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E-grāmata: Recognizing Catastrophic Incident Warning Signs in the Process Industries

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  • Formāts: EPUB+DRM
  • Izdošanas datums: 01-Jul-2013
  • Izdevniecība: Wiley-AIChE
  • Valoda: eng
  • ISBN-13: 9781118178591
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Recognizing Catastrophic Incident Warning Signs in the Process IndustriesPalielināt
  • Formāts: EPUB+DRM
  • Izdošanas datums: 01-Jul-2013
  • Izdevniecība: Wiley-AIChE
  • Valoda: eng
  • ISBN-13: 9781118178591
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This book provides guidance on characterizing, recognizing, and responding to warning signs to help avoid process incidents and injuries before they occur. The guidance can be used by both process safety management (PSM) professionals in evaluating their processes and PSM systems as well as for operators who are often the frontline defense against process incidents. Warning signs may consist of process deviations or upsets, instrumentation warnings or alarms, past operating history and incidents, observable problems such as corrosion or unusual odors, audit results indicating procedures are not being followed, or a number of other indicators. Filled with photos and practical tips, this book will turn anyone in a process plant into a hazard lookout and will help prevent potential incidents before they turn into catastrophic events.

Recenzijas

"The CCPS and the authors (AntiEntropcis, Inc,) are to be commended on producing a very informative and useful book that will help to minimize process plant accidents if the principles in the book are followed . . . This book will be very useful to plant operating personnel and process safety/loss prevention specialists to help them evaluate their processes and systems." (Process Safety Progress, 1 June 2012)  

List of Tables
xix
List of Figures
xxi
Files on the Web Accompanying This Book xxiii
Acknowledgments xxv
Foreword xxvii
Preface xxix
1 Introduction
1(16)
1.1 Process safety management
3(1)
1.1.1 Identifying process safety management system deficiencies
3(1)
1.2 Normalization of deviance
4(1)
1.3 A strategy for response
5(2)
1.4 Maintaining organizational memory and a healthy sense of vulnerability
7(1)
1.5 Risk Based Process Safety
8(3)
1.6 Our target audience
11(1)
1.7 How to use this book
12(1)
1.8 Case study - Toxic gas release in India
13(4)
2 Incident Mechanics
17(12)
2.1 Incidents do not just happen
17(1)
2.2 Incident models
17(10)
2.2.1 The difference between incidents and catastrophic incidents
18(1)
2.2.2 The Swiss cheese incident model
19(3)
2.2.3 The bonfire incident analogy
22(1)
2.2.4 The dam incident analogy
22(1)
2.2.5 The iceberg incident analogy
23(1)
2.2.6 Incident trends and statistics
24(1)
2.2.7 Root cause analysis
25(1)
2.2.8 Multiple root cause theory
26(1)
2.3 Case study - Benzene plant explosion in China
27(2)
3 Leadership and Culture
29(20)
3.1 How does leadership affect culture?
29(3)
3.1.1 Communication
30(1)
3.1.2 Operational discipline
30(1)
3.1.3 Process safety culture
31(1)
3.1.4 Process safety versus occupational safety
31(1)
3.2 The leadership and culture related warning signs
32(15)
3.2.1 Operating outside the safe operating envelope is accepted
33(1)
3.2.2 Job roles and responsibilities not well defined, confusing, or unclear
34(1)
3.2.3 Negative external complaints
34(1)
3.2.4 Signs of worker fatigue
35(1)
3.2.5 Widespread confusion between occupational safety and process safety
35(1)
3.2.6 Frequent organizational changes
36(1)
3.2.7 Conflict between production goals and safety goals
37(1)
3.2.8 Process safety budget reduced
37(1)
3.2.9 Strained communications between management and workers
37(1)
3.2.10 Overdue process safety action items
38(1)
3.2.11 Slow management response to process safety concerns
39(1)
3.2.12 A perception that management does not listen
39(1)
3.2.13 A lack of trust in field supervision
39(1)
3.2.14 Employee opinion surveys give negative feedback
40(1)
3.2.15 Leadership behavior implies that public reputation is more important than process safety
40(1)
3.2.16 Conflicting job priorities
41(1)
3.2.17 Everyone is too busy
41(1)
3.2.18 Frequent changes in priorities
42(1)
3.2.19 Conflict between workers and management concerning working conditions
42(1)
3.2.20 Leaders obviously value activity-based behavior over outcome-based behavior
42(1)
3.2.21 Inappropriate supervisory behavior
43(1)
3.2.22 Supervisors and leaders not formally prepared for management roles
43(1)
3.2.23 A poorly defined chain of command
44(1)
3.2.24 Workers not aware of or not committed to standards
44(1)
3.2.25 Favoritism exists in the organization
45(1)
3.2.26 A high absenteeism rate
45(1)
3.2.27 An employee turnover issue exists
45(1)
3.2.28 Varying shift team operating practices and protocols
46(1)
3.2.29 Frequent changes in ownership
46(1)
3.3 Case study - Challenger space shuttle explosion in the United States
47(2)
4 Training and Competency
49(16)
