienced Technicians
   Less Experienced Technicians
   Engineering / Management
   DCS / SCADA Programmers
   Auditors, Regulators and Inspectors
   Translators
Elements of OIM
   Workforce Involvement
   Knowledge Management
   Hazard Identification and Risk Management
   Management of Change
   Operational Readiness
   Emergency Management
Information Manual
Types of Operating Procedure
Steady-State Operating Procedures
   Types of Steady-State Procedure
   Shift Change
Start-Up Procedures
Shutdown Procedures
   Levels of Shutdown
      Stand-By
      Unit Shutdown
      Process Shutdown
      Emergency Shutdown
      Turnaround
Troubleshooting Procedures
   Elements of Troubleshooting Procedures
   Guidance - Not Instructions
   Structure of Troubleshooting Procedures
Temporary Operating Procedures
Batch Procedures
Standard Operating Procedures
Maintenance Procedures
Job Safe Practices
The Operating Manual
Software Analogy
   Modular Design
      Connecting the Modules
      If / Then / Else Instructions
      Modular Operating Manual
Data Base Structure
   Top-Down Development
   Prototyping
   Limitations of Modularity
Design of an Operating Manual
   Adding and Removing Modules
   Numbering the Modules
Module Design
   The Title Block
Procedure Name
Module Number
Purpose of the Procedure
      Revision Number
      Date of Revision
      Covered Persons
      Company / Facility
      Safe Upper and Lower Limits
      Special Safety Items
      Equipment Information
      Training
   The Operating Task Instructions
      Step Number Column
      Person
      Action
      Discussion / Illustration
   The Authorization Block
      Written By
      Approval - Superintendent
      Approval - Manager
      Authorization Sheet
   Overall Module
   Links to Other Procedures and Manuals
   Links to Technical Information
   Training
   Two-Page Modules
Content Development
   Level of Detail
      Level 1 - Overview / Checklists
      Level 2 - Equipment Description
      Level 3 - Valve Detail
   Sources of Information
      Existing Procedures
      Technician Interviews
      Engineering Information
      Vendor Manuals
      Process Hazards Analyses
The Procedures-Writing Team
Writing and Publishing
Project Organization
1. Define the Scope of Work
   Physical Area / Equipment Covered
   Users
   Types of Procedure
   Job Task Analysis
   Design of the Manual
   Regulations / Standards
   Writer's Guide
2. Create the Team
   Steering Committee
   Project Manager
   Project Lead
   Technicians
   Technology Expert
   Interviewer-Writers
   Publisher / Webmaster
3. Develop a Detailed Plan
   Schedule and Progress Metric
   Budget
   Prepare the SOPs
4. Collect Information
   Operator Interviews
   Existing Procedures / Vendor Manuals
   Logbooks
5. Write the Procedures
   Draft Releases
   Plan to Throw One Away - You Will Anyway
6. Review and Sign
7. Publish
Potential Difficulties
   Poorly Defined Goals
   Too Many People
   Extended Review Cycle
   Lack of Signatures
Maintaining the Procedures
   Procedures Modification Process
   Organization
   Writing Guidelines
   Vigorous Writing
   Minimalist Writing
   Short, Pithy Instructions
   Avoid Repetition of Instructions
   Omit Needless Words
   Omit Adverbs
   Short and Old Words
   Avoid Wordy Phrases and Padded Syllables
Writing Style
   Imperative Tense
   Active Voice
   Reading Grade Level
   List Instructions Singly
   Implied Instructions
   Bulleted Lists
   Conditional Instructions
   Positive / Negative Instructions
Vocabulary
   Identification of Equipment
   Consistency
   Should / Would / Could
   The Word "You"
   The Word "This"
   Tautologies
   Arabic Numerals
   Adverbs and Adjectives
   Articles
   Humor
   Spelling
   Latinate Abbreviations
   Apostrophes
   Ambiguous Words
Cobblestone Writing
Repetition of Messages
   Danger, Warning, Caution, Note
   Proofreader Marks
   Illustrations
   Photographs
   P&IDs
   Iconic Flow Diagrams
   Maps / Plot Plans
Publishing
   Color
   White Space
   Fonts
   Paragraph Formatting
   Emphasis Techniques
   Heading
   Page Numbering
   Single-Sided versus Double-Sided Printing
   Indexing
   Glossary
   The Binder
Multiple Languages

