Need / Call to Action | AIChE

Need / Call to Action

Excavation - Need / Call to Action

Incidents Continue to Happen

 

“Sentence following multiple deaths on excavation site. Two companies have been fined a total of £700,000”.

http://press.hse.gov.uk/ May 2017

 

“Building boss guilty of manslaughter, verdict after trench collapse death”. 

Construction Enquirer www.constructionenquirer.com/ 2017/06/13

 

Maintain a Sense of Vulnerability

 

A Sense of Vulnerability Is Healthy – Just because it has not happened yet (or here) does not mean it will not happen in the future!

  • Is a sense of vulnerability a critical part of the mindset of every employee and contractor?
  • Do you require consistency in practice from everyone in the organization?
  • Do you have systems in place to determine if inconsistencies exist?
  • Do people believe that “yes, it can happen here”?
  • Do people believe that “yes, we have similar vulnerabilities”?
  • Have you experienced similar incidents but without consequences (i.e., near misses)?
  • Do you combat organizational overconfidence that can be stimulated by past good performance?
  • Do discussions on potential vulnerabilities take place between operations and senior leadership?
 

Prevent Normalization of Deviation

 

Normalization of deviation is defined as…..

The gradual process through which unacceptable practice or standards become acceptable. As the deviant behaviour is repeated without catastrophic results, it becomes the social norm for the organization.

– Sociologist Dr. Diane Vaughan (The Challenger Launch Decision, 1996)

A gradual erosion of standards of performance as a result of increased tolerance of non-conformance.

– CCPS Glossary (iPhone Application)

 

Signs of Normalization of Deviations – Does this describe your organization?

  • If a deviation is absolutely necessary, are there defined steps that must be taken (i.e., a written variance procedure)?
  • Do these defined steps (or variance procedure) require a detailed risk assessment and approval from multiple levels within the organization?
  • Are your the expectations clear that no one individual alone is permitted to determine whether a deviation is permissible?
  • Do you allow operations outside established limits without a detailed risk assessment?
  • Are wilful, conscious, violations of established procedures tolerated without investigation or without consequences for the persons involved?
  • Can employees be counted on to strictly adhere to safety policies and practices when supervision is not around to monitor compliance?
  • Are you tolerating practices, or conditions that would have been deemed unacceptable a year or two ago?
 

Evaluate Your Program

 

Do you audit your Excavation program to ensure the program is yielding the intended results?

  • Are all employees empowered to stop work for any situation deemed unsafe?
  • Are excavated areas reviewed for underground hazards such as electrical cables, pipelines, etc.?
  • Are marked-up drawings of excavated areas approved by a qualified Supervisor available in location?
  • Do you allow initial ground penetration without an approved drawing, showing existing underground utilities?
  • Is it company practice to perform a joint site visit by Operations, Maintenance and Utilities personnel to identify and to mark underground utilities?
  • Is it company practice to attach excavation plans to permits?
  • Do you allow work to proceed without completing excavation checklist?
  • If the excavation is to be entered, is a Confined Space Entry permit in place?
  • Is all equipment and materiel located safe distance away from the excavation site?
  • If the excavation is to be entered, is proper access/egress available?
 

Do you review the following items?

  • Written excavation procedure?
  • Excavation certificates/permits?
  • Excavation checklists?
  • Roles and responsibilities of persons involved in excavation activities?
  • Training and competency provided to persons involved in excavation activities?
  • Hazard assessments performed before excavation activities are conducted?
  • Job observations performed on excavation activities?
 

Have you audited your Excavation permits and discussed the results of the audits? Was there evidence that:

  • Permits were not completely filled out?
  • Permits were not signed?
  • Permits showed evidence that the standby watchman failed to check the site after job completion?
  • The permit writer was not trained?
  • The standby watchman was not trained?
  • Permit conditions were not communicated within the subject work team?
  • Work was not coordinated between work groups (permit writing group vs. group(s) that perform the work)?
  • Work extended beyond the authorized period of time?
  • The work area covered by the permit was too large?
  • Certain technical provisions of the permit were not followed?
  • Gas detection was not performed properly or continuously?
 

Have you evaluated your Excavation audit program?

  • To ensure the quality of the audit process (i.e., protocols, sampling strategies, etc.)?
  • To ensure the competency levels of the auditors?
  • Does your Excavation procedure reflect the desired intent and is this intent adequately detailed in procedural instruction?
    • Is the “goal” of your program to complete the permit or to use the permit as a tool to facilitate the execution of safe work?
  • Does the execution of the procedure yield the intended results? Are you evaluating your program for:
    • Procedural Compliance – are actions and tasks in compliance with procedural requirements? (Paper Control), and
    • Program Health – is your system providing the intended results? (Actual Execution)
  • Do you know of any site or company incidents related to excavation?
  • Have you discussed the results and causes within your organization?
  • Do you know of any site or company near misses related to excavation?
  • Have you discussed the results and causes within your organization?
 

Continually Improve Your Program

 

Are you considering improvements to prevent future incidents?  Here are some ideas you may want to consider:

  • How frequently do you review CSB, Process Safety Beacon and other relevant incident communication having learning potential with all members of the organization?
  • Do you track specific excavation-related metrics that can be used to determine program effectiveness and improve performance?
  • Have you benchmarked your program against other programs in your industry?
  • How often do your senior managers visit the field to watch excavation in action?
  • Do you have a requirement to periodically update your program?
  • Do your workers (those closest to the work), have an easy method to suggest improvements to your program?
 

Organizational Culture

 

A successful Excavation program depends on the actions of individuals within the organization.  Do the values and behaviors of your organization determine the manner in which your Excavation program is managed and executed?