4.1 What is effective training, and how is competency measured?
49(2)
4.1.1 Three basic levels of training
50(1)
4.1.2 Competency assessment
51(1)
4.2 The training and competency related warning signs
51(11)
4.2.1 No training on possible catastrophic events and their characteristics
52(1)
4.2.2 Poor training on hazards of the process operation and the materials involved
53(1)
4.2.3 An ineffective or nonexistent formal training program
53(1)
4.2.4 Inadequate training on facility chemical processes
54(1)
4.2.5 No formal training on process safety systems
55(1)
4.2.6 No competency register to indicate the level of competency achieved by each worker
56(1)
4.2.7 Inadequate formal training on process-specific equipment operation or maintenance
56(1)
4.2.8 Frequent performance errors apparent
56(1)
4.2.9 Signs of chaos during process upsets or unusual events
57(1)
4.2.10 Workers unfamiliar with facility equipment or procedures
57(1)
4.2.11 Frequent process upsets
58(1)
4.2.12 Training sessions canceled or postponed
59(1)
4.2.13 Procedures performed with a check-the-box mentality
59(1)
4.2.14 Long-term workers have not attended recent training
60(1)
4.2.15 Training records are not current or are incomplete
60(1)
4.2.16 Poor training attendance is tolerated
61(1)
4.2.17 Training materials not suitable or instructors not competent
61(1)
4.2.18 Inappropriate use or overuse of computer-based training
62(1)
4.3 Case study - Gas plant vapor cloud explosion in Australia
62(3)
5 Process Safety Information
65(14)
5.1 Critical information to identify hazards and manage risk
65(1)
5.2 The process safety information related warning signs
66(10)
5.2.1 Piping and instrument diagrams do not reflect current field conditions
67(1)
5.2.2 Incomplete documentation about safety systems
68(1)
5.2.3 Inadequate documentation of chemical hazards
69(1)
5.2.4 Low precision and accuracy of process safety information documentation other than piping and instrument diagrams
70(1)
5.2.5 Material safety data sheets or equipment data sheets not current
70(1)
5.2.6 Process safety information not readily available
71(1)
5.2.7 Incomplete electrical / hazardous area classification drawings
72(1)
5.2.8 Poor equipment labeling or tagging
72(1)
5.2.9 Inconsistent drawing formats and protocols
73(1)
5.2.10 Problems with document control for process safety information
74(1)
5.2.11 No formal ownership established for process safety information
75(1)
5.2.12 No process alarm management system
75(1)
5.3 Case study - Batch still fire and explosion in the UK
76(3)
6 Procedures
79(18)
6.1 Safe and consistent operation
79(2)
6.2 The procedure related warning signs
81(14)
6.2.1 Procedures do not address all equipment required
81(1)
6.2.2 Procedures do not maintain a safe operating envelope
82(1)
6.2.3 Operators appear unfamiliar with procedures or how to use them
83(1)
6.2.4 A significant number of events resulting in auto initiated trips and shutdowns
84(1)
6.2.5 No system to gauge whether procedures have been followed
85(1)
6.2.6 Facility access procedures not consistently applied or enforced
86(1)
6.2.7 Inadequate shift turnover communication
87(1)
6.2.8 Poor quality shift logs
88(1)
6.2.9 Failure to follow company procedures is tolerated
88(1)
6.2.10 Chronic problems with the work permit system
89(2)
6.2.11 Inadequate or poor quality procedures
91(1)
6.2.12 No system for determining which activities need written procedures
92(1)
6.2.13 No established administrative procedure and style guide for writing and revising procedures
93(2)
6.3 Case study - Nuclear plant meltdown and explosion in the Ukraine
95(2)
7 Asset Integrity
97(20)
7.1 Systematic implementation
97(2)
7.2 The asset integrity related warning signs
99(15)
7.2.1 Operation continues when safeguards are known to be impaired
100(1)
7.2.2 Overdue equipment inspections
100(1)
7.2.3 Relief valve testing overdue
101(1)
7.2.4 No formal maintenance program
102(1)
7.2.5 A run-to-failure philosophy exists
102(1)
7.2.6 Maintenance deferred until next budget cycle
103(1)
7.2.7 Preventive maintenance activities reduced to save money
103(1)
7.2.8 Broken or defective equipment not tagged and still in service