Chapter 7 - Training and Competence
top of page
Introduction
Levels of Competence
   Level 1 - Basic Skills
   Level 2 - Certification
   Level 3 - Master Technician
Elements of a Training Program
   Orientation
   Initial / Basic Training
   Site Training
   Abnormal Situation Management
   Refresher Training
SEMS (BSEE)
PSM (OSHA)
Procedures and Training
Management of a Training Program
   Training Matrix
   Budget Allocation
   Measuring Progress
Economics of Training
Process Simulators and Emulators
   Features
   Benefits
   Simulator Design
Testing and Certification
Safe Gulf
Pipeline Operator Training

Chapter 8 - Prestartup Reviews
top of page
Introduction
What the Review Is Not
Regulations
   OSHA's PSM
      (i) Construction and Equipment
      (ii) Procedures
      (iii) New / Modified Facilities
   SEMS
Types of Review
   Review Not Required
   Small Projects / Engineering Changes
   Medium Size
   Large Projects
Restart Reviews
Organizational Responsibility
   Time Required
   Team Structure
Using the Elements of Process Safety Management
   Knowledge Management
   Operating Procedures
   Asset Integrity / Reliability
   Training / Performance

Chapter 9 - Asset Integrity
top of page
Introduction
Engineering Standards
Inherent Safety
   Eliminate
      Remove Equipment
      Remove People
   Minimize
   Substitute
   Moderate
      Equipment Modification
      Spacing
      Underground Location
   Simplify
   Applying Inherent Safety
   Law of Unintended Consequences
      Serendipity
      Undesirable Outcome
      Original Situation Worse
   Passive Safety Systems
   Active Safety Systems
   Administrative Safety Systems
   Safety Critical Items
      Priority 1
      Priority 2
      Priority 3
RAGAGEP

Chapter 10 - Management of Change
top of page
Introduction
Benefits of Management of Change
   Increased Production, Productivity and Quality
   Maintenance Expense and Safety
   Environmental Performance
   Personal Reputation
Definition of MOC
   Deviation beyond Limits
   Impact on other Process Safety Elements
   Critical Changes
In-Kind / Not-In-Kind Change
   Same Specification
   Same Service and Materials of Construction
   Same Storage and Handling Process
   Procedural Replacement
   Process Chemistry
   Instrumentation and Control Systems
Types of Change
   Initiated Equipment Change
      Large and Small Changes
      Turnarounds
      Field Change
   Non-Initiated Equipment Change
      Overt Change
      Covert Change
   Temporary Changes
   Emergency Changes
   Administrative and Organizational Change
      Reorganization
      Management by Contractors
Informal Aspects of MOC
The Management of Change Process
Section A - Initiator Request
   Initiator
      Personal Recognition
      Company Loyalty
      Safety
   Sponsor
   Request Process
      Step 1 - Problem / Opportunity Identified
      Step 2 - Need For Change
      Step 3 - Corrective Action
      Step 4 - System Change
Management of Change Form - Section A
   Name of the Sponsor / Initiator(s) / Date
   Description of Problem and Its Consequences
   Proposed Change
   Justification
   Emergency Change/ Temporary Change
   Previous Actions Taken
Section B - First Review
   In-Kind / Not-In-Kind Change
   Selecting the First Reviewers
   Management of Change Form - Section B
      Name / Date
      Discussion
      Suggested Modifications
Section C - Detailed Evaluation
   Review Process
   MOC Coordinator
   Review Team
      Process Manager
      Engineering Manager
      Operations Manager
   Builders
   Project Team
   Software
   Reviewers
      1. Confirm the Problem
      2. Problem Analysis
      3. Identify Possible Solutions
   Qualifications
      Experience
      Technical Knowledge
      Feasibility
      "Out-of-the-Box" Thinking
   Recommendations
Management of Change Form - Section C
Section D - Formal Approval
   Management of Change Committee
      Operations
      Maintenance
      Technical
      Engineering/Construction
   Process Hazards Analysis
   Variance Procedures
Section E - New Limits / Process Safety Update
Section F - Notification
Section G - Implementation
Section H - Follow-Up