  • Does management and supervision reinforce desired behaviors to ensure they become integrated into the group’s values?
  • Are high standards of excavation performance clearly established?
  • Is open and effective communication encouraged and supported?
  • Has management established safety as a core value?
  • Does management and supervision provide strong leadership?
  • Has management formalized the safety culture emphasis and approach?
  • Does management work to ensure employees maintain a sense of vulnerability?
  • Are individuals empowered to successfully fulfill their safety responsibilities?
  • Does management ensure open and effective communication exists?
  • Does management support and foster mutual trust?
  • Does management establish and enforce high standards of performance?
  • Does management defer to expertise?
  • Has management established a questioning/learning environment?
  • Does management require timely responses provided to safety issues and concerns?
  • Does management provide continuous monitoring of performance?
 
Read More

SWP Element 

Equipment Identification - Need / Call to Action

Incidents Continue to Happen 

 

“Release of toxic chlorine gas during a routine delivery activity due to the inadvertent mixing of sulphuric acid and sodium hypochlorite, injuring 140 people in a nearby community. Improper Equipment Identification of piping, specifically chemical lines containing incompatible materials, resulted in a release of chlorine gas. Investigation recommends that attention be paid for design, identification and operation of the equipment.” 

More: https://www.youtube.com/watch?v=Tflm9mttAAI

U.S. Chemical Safety Board

 

Maintain a Sense of Vulnerability

 

A Sense of Vulnerability Is Healthy – Just because it has not happened yet (or here) does not mean it will not happen in the future!

  • Is a sense of vulnerability a critical part of the mindset of every employee and contractor?
  • Do you require consistency in practice from everyone in the organization?
  • Do you have systems in place to determine if inconsistencies exist?
  • Do people believe that “yes, it can happen here”?
  • Do people believe that “yes, we have similar vulnerabilities”?
  • Have you experienced similar incidents but without consequences (i.e., near misses)?
  • Do you combat organizational overconfidence that can be stimulated by past good performance?
  • Do discussions on potential vulnerabilities take place between operations and senior leadership?
  • Do systems exist that can identify improper or insufficient Equipment Identification?
  • Have you experienced incidents or near misses due to improper or incomplete labelling, tagging, or identification?
  • Are Equipment Identification checks included on Return to Operation or Return to Service checklists?
 

Prevent Normalization of Deviation

 

Normalization of deviation is defined as…..

The gradual process through which unacceptable practice or standards become acceptable.  As the deviant behavior is repeated without catastrophic results, it becomes the social norm for the organization.                                                    

Sociologist Dr. Diane Vaughan (The Challenger Launch Decision, 1996)

 

A gradual erosion of standards of performance as a result of increased tolerance of nonconformance.                                                                                      

CCPS Glossary (iPhone Application)

 

Signs of Normalization of Deviations – Does this describe your organization?

  • If a deviation is absolutely necessary, are there defined steps that should be taken (i.e., a written variance procedure)?
  • Do these defined steps (or variance procedure) require a detailed risk assessment and approval from multiple levels within the organization?
  • Are the expectations clear that no one individual alone is permitted to determine whether a deviation is permissible?
  • Do you allow operations outside established safe operating limits without a detailed risk assessment?
  • Are willful, conscious, violations of established procedures tolerated without investigation or without consequences for the persons involved?
  • Can employees be counted on to strictly adhere to safety policies and practices when supervision is not around to monitor compliance?
  • Are you tolerating practices, or conditions that would have been deemed unacceptable a year or two ago? 
  • Are all employees empowered to stop work for any situation deemed unsafe?
  • Are all levels of the organization comfortable with calling out identified gaps?
  • Have you experienced incidents or near misses due to improper or incomplete labelling, tagging, or identification?
 

Evaluate Your Program

 

Do you audit your Equipment Identification program to ensure the program is yielding the intended results?

 

Do you review the following items?

  • Written procedures?
  • Roles and responsibilities of persons involved in Equipment Identification activities?
  • Training and competency provided to persons involved in equipment identification activities?
  • Hazard assessments performed before equipment identification activities are conducted?
  • Job observations performed on equipment identification activities?

 

Items to consider when evaluating your Equipment Identification program include:

  • How is the identification and tagging of equipment and materials done as a practice?
  • Is the local procedure in line with the codes and regulations specifying requirements for various classes of material equipment/pipeline tagging? 
  • How frequently are the unique identifiers reviewed and corrections or updates made to highly critical equipment?
  • Does the Permit to Work (PTW) cover how to identify incorrect tagging of the equipment?
    • Are there corrective actions prescribed if any discrepancies are found that might result in a hazardous situation?
  • Do you check equipment identification, tagging, or marking before issuing a permit?
  • Are spares identified properly? Do you have a procedure to check the tagging of new spares?
  • Are any work flow documents referred to before issuing a job permit?
  • Are changes to the equipment made that are not identified or labeled properly?
  • Are there tasks that are done on a daily basis such as sampling or unloading of tankers that have nearby incompatible material connection?
  • Have incompatible materials been identified and segregated in bulk storage locations?
  • Have you experienced incidents or near misses due to improper or incomplete labeling, tagging, or identification of equipment?
  • Are equipment identification checks included on Return-to-Work or Return-to-Service checklists?
  • Are equipment identification checks included on field inspection checklists?
 