103(1)
7.2.9 Multiple and repetitive mechanical failures
104(1)
7.2.10 Corrosion and equipment deterioration evident
105(1)
7.2.11 A high frequency of leaks
105(1)
7.2.12 Installed equipment and hardware do not meet good engineering practices
106(1)
7.2.13 Improper application of equipment and hardware allowed
107(1)
7.2.14 Facility firewater used to cool process equipment
107(1)
7.2.15 Alarm and instrument management not adequately addressed
108(1)
7.2.16 Bypassed alarms and safety systems
108(1)
7.2.17 Process is operating with out-of-service safety instrumented systems and no risk assessment or management of change
109(1)
7.2.18 Critical safety systems not functioning properly or not tested
109(1)
7.2.19 Nuisance alarms and trips
110(1)
7.2.20 Inadequate practices for establishing equipment criticality
110(1)
7.2.21 Working on equipment that is in service
111(1)
7.2.22 Temporary or substandard repairs are prevalent
111(1)
7.2.23 Inconsistent preventive maintenance implementation
112(1)
7.2.24 Equipment repair records not up to date
112(1)
7.2.25 Chronic problems with the maintenance planning system
113(1)
7.2.26 No formal process to manage equipment deficiencies
113(1)
7.2.27 Maintenance jobs not adequately closed out
114(1)
7.3 Case study - Refinery naphtha fire in the United States
114(3)
8 Analyzing Risk and Managing Change
117(22)
8.1 Risk management
117(4)
8.1.1 Hazard identification and risk analysis
117(1)
8.1.2 The definitions of hazard and risk
117(2)
8.1.3 Management of change
119(1)
8.1.4 What is your role in risk management?
120(1)
8.2 The risk analysis and management of change related warning signs
121(11)
8.2.1 Weak process hazard analysis practices
122(1)
8.2.2 Out-of-service emergency standby systems
123(1)
8.2.3 Poor process hazard analysis action item follow-up
123(1)
8.2.4 Management of change system used only for major changes
124(1)
8.2.5 Backlog of incomplete management of change items
124(1)
8.2.6 Excessive delay in closing management of change action items to completion
124(1)
8.2.7 Organizational changes not subjected to management of change
125(1)
8.2.8 Frequent changes or disruptions in operating plan
125(1)
8.2.9 Risk assessments conducted to support decisions already made
126(1)
8.2.10 A sense that we always do it this way
126(1)
8.2.11 Management unwilling to consider change
127(1)
8.2.12 Management of change item review and approval lack structure and rigor
127(1)
8.2.13 Failure to recognize operational deviations and initiate management of change
128(1)
8.2.14 Original facility design used for current modifications
128(1)
8.2.15 Temporary changes made permanent without management of change
128(1)
8.2.16 Operating creep exists
129(1)
8.2.17 Process hazard analysis revalidations are not performed or are inadequate
129(1)
8.2.18 Instruments bypassed without adequate management of change
129(1)
8.2.19 Little or no corporate guidance on acceptable risk ranking methods
130(1)
8.2.20 Risk registry is poorly prepared, nonexistent, or unavailable
131(1)
8.2.21 No baseline risk profile for a facility
131(1)
8.2.22 Security protocols not enforced consistently
132(1)
8.3 Case study - Cyclohexane explosion in the UK
132(7)
9 Audits
139(10)
9.1 Audits support operational excellence
139(2)
9.1.1 Audit team characteristics
139(1)
9.1.2 Internal and external audits
140(1)
9.1.3 Audit protocols
140(1)
9.1.4 Addressing audit results
141(1)
9.2 The audit related warning signs
141(6)
9.2.1 Repeat findings occur in subsequent audits
142(1)
9.2.2 Audits often lack field verification
142(1)
9.2.3 Findings from previous audits are still open
143(1)
9.2.4 Audits are not reviewed with management
143(1)
9.2.5 Inspections or audits result in significant findings
144(1)
9.2.6 Regulatory fines and citations have been received
144(1)
9.2.7 Negative external complaints are common
145(1)
9.2.8 Audits seem focused on good news
145(1)
9.2.9 Audit reports are not communicated to all affected employees
146(1)
9.2.10 Corporate process safety management guidance does not match a site's culture and resources
146(1)
9.3 Case study - Chemical warehouse fire in the UK
147(2)