Chapter 11 - Incident Investigation and Root Cause Analysis
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Introduction
Management Level
   Line Supervision
   Facility Management
   Executive Management
   Industry Regulations and Standards
Incident Investigation and Analysis Philosophy
   Trust and Candor
   Listen to the Facts
   Technical Expertise
   Root Cause Analysis
      Difficulties with "Root Cause"
      Ockham's Razor
   Project Management
   Attorney-Client Privilege
Blame and Fault-Finding
   Management Trust
   Early Reporting of Bad News
   Management Pressure
   Safety as a Cause of Incidents
Communications
   Technicians
   Mid-Level Managers
   Senior Managers
Definitions
   Incident
   Accident
   Near Miss / Hit
   Potential Incident
   High Potential Incident
Incident Investigation Steps
   Step 1 - Initial Investigation
   Step 2 - Evaluation and Team Formation
   Step 3 - Information Gathering
   Step 4 - Timeline Development
   Step 5 - Root Cause Analysis
   Step 6 - Report and Recommendations
Step 1. Initial Investigation
   The 'Go Team'
      Immediate Actions
      Team Preparation
   Drug and Alcohol Testing
   Incident Report Form
      Incident Number
      Title
      Location, Date and Time of Event
      Duration of Event
      Date and Time of Report
     How Observed
      Person(s) Reporting
      Preliminary Ranking
      Incident Type
      Incident Flags
      First Description of Event
      Immediate Corrective Actions Taken
      Witnesses
      Contractor Involvement
      Detailed Location
      Consequences
      Emergency Response
      Security Issues
      System Alert
      Incident Owner / Department
      Notes and Attachments
   First Management Report
Step 2. Evaluation and Team Formation
   Evaluation
   Team Formation
   Outside Investigators
   Corporate Support
   Team Members
      Sponsor
      Incident Owner
      Facility Manager
      Lead Investigator
      Administrator
      Area Supervisor
      inherent-safety Representative
      Process Safety Management Coordinator
      Employee Representative
      Process / Facilities Engineer
      Maintenance Technicians
      Subject Matter Experts
      Contractors / Vendors
      Emergency Response Specialists
      Attorneys
   Charter / Terms of Reference
   Team Member Qualifications
      Objectivity
      Common Sense
      Jumping to Conclusions
      Haughtiness and Empathy
      Understand Incident Investigation Methodology
      You Do Know What You Don't Know
      Understand Process Systems
      Logical Thinking / Painstaking
Step 3. Information Gathering
   Interviews
   Interview Guidelines
   Regulatory / Legal Interviews
   Witness Interviews
   Interviewer Attributes
      Rapport and Trust
      Technical Skills
      Critical Factors Recognition
      Objective
      Effective Note Taking
      Management Interviews
   Documentation
   Engineering Information
   Operating Information
      Instrument Records
      Log Books, Maintenance Records and JSAs
      Hazards Analysis Reports
      Management of Change Records
      Operating Manuals / Procedures
      Incident Investigations and Audits
   Vendor Data
   Field Information
   Damage Assessment
   Photographs and DVDs
   Closed Circuit Television
   Instrument Records
   Testing / Lab Analysis
Step 4. Timeline Development
   Timeline Steps
      Section 1 - Events Prior to the Incident
      Section 2 - The Incident
      Section 3 - Post-Incident Response
   Timeline Construction
   Conditions
   Multiple Timelines
   Timeline Table
   Background Information
Step 5. Root Cause Analysis
   Levels of Root Cause
      Single Incidents
      Multiple Incidents
   Types of Root Cause Analysis
   Argument by Analogy: Story Telling
      False Extrapolation
      Linearity
      World Views
   Safeguards
   Management Action
   Categorization
      Equipment Failure
      Human Error as a Root Cause
      Process Systems Failure
   System Analysis
   Why Trees
      Single Chain of Events
      Wrong Chain
   Fault Tree Analysis
   Linkage of Fault Trees to the Timeline
   Common Cause Events
6. Report and Recommendations
   Levels of Recommendation
      Short Term Recommendations
      Intermediate Recommendations
      Long Term Recommendations
      Industry Guidance
   Report Structure
      Executive Summary
      What Happened?
      What Could Have Happened?
      What Was the Cause?
      What Actions Should Be Taken?
      Recognition
      Terms of Reference
      Reason for Selection
      Sequence of Events
      Consequences
      Root Causes
      Other Hazards
      Recommendations
      Attachments
      Attachment A - Regulations and Standards
      Attachment B - Root Cause Analysis
      Attachment C - Organization Chart
      Attachment D - Review of Similar Events
      Attachment E - Investigation Team
      Attachment F - Review of Modern Designs
      Attachment G - Index to Pictures and Documents
      Attachment H - Detailed Timeline
   Issuing the Report
      Writing the Report
      Presenting the Report
      Follow Up and Recommendations Tracking
      Legal Issues
Information Security and Chain of Custody
   Record Retention
   Removing Evidence
   File Systems
   Incident / Risk Register
Feedback
Incident Data Bases
   National Response Center (NRC)
   Accidental Release Information Program (ARIP) Database
   CFOI (Census of Fatal Occupational Injuries)
   Major Accident Reporting System (MARS)
   Marsh & McLennan Reviews
   Annual Loss Prevention Symposia
   Process Safety Beacon
   Government Agencies