Continually Improve Your Program

 

Are you considering improvements to prevent future incidents due to Equipment Identification deficiencies?  Few ideas you may want to consider:

  • How frequently do you review US Chemical Safety Board (CSB) reports, CCPS Process Safety Beacons, internal learnings and alerts from incidents, or any other relevant incident communication having Equipment Identification learning potential with all members of the organization?
  • How often do your senior managers visit the field to identify any improper Equipment Identification in highly hazardous areas?
  • Do you have a requirement to periodically update any review program that targets identification of improper equipment tagging and marking?
  • Do your workers (those closest to the work), have a method to point out deficiencies and suggest improvements to your program?
 

Organizational Culture

 

A successful Equipment Identification program depends on the actions of individuals within the organization.  Do the values and behaviors of your organization determine the manner in which your Equipment Identification program is managed and executed?

  • Does management and supervision reinforce desired behaviors to ensure they become integrated into the group’s values?
  • Are performance expectations / standards clearly established?
  • Is open and effective communication encouraged and supported?
  • Has management established safety as a core value?
  • Does management and supervision provide strong leadership?
  • Has management formalized a safety culture emphasis and approach?
  • Does management work to ensure employees maintain a sense of vulnerability?
  • Are individuals empowered to successfully fulfill their safety responsibilities?
  • Does management ensure open and effective communication exists?
  • Does management support and foster mutual trust?
  • Does management establish and enforce high standards of performance?
  • Does management defer to expertise?
  • Has management established a questioning / learning environment?
  • Does management require timely responses provided to safety issues and concerns?
  • Does management provide continuous monitoring of performance?
Read More

SWP Element 

Scaffolding - Need / Call to Action

Incidents Continue to Happen

“In the USA, an estimated 2.3 million construction workers, or 65 percent of the construction industry, work on scaffolds. Protecting these workers from scaffold-related accidents may prevent some of the 4,500 injuries and over 60 deaths every year”. 

(Bureau of Labor Statistics (BLS), 2003

 

“In the UK, around three-quarters of fatal injuries in both 2017 and 2018 and the combined five-year period 2013-2018 were accounted for by just five different accident kinds. Falls from a height, being struck by a moving vehicle and being struck by a moving object (including flying or falling objects) continue as the three main causes of fatal injury, between them accounting for over half of all fatal injuries each year since at least 2001”. 

http://www.hse.gov.uk/statistics/pdf/fatalinjuries.pdf, Published 4th July 2018

 

Maintain a Sense of Vulnerability

A Sense of Vulnerability Is Healthy – Just because it has not happened yet (or here) does not mean it will not happen in the future!

  • Is a sense of vulnerability a critical part of the mindset of every employee and contractor?
  • Do you require consistency in practice from everyone in the organization?
  • Do you have systems in place to determine if inconsistencies exist?
  • Do people believe that “yes, it can happen here”?
  • Do people believe that “yes, we have similar vulnerabilities”?
  • Have you experienced similar incidents but without consequences (i.e., near misses)?
  • Do you combat organizational overconfidence that can be stimulated by past good performance?
  • Do discussions on potential vulnerabilities take place between operations and senior leadership?

 

Prevent Normalization of Deviation

Normalization of deviation is defined as…..

The gradual process through which unacceptable practice or standards become acceptable.  As the deviant behavior is repeated without catastrophic results, it becomes the social norm for the organization.                                                     

Sociologist Dr. Diane Vaughan (The Challenger Launch Decision, 1996)

 

A gradual erosion of standards of performance as a result of increased tolerance of nonconformance.                                                                                      

CCPS Glossary (iPhone Application)

 

Signs of Normalization of Deviations – Does this describe your organization?

  • If a deviation is absolutely necessary, are there defined steps that must be taken (i.e., a written variance procedure)?
  • Do these defined steps (or variance procedure) require a detailed risk assessment and approval from multiple levels within the organization?
  • Are your the expectations clear that no one individual alone is permitted to determine whether a deviation is permissible?
  • Do you allow operations outside established safe operating limits without a detailed risk assessment?
  • Are willful, conscious, violations of established procedures tolerated without investigation or without consequences for the persons involved?
  • Can employees be counted on to strictly adhere to safety policies and practices when supervision is not around to monitor compliance?
  • Are you tolerating practices, or conditions that would have been deemed unacceptable a year or two ago?  For example:
    • Do you allow hot work to start/progress with an LEL reading greater than 2%?
  • Are all employees empowered to stop work for any situation deemed unsafe?
 

Evaluate Your Program

Do you audit your Scaffolding program to ensure the program is yielding the intended results?

 

Do you review the following items:

  • Written Scaffolding procedure?
  • Scaffolding permits?
  • Roles and responsibilities of persons involved in Scaffolding activities?
  • Training and competency provided to persons involved in Scaffolding activities?
  • Hazard assessments performed before Scaffolding activities are conducted?
  • Job observations performed on Scaffolding activities?
 

Have you audited your Scaffolding permits and discussed the results of the audits?  Was there evidence that:

  • Permits were not completely filled out?
  • Permits were not signed?
  • The permit writer was not trained?
  • The standby person was not trained?
  • Permit conditions were not communicated within the subject work team?
  • Work was not coordinated between work groups (permit writing group vs. group(s) that perform the work?
  • Work extended beyond the authorized period of time?
  • The work area covered by the permit was too large?
  • Certain technical provisions of the permit were not followed?
 

Have you evaluated your Scaffolding audit program?