10 Learning from Experience
149(14)
10.1 Methods for continuous improvement
149(2)
10.1.1 Incident investigation
149(1)
10.1.2 Measurement and metrics
150(1)
10.1.3 External incidents
150(1)
10.1.4 Management review and continuous improvement
150(1)
10.2 The learning from experience warning signs
151(8)
10.2.1 Failure to learn from previous incidents
151(1)
10.2.2 Frequent leaks or spills
152(1)
10.2.3 Frequent process upsets or off-specification product
153(1)
10.2.4 High contractor incident rates
153(1)
10.2.5 Abnormal instrument readings not recorded or investigated
154(1)
10.2.6 Equipment failures widespread and frequent
154(1)
10.2.7 Incident trend reports reflect only injuries or significant incidents
155(1)
10.2.8 Minor incidents are not reported
155(1)
10.2.9 Failure to report near misses and substandard conditions
156(1)
10.2.10 Superficial incident investigations result in improper findings
156(1)
10.2.11 Incident reports downplay impact
157(1)
10.2.12 Environmental performance does not meet regulations or company targets
158(1)
10.2.13 Incident trends and patterns apparent but not well tracked or analyzed
158(1)
10.2.14 Frequent activation of safety systems
159(1)
10.3 Case study - Space shuttle Columbia incident in the United States
159(4)
11 Physical Warning Signs
163(12)
11.1 The everyday things matter
163(1)
11.2 The physical warning signs
164(8)
11.2.1 Worker or community complaints of unusual odors
164(1)
11.2.2 Equipment or structures show physical damage
164(1)
11.2.3 Equipment vibration outside acceptable ranges
165(1)
11.2.4 Obvious leaks and spills
165(1)
11.2.5 Dust buildup on flat surfaces and in buildings
166(1)
11.2.6 Inconsistent or incorrect use of personal protective equipment
167(1)
11.2.7 Missing or defective safety equipment
168(1)
11.2.8 Uncontrolled traffic movement within the facility
168(1)
11.2.9 Open and uncontrolled sources of ignition
169(1)
11.2.10 Project trailers located close to process facilities
169(1)
11.2.11 Plugged sewers and drainage systems
169(1)
11.2.12 Poor housekeeping accepted by workers and management
169(1)
11.2.13 Permanent and temporary working platforms not protected or monitored
170(1)
11.2.14 Open electrical panels and conduits
170(1)
11.2.15 Condensation apparent on inner walls and ceilings of process buildings
170(1)
11.2.16 Loose bolts and unsecured equipment components
171(1)
11.3 Case study - Resin plant dust explosion in the Unites States
172(3)
12 A Call to Action
175(12)
12.1 Actions that you can take now for each warning sign
176(1)
12.1.1 Periodic employee participation in analyzing warning signs
176(1)
12.1.2 Use the warning signs as part of your next process safety audit
177(1)
12.2 A simple plan to consider for rigorous implementation and follow-up
177(3)
12.2.1 Perform an initial warning signs survey
177(1)
12.2.2 Build warning sign analysis into your management system
178(1)
12.2.3 Use the new system and track related action items
178(1)
12.2.4 Evaluate effectiveness in the next compliance audit
179(1)
12.2.5 Maintain vigilance against recurring warning signs
179(1)
12.3 Actions to consider
180(3)
12.3.1 Senior management
180(1)
12.3.2 Managers
181(1)
12.3.3 Supervisors
181(1)
12.3.4 Using incident warning signs for operations leader training
182(1)
12.3.5 All employees
183(1)
12.4 Summary
183(1)
12.5 Case study - Oil platform explosion and fire in the North Sea
183(4)
Appendix A Incident Warning Sign Self-Assessment Tool 187(12)
Appendix B Composite List of Catastrophic Incident Warning Signs 199(6)
References and Selected Regulations 205(8)
Acronyms and Abbreviations 213(2)
Glossary 215(6)
Index 221
Since 1985, the Center for Chemical Process Safety (CCPS) has been the world leader in developing and disseminating information on process safety management and technology. CCPS, an industry technology alliance of the American Institute of Chemical Engineers (AIChE), has published over eighty books in its process safety guidelines and process safety concepts series, and over a hundred training modules through its Safety in Chemical Engineering Education (SACHE) series.
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