Chapter 12 - Emergency Management
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Introduction
Abnormal Situation Management
Human Response
   Human Error Rate
   Fixation
   Heroism and Buddy Loyalty
Trouble Shooting
Levels of Emergency
   Cause of Emergency
   Emergency Operations
   Local Emergency Response
   General Emergency Response
   Recovery Operations
   Investigation and Follow Up
Emergency Planning
   Organization and Personnel
   Emergency Response Manual
   Emergency Procedures
   Emergency Response Training
   Communications
Emergency Shutdown
   ESD Hierarchy
   Shutdown Zones
   System Reset
Fire and Gas Detection
   Fire Detection
   Fire Eyes / Flame Detectors
   Smoke Detectors
   Heat Detectors
   Fusible Links
   Low Oxygen Detectors
   Combustible Gas Detectors
   Manual Call Points
   Toxic Gas Releases
Escape Routes
Fire Fighting
   Single Fire Concept
   Deluge Systems
   Fire Zones

Chapter 13 - Audits and Assessments
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Introduction
Formal Audits
   Reasons for Audits
      Accident Follow-Up
      Regulatory / Standards Compliance
      Stakeholder Outreach
      Voluntary Check
      Insurance and Business Security
   Audit Standards
      Regulations
      Reporting Requirements
      Industry Standards
      Internal Standards
   Audit Frequency
   Audit Personnel
      Outside Auditors
      Internal Auditors
      Team Composition
   Auditor Attributes
      Audit Service Providers
      Interview Skills
      Technical Knowledge
      Writing Skills
      Demeanor
   The Host Company
      First Impressions
      Employees
   Planning the Audit
      Goals
      Determine the Audit Standard
      Scope
      Budget
      Schedule
      One-Point Contact
      Pre-Audit Activities
   Audit Forms
   Conducting the Audit
      Auditor Preparation
      Kick Off Meeting
      Plant Tour
      Information Collection
      Role of Personnel
      Interviews
      On-Site Inspection
      Close-Out Meeting
   Report
      Draft Report
      Generalities
      Report Distribution
      Letter of Certification
      Audit Verification
      Positive Findings
      Report Retention
   Findings
   Follow Up
   Unannounced Audits
The SEMS Audit Rule
SEMS II
   Audit Requirements
   Independent Third Party Auditors (I3Ps)
   I3P Qualifications
National Emphasis Program (NEP)
Reviews and Expert Assessments
   Review Issues
   Management Systems Effectiveness
      Workforce Involvement
      Real World Usefulness
      "Learned to Live with It" Problems
      Lessons Learned
   Reviewer Attributes
Management Elements Assessment
   Level 1 - Risk Management
   Level 2 - Management Element Spreadsheet
   Level 3 - Detailed Questions
   Scoring Template
   Guidance
   Benefits of the Elements Assessment Approach
      Independent of Events
      Handling Abstraction
      Smoothing of Results
      Objectivity

Chapter 14 - Consequence Analysis
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Introduction
Range of Consequences
   Safety
   Health
   Environmental
   Economic
   Effect of a Release
Hole Size
Fires
   Flammable Range
   Ignition Temperature / Energy
   Spontaneous Combustion
   Ignition Sources
      Vacuum Trucks
      Radiant Heat
      Static Electricity
      Lightning
      Pyrophorics / Iron Sulfide
   Flammability Hazard Ranking
   Passive Fire Protection / Fireproofing
Explosions
   Physical Explosions
   Vapor Cloud Explosions
   Deflagrations and Detonations
   Blast Effects
   BLEVEs
   Dust Explosions
Toxic Gas Releases
   Gas Release Modeling
   Effect of Toxic Gases
   Probit Equations
   Short-Term Exposure Limits
      Emergency Response Planning Guidelines (ERPGs)
      Immediately Dangerous to Life and Health
      Permissible Exposure Limits (PEL)
      Threshold Limit Values (TLV)
      Short Term Exposure Limit (STEL)
      Levels of Concern (EPA)
      Acutely Toxic Concentration / Levels (New Jersey / Delaware)
      Substance Hazards Index
Location of Monitors