  • To ensure the quality of the audit process (i.e., protocols, sampling strategies, etc.)?
  • To ensure the competency levels of the auditors?
  • To ensure the program includes details on the following scaffolding elements: design, erection, inspection, safe use, alternatives, and dismantling?
  • Does your Scaffolding procedure reflect the desired intent and is this intent adequately detailed in procedural instruction?
    • Is the “goal” of your program to complete the permit or to use the permit as a tool to facilitate the execution of safe work?
  • Does the execution of the procedure yield the intended results?  Are you evaluating your program for:
    • Procedural Compliance – are actions and tasks in compliance with procedural requirements?  (Paper Control), and
    • Program Health – is your system providing the intended results?  (Actual Execution)
  • Do you know of any site or company incidents related to Scaffolding?
    • Have you discussed the results and causes within your organization?
  • Do you know of any site or company near misses related to Scaffolding?
    • Have you discussed the results and causes within your organization?
 

Continually Improve Your Program

Are you considering improvements to prevent future incidents?  Here are some ideas you may want to consider:

  • How frequently do you review trade publications and other relevant incident communication having learning potential with all members of the organization?
  • Do you track specific Scaffolding-related metrics that can be used to determine program effectiveness and improve performance?
  • Have you benchmarked your program against other programs in your industry?
  • How often do your senior managers visit the field to watch Scaffolding in action?
  • Do you have a requirement to periodically update your program?
  • Do your workers (those closest to the work), have an easy method to suggest improvements to your program?
 

Organizational Culture

A successful Scaffolding program depends on the actions of individuals within the organization.  Do the values and behaviors of your organization determine the manner in which your Scaffolding program is managed and executed?

  • Does management and supervision reinforce desired behaviors to ensure they become integrated into the group’s values?
  • Are high standards of Scaffolding performance clearly established?
  • Is open and effective communication encouraged and supported?
  • Has management established safety as a core value?
  • Does management and supervision provide strong leadership?
  • Has management formalized the safety culture emphasis and approach?
  • Does management work to ensure employees maintain a sense of vulnerability?
  • Are individuals empowered to successfully fulfill their safety responsibilities?
  • Does management ensure open and effective communication exists?
  • Does management support and foster mutual trust?
  • Does management establish and enforce high standards of performance?
  • Does management defer to expertise?
  • Has management established a questioning/learning environment?
  • Does management require timely responses provided to safety issues and concerns?
  • Does management provide continuous monitoring of performance?
 
Read More

SWP Element 

Equipment Filling and Mixing - Need / Call to Action

Incidents Continue to Happen

“High risk operations, like the delivery and handling of hazardous chemicals, require strict adherence to safety protocols. An inadvertent mixture can result in a chemical reaction with extremely dangerous consequences. Our findings reaffirm the need for facilities to pay careful attention to the design and operation of chemical transfer equipment to prevent similar events.”

CSB Chairperson Vanessa Allen Sutherland

 

Maintain a Sense of Vulnerability

A Sense of Vulnerability Is Healthy – Just because it has not happened yet (or here) does not mean it will not happen in the future!

  • Is a sense of vulnerability a critical part of the mindset of every employee and contractor?
  • Do you require consistency in practice from everyone in the organization?
  • Do you have systems in place to determine if inconsistencies exist?
  • Do people believe that “yes, it can happen here”?
  • Do people believe that “yes, we have similar vulnerabilities”?
  • Have you experienced similar incidents but without consequences (i.e., near misses)?
 

Prevent Normalization of Deviation

Normalization of deviation is defined as…..

The gradual process through which unacceptable practice or standards become acceptable.  As the deviant behavior is repeated without catastrophic results, it becomes the social norm for the organization.                                                     

Sociologist Dr. Diane Vaughan (The Challenger Launch Decision, 1996)

 

A gradual erosion of standards of performance as a result of increased tolerance of nonconformance.                                                                                       

CCPS Glossary (iPhone Application)

 

Signs of Normalization of Deviations – Does any of these describe your organization?

  • If a deviation is absolutely necessary, are there defined steps that must be taken (i.e., a written variance procedure)?
  • Do these defined steps (or variance procedure) require a detailed risk assessment and approval from multiple levels within the organization?
  • Are your the expectations clear that no one individual alone is permitted to determine whether a deviation is permissible?
  • Do you allow operations outside established safe operating limits without a detailed risk assessment?
  • Are willful, conscious, violations of established procedures tolerated without investigation or without consequences for the person(s) involved?
  • Can employees be counted on to strictly adhere to safety policies and practices when supervision is not around to monitor compliance?
  • Are you tolerating practices, or conditions that would have been deemed unacceptable a year or two ago? 
  • Are all employees empowered to stop work for any situation deemed unsafe?
 

Evaluate Your Program

Do you audit your equipment filling and mixing practices and procedures to ensure they are yielding the intended results?

Do you review the following items?

  • Hazardous reactions which can occur if materials in your plant are accidentally mixed?
  • Unloading pipe connections are clearly labeled, including the use of a code or numbering system to avoid confusion of materials with similar names?
  • Roles and responsibilities of persons involved in hazard identification activities?
  • Training and competency provided to persons involved in chemicals handling activities?
  • Hazard assessments performed before de-commissioning activities are conducted?
  • Location of chemicals stored?
  • Availability of appropriate emergency response equipment?
 

Continually Improve Your Program

Are you considering improvements to prevent future incidents?  Here are some ideas you may want to consider:

  • How frequently do you review Chemical Safety Board (CSB) reports, CCPS Process Safety Beacons, and other relevant incident communication having learning potential with all members of the organization?
  • Do you track specific process safety incidents due to mixing of incompatible fluids-related metrics that can be used to determine program effectiveness and improve performance?
  • Have you benchmarked your program against other programs in your industry?
  • How often do your senior managers visit the field to watch filling and mixing operations in action?
  • Do you have a requirement to periodically update your program?
  • Do your workers (those closest to the work), have an easy method to suggest improvements to your program?
 

