Elements of Process Safety

This paper describes an integrated toolset, called the Human Factors Workbench, which addresses the proactive and reactive control of human error in process operations. It is a practical application of the tools described in the CCPS publication: ‘Guidelines for Preventing Human Error in Process...

There have been a number of devastating incidents related to natural gas piping system and the start-up and commissioning of equipment. It's very rarely that an incident occurs when equipment is at the ready and in some normal operating routine. The vast majority of incidents are directly related...

On May 24, 2007 an explosion and subsequent fire destroyed a tank farm located at a gasoline purification plant in Sløvåg, Norway. In addition to the tank farm, an office building and some neighboring tank trucks were destroyed. There were no casualties in the accident, but at least two people...

A procedural operation consists of a set of tasks that are conducted in a set way time-after-time to achieve a certain goal such as starting or shutting down a unit or making a product. As demonstrated by Paul McKenzie (Bristol Myers Squibb) at the WBF NA Conference 2007 in Baltimore, it could even...

This paper discusses the investigation of an accident caused by the mixing of incompatible chemicals, a strong oxidizing agent with a reducing agent. The exact mixture and sequence of mixing was unknown, but the materials included an aqueous solution of 40% sodium permanganate (NaMnO4) and possibly...

A small specialty chemicals plant experienced an unusual power outage as the result of a lightning strike. The lightning strike damaged several of the electrical distribution systems and local controls and instrumentation systems in such a way that the extent of the damages to controls systems were...

In developing systems for Process Safety Management, compliance audits are integral with verification that practices and procedures are developed and are effective for compliance. Data collected during compliance audits is often subjective and findings are descriptive in nature. It is therefore...

An explosion occurred in the boiler room of a food processing plant as the steam generation system was coming online after a maintenance shutdown. The explosion shattered the case of the condensate return pump fatally injuring an employee, while another employee was burned by the escaping steam...

On February 7, 2008, at about 7:15 p.m., a series of sugar dust explosions at the Imperial Sugar manufacturing facility in Port Wentworth, Georgia, resulted in 14 worker fatalities. Thirty six workers were treated for serious burns and injuries—some caused permanent, life altering conditions. The...

Many LOPA scenarios have an independent protection layer (IPL) credit for operator intervention to prevent or mitigate the scenario. It is often difficult for the LOPA team or other safety teams to assess if the appropriate operator response credit is being taken. To allow a more consistent...