Chapter 15 - Frequency Analysis
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Introduction
The Pareto Principle
Importance Ranking
Fault Tree Analysis
   Gates
      OR Gate
      AND Gate
      VOTING Gate
   Events
      Top Event
      Intermediate Events
      Base Events
      House Event
   Top-Down Development of a Fault Tree
      1. Define the Top Event
      2. Build the Tree
      3. Identify the Cut Sets
      4. Eliminate Repeat Sets
      5. Eliminate Repeat Events in a Set
      6. Eliminate Redundant Events
      7. Quantify the Risk
      Mathematics of an OR Gate
      Mathematics of an AND Gate
      Mathematics of a Voting Gate
      Cut Set Quantification
      8. Risk Rank
      Event Contribution
      Important Few
      Unimportant Many
      Power of the AND Gate
      Importance Equalization
      Cost-Benefit Analysis
Importance Ranking Using Cut Sets
Birnbaum Factor Method
Fussell-Vesely Method
Perturbation Method
Common Cause Events
Fukushima-Daiichi
Generic Fault Trees
Generic Safety Fault Tree
Generic Reliability Fault Tree
Discussion of the Fault Tree Method
Qualitative Fault Tree Analysis
Event Tree Analysis
Quantification of an Event Tree
Scope of Event
Combining Event Trees and Fault Trees
Short Sequence of Events
Many Events
Partial Success
Discrete Event Analysis
Non-Linearities and Complexities
Conveying Statistical Uncertainty
Monte Carlo Simulation
Random Number Generators
Seed Numbers
Speeding the Simulation
Markov Models
Top-Down / Bottom-Up Approach
Top-Down
Bottom-Up
Qualitative Insights
Limitations to Quantification
Mathematical Understanding
Value-Laden Assumptions
Lack of Exhaustivity
Human Behavior
Data Quality
Safeguards
Safeguard Level 1: Normal Operations
Safeguard Level 2: Procedural Safeguards
Safeguard Level 3: Safety Instrumented Systems
Safeguard Level 4: Mechanical Safeguards
Safeguard Level 5: Passive Safeguards
Safeguard Level 6: Emergency Response
Layer of Protection Analysis
The LOPA Process
Single Scenarios
IPLs
Specific
Independent
Dependable
Auditable
Human Response
Implementing LOPA
Team Makeup
Timing
Tools
Procedures and Inspections
Risk Criteria
Failure Rate Data
Conditional Probability / Bayes' Theorem
Evaluation of Tests
Sequential Observations
Combining Data Sources

Chapter 16 - Reliability, Availability and Maintainability
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Introduction
Benefits of a RAM Program
   Increased Production and Profitability
   Increased Productivity
   Reduced Investment
   Lower Maintenance Costs
   Lower Inventories
   Enhanced Customer Satisfaction
   Personal Recognition
   Personal Life
   Improved Public Perception
Reliability and Safety
   Hazardous Operations
   Unsafe Process Conditions
   Transient Stresses
   Reduced Chance of Catastrophic Losses
   Increased Safety May Reduce Reliability
   Loss of Experience
   Engineering Practices
   Daily Operations
Definitions
   Reliability
   Availability
   Effectiveness
   Maintainability
Failure Modes
   Equipment Description
   Primary, Secondary and Command Failures
   Catastrophic, Degraded and Incipient Failures
   Real Failures / Necessary Replacements
Failure Rates
   Constant / Exponential Distribution
   Lognormal Distribution
   Bathtub Curve
      Early Failures
      Constant Failure Rate
      Wear-Out Failures
   Reliability Block Diagrams
   Active / Standby Redundancy
   Quantification of Block Diagrams
Human Reliability
   Types of Human Error
      Errors of Intent
      Mistakes
      Slips
      Fixation
      Error in an Emergency
      Incorrect Response
   Human Reliability Analysis
   THERP