Organizational Culture

A successful equipment filling and mixing program depends on the actions of individuals within the organization.  Do the values and behaviors of your organization determine the manner in which your equipment filling and mixing program is managed and executed?

  • Does management and supervision reinforce desired behaviors to ensure they become integrated into the group’s values?
  • Are high standards of equipment filling and mixing performance clearly established?
  • Does management establish and enforce high standards of performance?
  • Does management defer to expertise?
  • Has management established a questioning/learning environment?
  • Does management require timely responses provided to safety issues and concerns?
  • Does management provide continuous monitoring of performance?


Read More

SWP Element 

Field Review of Permits - Need / Call to Action

Incidents Continue to Happen 

Fertilizer Plant Fire - Following the completion of welding work by contractors, a fire spread due to the presence of combustible materials in the area including cable trays and conveyor belts.

(Area was not inspected after completion of the Hot Work).

LMA OG&P Loss Analysis

 

Refinery Fire - incident occurred during start-up of the main crude unit following a unit turnaround. Maintenance personnel worked on the wrong flange leading to a release of hydrocarbon and major fire at the base of the main column. 

(The work location was not adequately identified by Operations).

LMA OG&P Loss Analysis

 

Toxic Release - Over 500,000 people were exposed to toxic methyl isocyanate, killing over 5000 people, most of them were women and children.

 (The leak was caused by a discharge of water into a storage tank. This was the result of a combination of operator error and weak permit-to-work system).

Union Carbide, Bhopal, India, 1984

 

Fire and Explosion - Occurred in cooling tower after removal of blind in cooling water header of adjacent cooling tower. 22 killed and 15 injured, who were engaged in hot job.

(Immediate cause was, permit failed to recognize the impact of commissioning the adjacent cooling tower on the crew engaged in Hot Work).

 

Confined Space Entry - Smoke carried from the fire outside the reactor killed 12 and injured 11 inside the EO reactor.

(Permit roles did not identify the location-specific hazards).

 

Maintain a Sense of Vulnerability

A Sense of Vulnerability Is Healthy – Just because it has not happened yet (or here) does not mean it will not happen in the future!

  • Is a sense of vulnerability a critical part of the mindset of every employee and contractor?
  • Do you require consistency in practice from everyone in the organization?
  • Do you have systems in place to determine if inconsistencies exist?
  • Do people believe that “yes, it can happen here”?
  • Do people believe that “yes, we have similar vulnerabilities”?
  • Have you experienced similar incidents but without consequences (i.e., near misses)?
  • Do you combat organizational overconfidence that can be stimulated by past good performance?
  • Do discussions on potential vulnerabilities take place between operations and senior leadership?
  • Do personnel believe that “Field visits before issuing the permits are important and all permits roles are responsible for executing the activities safely “?
  • Do systems exist that would provide sufficient time for Permit roles to identify Task and Location specific Hazards, and to consider other ongoing work or simultaneous operations (SIMOPS) ongoing in area?
  • Have you experienced incidents that were near misses due to improperly identifying location specific hazards or situational factors?
  • Have you experienced major incidents on routine activities due to inadequate identification of specific hazards present on the day of incident?
  • Have you experienced major accidents in last day of scheduled maintenance activity?
  • Have you experienced permits issued on running/live equipment?
  • Have you experienced cutting of wrong pipelines even though the permit was issued?
  • Have you experienced tripping of plant due to bypassing of wrong Interlock?
  • Have you experienced work initiated on equipment which was not yet supposed start at that time?
 

Prevent Normalization of Deviation

Normalization of deviation is defined as…..

 

The gradual process through which unacceptable practice or standards become acceptable.  As the deviant behavior is repeated without catastrophic results, it becomes the social norm for the organization.                                                    

Sociologist Dr. Diane Vaughan (The Challenger Launch Decision, 1996)

 

A gradual erosion of standards of performance as a result of increased tolerance of nonconformance.                                                                                       

CCPS Glossary (iPhone Application)

 

Signs of Normalization of Deviations – Does this describe your organization?

  • If a deviation is absolutely necessary, are there defined steps that should be taken (i.e., a written variance procedure)?
  • Do these defined steps (or variance procedure) require a detailed risk assessment and approval from multiple levels within the organization?
  • Are your the expectations clear that no one individual alone is permitted to determine whether a deviation is permissible?
  • Do you allow operations outside established safe operating limits without a detailed risk assessment?
  • Are willful, conscious, violations of established procedures tolerated without investigation or without consequences for the persons involved?
  • Can employees be counted on to strictly adhere to safety policies and practices when supervision is not around to monitor compliance?
  • Are you tolerating practices, or conditions that would have been deemed unacceptable a year or two ago? 
  • Are all employees empowered to stop work for any situation deemed unsafe?
  • Do we have PTW policy which mandates field review of permits?
  • Do we allow enough time to permit roles to carry out field review?
  • Is there a review of staffing/manpower loading (number of permits vs. operators to review jobs)?
  • Do competent person inspect work site before the risk assessment is completed?
  • Do we have planning process defined and working?
  • Do we estimate the time for each permit and the maximum number of permits that should be issued by each issuer?
  • Do we have a defined list of competent permit roles authorized for the area they know?
  • Do Permit roles sign the permits in control room without field review?
  • Do we use generic risk assessments to identify the hazards and controls?
  • Do we have a system to audit sample of live and completed permits to assess quality and compliance?
 

Evaluate Your Program

How is the planning and risk assessment of the job done as a practice?

  • How is the field review of permits done as a practice?
  • Who are responsible for field review?
  • Is it required to carry out field review before issuing the permit?  What about during the work and after the work has been complete?
  • Is the local procedure in line with the codes and regulations specifying requirements for the field review of job to be executed? 
  • How frequently are the Critical jobs are reviewed and corrections/updating made to local practices?
  • How does the PTW process ensure that the field review is completed? Are there any corrective actions prescribed if any discrepancies are found that might result in a hazardous situation?
 

Continually Improve Your Program

Are you considering improvements to prevent any future incidents due to deficiencies in field review by permit roles?  Here are some ideas you may want to consider:

  • How frequently do you review Chemical Safety Board (CSB) reports, Process Safety Beacon and other relevant incident communication having learning potential with all members of the organization?
  • Do PTW form includes the requirement of field inspection of the Safe Work Permit requested, before, during and after execution of the job?
  • Do you involve work crew representative/s during planning, task risk assessment and field inspection at different stages of work activity?
  • How do you make permit roles feel empowered, particularly area operator and work crew members?
  • Do you have a system to improve engagement of people, e.g., Safety Observation process or safety walk?
  • Do you have a requirement to verify controls for high risk maintenance activities by senior leadership before the permit is issued for execution?
  • How often do your senior managers visit the field / plant site/ job location to verify the risk assessments prepared by the team and execution of controls identified in risk assessment?
  • Do your workers (those closest to the work), have a method to point out deficiencies in identified controls before or during execution of the job?
 

Organizational Culture

A successful Permit to Work program depends on the actions of individuals within the organization.  Do the values and behaviors of your organization determine the manner in which your Permit to Work program is managed and executed?

  • Does management and supervision reinforce desired behaviors to ensure they become integrated into the group’s values?
  • Are high standards of Permit to Work performance clearly established?
  • Is open and effective communication encouraged and supported?
  • Has management established safety as a core value?
  • Does management and supervision provide strong leadership?
  • Has management formalized the safety culture emphasis and approach?
  • Does management work to ensure employees maintain a sense of vulnerability?
  • Are individuals empowered to successfully fulfill their safety responsibilities?
  • Does management ensure open and effective communication exists?
  • Does management support and foster mutual trust?
  • Does management establish and enforce high standards of performance?
  • Does management defer to expertise?
  • Has management established a questioning/learning environment?
  • Does management require timely responses provided to safety issues and concerns?
  • Does management provide continuous monitoring of performance?
 
Read More

SWP Element 

Hot Tapping - Need / Call to Action

Incidents Continue to Happen

  • Incidents during hot tapping are sparsely reported or available.  
  • The worst-case scenario during hot tapping is a burn-through during welding of the nozzle on a live piece of pipeline or equipment.  If the leaking fluid is flammable, it could immediately lead to fire and/or explosion with potentially catastrophic consequences.  
  • Other fluids like steam and/or condensate, etc., at high temperature can cause serious injuries to personnel close to the hot tap location.
 

Maintain a Sense of Vulnerability

A Sense of Vulnerability is Healthy – Just because it has not happened yet (or here) does not mean it will not happen in the future!

  • Is a sense of vulnerability a critical part of the mindset of every employee and contractor?
  • Do you require consistency in practice from everyone in the organization?
  • Do you have systems in place to determine if inconsistencies exist?
  • Do people believe that “yes, it can happen here”?
  • Do people believe that “yes, we have similar vulnerabilities”?
  • Have you experienced similar incidents but without consequences (i.e., near misses)?
  • Do you combat organizational overconfidence that can be stimulated by past good performance?
  • Do discussions on potential vulnerabilities take place between operations and senior leadership?
 

Prevent Normalization of Deviation

Normalization of deviation is defined as…..

The gradual process through which unacceptable practice or standards become acceptable.  As the deviant behavior is repeated without catastrophic results, it becomes the social norm for the organization.                                                    

Sociologist Dr. Diane Vaughan (The Challenger Launch Decision, 1996)

A gradual erosion of standards of performance as a result of increased tolerance of nonconformance.                                                                                      

CCPS Glossary (iPhone Application)

 

Signs of Normalization of Deviations – Does this describe your organization?

  • If a deviation is absolutely necessary, are there defined steps that must be taken (i.e., a written variance procedure)?
  • Do these defined steps (or variance procedure) require a detailed risk assessment and approval from multiple levels within the organization?
  • Are your expectations clear that no one individual alone is permitted to determine whether a deviation is permissible?
  • Do you allow operations outside established safe operating limits without a detailed risk assessment?
  • Are willful, conscious, violations of established procedures tolerated without investigation or without consequences for the persons involved?
  • Can employees be counted on to strictly adhere to safety policies and practices when supervision is not around to monitor compliance?
  • Are you tolerating practices, or conditions that would have been deemed unacceptable a year or two ago? 
  • Are all employees empowered to stop work for any situation deemed unsafe?
 

Evaluate Your Program

Do you audit your Hot Tapping program to ensure the program is yielding the intended results?

 

Do you routinely review the following items:

  • Written Hot Tapping procedure?
  • Hot Tapping permits?
  • Roles and responsibilities of persons involved in Hot Tapping activities?
  • Training and competency provided to persons involved in Hot Tapping activities?
  • Hazard assessments performed before Hot Tapping activities are conducted?
  • Job observations performed on Hot Tapping activities?
 

Have you audited your Hot Tapping permits and discussed the results of the audits?  Was there evidence that:

  • Permits were not completely filled out?
  • Permits were not signed?
  • The permit writer was not trained?
  • Permit conditions were not communicated within the subject work team?
  • Work was not coordinated between work groups (permit writing group vs. group(s) that perform the work?
  • Work extended beyond the authorized period of time?
  • The work area covered by the permit was too large?
  • Certain technical provisions of the permit were not followed?
  • Gas detection was not performed properly or continuously?
  • Emergency response measures were not in place?
 