Chapter 17 - Managing a Risk Program
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Introduction
Clients / Customers
   Senior Management
   Facility Managers
   Project Managers and Design Engineers
   Regulators / Auditors
Program Organization
   Step 1 - Determine the Objectives
   Step 2 - Set Up an Organization
      Management
      Steering Committee
      Coordinator
      Sub-Committees
      Operating Binders
   Step 3 - Create the Metrics and Baseline
   Step 4 - Develop a Plan
      Goals
      Resources Needed
      Develop a Schedule
      Reviews and Signatures
   Step 5 - Implement the Plan
   Step 6 - Audit / Improve

Chapter 18 - Project Management
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Introduction
Phase / Gate System
Hazards Analysis on Projects
Phase I - Concept Selection
   Documents
   Hazards Analysis
Phase II - Preliminary Design (FEED)
   Documents
   Hazards Analysis
Phase III - Detailed Engineering
   Documents
   Hazards Analysis
Phase IV - Fabrication and Construction
   Precommissioning
   Punchlists
   Transfer of Care, Custody and Control
   Documents
      Turnover Packages
      Procedures
   Hazards Analysis
Phase V - Commissioning and Start-Up
   Commissioning
   Operational Readiness Review
   Startup and Line Out
   Documents
      Start-Up Procedures
      Acceptance Test
      Warranty
   Hazards Analysis
Project Organization

Chapter 19 - Contractors
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Introduction
Regulations and Standards
   OSHA PSM Standard
   OSHA PSM Guidance
      Application
      Employer Responsibilities
   BSEE SEMS
   API RP 76
Types of Contractor
   Contract Companies
      Selecting a Contract Company
      Contractor inherent-safety Program
   Design Companies
   Subcontractors
   Contract Workers
   Maintenance Contractors
   Visitor / Consultant
Bridging Documents
   Operator/Contractor Bridging Document
   Bridging through a Regulation
Contractor Management
   Contractor Selection
   Record Keeping
   Contractor Training
   Safety Meetings
   Equipment
   Infractions
   Contractor Training
   Safety Meetings
   Contractor Evaluation

Chapter 20 - The Risk Management Professional
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Introduction
The Risk Management Professional
Attributes
   Education and Certification
   Technical Knowledge
   Holistic
   Numerate
   Communication Skills
   Industrial Experience
   Knowledge of Past Events
   Professional Involvement
   Network
   The Resume / CV
      Level of Detail
      Publications
      Gaps / Negative Facts
      Multiple Resumés
      Declining Experience
   Professional Engineer
   Consultants
      True Expertise
      The Consultant as Outsider
      Consultants - Not Doers
      Quick Study
      Role of the Client
      Response to Criticism
      Marketing
Communicating with Management/Clients
   Presentations
   Meetings
Report Writing
   Draft Report
   Language of the Report
   Completeness / Thoroughness
   Personal Information
   Writing Style
      Non-Emotional Language
      Minimalist Writing - Make Every Word Tell
      Omit Needless Words
      Short, Simple Words
      Minimize "Soft" Materials
      Eschew Obfuscation
      Develop a Theme
      Modifiers
      No Typos
      Date Format
      Active/Passive Voice
      He / She
      You / I
      Choice of Words
      Use of Humor
   Copyright
   Responsible Document Creation
Anecdotes
   Stories
   Elements of a Story
      Characters
      Setting
      Plot
      Conflict
      Resolution
   Sensitivity
Communicating with the Public
   The Community
   Other Businesses
   The Media
   Regulators / Non-Governmental Organizations (NGOs)
   Types of Public Communication
   Developing a Risk Communication Program
   Communicating New Paradigms
Trade Secrets (OSHA)
Litigation Support
   Use of Legal Services
   Types of Litigation
   The Participants
   Timeline / Story Line
   Documentation
   The Discovery Process
   Depositions
   Witnesses to Fact
The Expert Witness
   Acceptance by the Court
   Daubert and Frye Rules
   Prior Testimony
   Timeline / Story Line
   The Report
   Attributes of an Expert Witness
      To Thine Own Self Be True
      Be Prepared
      Be a True Expert
      Be a Teacher
      "Reasonable" Risk
   Privilege

Citations
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About the Author

Ebook: Inherent Safety

Ian Sutton is a chemical engineer with over 40 years experience in the process industries. He has worked on the design and operation of offshore platforms, refineries, chemical plants, pipelines and minerals processing facilities.

 



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