Have you evaluated your Hot Tapping audit program?

  • To ensure the quality of the audit process (i.e., protocols, sampling strategies, etc.)?
  • To ensure the competency levels of the auditors?
  • Does your Hot Tapping procedure reflect the desired intent and is this intent adequately detailed in procedural instruction?
    • Is the “goal” of your program to complete the permit or to use the permit as a tool to facilitate the execution of safe work?
  • Does the execution of the procedure yield the intended results?  Are you evaluating your program for:
    • Procedural Compliance – are actions and tasks in compliance with procedural requirements?  (Paper Control), and
    • Program Health – is your system providing the intended results?  (Actual Execution)                                                                                                                    
  • Do you know of any site or company incidents related to Hot Work?
    • Have you discussed the results and causes within your organization?
  • Do you know of any site or company near misses related to Hot Work?
    • Have you discussed the results and causes within your organization?
 

Continually Improve Your Program

Are you considering improvements to prevent future incidents?  Here are some ideas you may want to consider:

  • How frequently do you review Chemical Safety Board (CSB) reports, CCPS Process Safety Beacons, and other relevant incident communication having learning potential with all members of the organization?
  • Do you track specific hot tapping -related metrics that can be used to determine program effectiveness and improve performance?
  • Have you benchmarked your program against other programs in your industry?
  • How often do your senior managers visit the field to watch hot tapping in action?
  • Do you have a requirement to periodically update your program?
  • Do your workers (those closest to the work), have an easy method to suggest improvements to your program?
 

Organizational Culture

A successful Hot Tapping program depends on the actions of individuals within the organization.  Do the values and behaviors of your organization determine the manner in which your Hot Tap program is managed and executed?

  • Does management and supervision reinforce desired behaviors to ensure they become integrated into the group’s values?
  • Are high standards of Hot Tapping performance clearly established?
  • Is open and effective communication encouraged and supported?
  • Has management established safety as a core value?
  • Does management and supervision provide strong leadership?
  • Has management formalized the safety culture emphasis and approach?
  • Does management work to ensure employees maintain a sense of vulnerability?
  • Are individuals empowered to successfully fulfill their safety responsibilities?
  • Does management ensure open and effective communication exists?
  • Does management support and foster mutual trust?
  • Does management establish and enforce high standards of performance?
  • Does management defer to expertise?
  • Has management established a questioning / learning environment?
  • Does management require timely responses provided to safety issues and concerns?
  • Does management provide continuous monitoring of performance?


Read More

SWP Element 

Confined Space Entry - Need / Call to Action

Incidents Continue to Happen

“Key Largo, FL, January 2017 – Three underground utility workers died after entering a confined space without the proper personal protective equipment or gas monitoring equipment.  According to initial inquiries, the first man entered a 15-foot deep drainage hole and became unresponsive.  The second worker entered the opening with the intention of savings the first man but also lost consciousness.  The third man climbed in to help his coworkers and was overcome.” 

– EHS Today, 2017


“On average, two people will go to work this week somewhere in the United States and not return home to their families as a result of entering a confined space.  According to the annual Census of Fatal Occupational Injuries, compiled by the Bureau of Labor Statistics, 136 U.S. workers died in incidents associated with confined spaces in 2015.” 

NFPA Journal, March-April 2017


“The accident took place on a container ship while on port.  After giving instructions to the engine room department, the 2nd Engineer along with the engine room fitter went into the ship’s tunnel to overhaul a leaky storm valve. The 2nd Engineer and the fitter started their work in the confined space of the tunnel.  They isolated the line and slackened the valve from the place. However, they neglected the point that the line can have trapped poisonous gases inside it.   As soon as the valve was removed, the toxic gas escaped into the confined space tunnel. The 2nd Engineer and fitter collapsed instantly.  This was not all.  After some time, the 4th Engineer went into the tunnel looking for the 2nd Engineer.  Unaware of the situation, the 4th Engineer also collapsed because of the poisonous gases as soon as he entered the confined space.  After few hours, the 3rd Engineer on not finding 2nd and 4th Engineers, informed the Chief Engineer about the situation.  A team entered the tunnel after taking proper precautions to rescue people from confined space along with breathing apparatus and discovered that 2nd Engineer, 4th Engineer and fitter had died due to suffocation by poisonous gases in the confined space.”

– Marine Insight, April 2017

 
 

Maintain a Sense of Vulnerability

 

A Sense of Vulnerability Is Healthy – Just because it has not happened yet (or here) does not mean it will not happen in the future!

 
  • Is a sense of vulnerability a critical part of the mindset of every employee and contractor?
  • Do you require consistency in practice from everyone in the organization?
  • Do you have systems in place to determine if inconsistencies exist?
  • Do people believe that “yes, it can happen here”?
  • Do people believe that “yes, we have similar vulnerabilities”?
  • Have you experienced similar incidents but without consequences (i.e., near misses)?

Do you combat organizational overconfidence that can be stimulated by past good performance?

 
 

Prevent Normalization of Deviation

 

Normalization of deviation is defined as…..

 
 

“The gradual process through which unacceptable practice or standards become acceptable.  As the deviant behavior is repeated without catastrophic results, it becomes the social norm for the organization.”                                                     

                                                                                                                 Sociologist Dr. Diane Vaughan (The Challenger Launch Decision, 1996)


“A gradual erosion of standards of performance as a result of increased tolerance of nonconformance.”                                                                                       

                                                                                                                                                                     - CCPS Glossary (iPhone Application)

 
 

Signs of Normalization of Deviations – Does this describe your organization?

 
  • If a deviation is necessary, are there defined steps that must be taken (i.e., a written variance procedure)?
  • Do these defined steps (or variance procedure) require a detailed risk assessment and approval from multiple levels within the organization?
  • Are your expectations clear that no one individual alone is permitted to determine whether a deviation is permissible?
  • Do you allow operations outside established safe operating limits without a detailed risk assessment?
  • Are willful, conscious, violations of established procedures tolerated without investigation or without consequences for the persons involved?
  • Can employees be counted on to strictly adhere to safety policies and practices when supervision is not around to monitor compliance?
  • Are you tolerating practices, or conditions that would have been deemed unacceptable a year or two ago?  For example:

o   Entering a vessel skirt without a proper confined space permit?

o   Not assuring that confined space to be entered is tested properly for hazards including lack of oxygen?

o   Not using confined space permit for excavations?

  • Are all employees empowered to stop work for any situation deemed unsafe?


Evaluate Your Program

 

Do you audit your Confined Space Entry program to ensure the program is yielding the intended results?

 

Do you review the following items:

 
  • Written Confined Space Entry procedure?
  • Confined Space Entry permits?
  • Roles and responsibilities of persons involved in Confined Space Entry activities?
  • Training and competency provided to persons involved in Confined Space Entry activities?
  • Hazard assessments performed before Confined Space Entry activities are conducted?
  • Job observations performed on Confined Space Entry activities?
  • Personal protective equipment requirements for Confined Space Entry?
  • Proper isolation techniques including blinds or physical disconnects?
  • Proper draining and cleaning equipment before Confined Space Entry?
  • Atmosphere testing procedure that includes testing for toxics and oxygen at different levels/locations in the equipment to be entered?
  • Equipment properly locked out?
  • Rescue procedures and equipment in place?
  • Fault interrupters used for electrical equipment?
  • Pneumatic tools not operated by nitrogen?
  • Proper ventilation and lighting provided?
 
 

Have you audited your Confined Space Entry permits and discussed the results of the audits?  Was there evidence that:

 
  • Permits were not completely filled out (i.e., last hazardous material contained in the line not identified?).
  • Permits were not signed?
  • Proper PPE requirements not identified?
  • The permit writer was not trained?
  • Equipment not properly cleaned or drained?
  • Equipment not isolated properly (blinds or disconnects)?
  • LOTO procedures not followed?
  • Rescue procedures and equipment were not available?
  • Permit conditions were not communicated within the subject work team?
  • Atmosphere was not tested for flammables (if handled), toxics and oxygen?
  • Proper ventilation and lighting not provided?
  • Work was not coordinated between work groups (permit writing group vs. group(s) that perform the work?
  • Work extended beyond the authorized period of time?
 
 

Have you evaluated your Confined Space Entry audit program?

  • To ensure the quality of the audit process (i.e., protocols, sampling strategies, etc.)?
  • To ensure the competency levels of the auditors?
  • Does your Confined Space Entry procedure reflect the desired intent and is this intent adequately detailed in procedural instruction? 

o   Is the “goal” of your program to complete the permit or to use the permit as a tool to facilitate the execution of safe work?

  • Does the execution of the procedure yield the intended results?  Are you evaluating your program for:

o   Procedural Compliance – are actions and tasks in compliance with procedural requirements?  (Paper Control), and

o   Program Health – is your system providing the intended results?  (Actual Execution)                                                                                                                    

  • Do you know of any site or company incidents related to Confined Space Entry?

o   Have you discussed the results and causes within your organization?

  • Do you know of any site or company near misses related to Confined Space Entry?

o   Have you discussed the results and causes within your organization?


Continually Improve Your Program

 

Are you considering improvements to prevent future incidents?  Here are some ideas you may want to consider:

 
  • How frequently do you review CSB, Process Safety Beacon and other relevant incident communication having learning potential with all members of the organization?
  • Do you track specific confined space entry-related metrics that can be used to determine program effectiveness and improve performance?
  • Have you benchmarked your program against other programs in your industry?
  • How often do your senior managers visit the field to watch confined space entry activity?
  • Do you have a requirement to periodically update your program?
  • Do your workers (those closest to the work) have an easy method to suggest improvements to your program?
 
 

Organizational Culture

 

A successful Confined Space Entry program depends on the actions of individuals within the organization.  Do the values and behaviors of your organization determine the manner in which your Confined Space Entry program is managed and executed?

 
  • Does management and supervision reinforce desired behaviors to ensure they become integrated into the group’s values?
  • Are high standards of Confined Space Entry program performance clearly established?
  • Is open and effective communication encouraged and supported?
  • Has management established safety as a core value?
  • Does management and supervision provide strong leadership?
  • Has management formalized the safety culture emphasis and approach?
  • Does management work to ensure employees maintain a sense of vulnerability?
  • Are individuals empowered to successfully fulfill their safety responsibilities?
  • Does management ensure open and effective communication exists?
  • Does management support and foster mutual trust?
  • Does management establish and enforce high standards of performance?
  • Does management defer to expertise?
  • Has management established a questioning/learning environment?
  • Does management require timely responses provided to safety issues and concerns?
  • Does management provide continuous monitoring of performance?
Read More

SWP Element 

Temporary Instrumentation and Controls Bypass - Need / Call to Action

Incidents Continue to Happen

Examples to be published soon.

Maintain a Sense of Vulnerability

A Sense of Vulnerability Is Healthy – Just because it has not happened yet (or here) does not mean it will not happen in the future!

  • Is a sense of vulnerability a critical part of the mindset of every employee and contractor?
  • Do you require consistency in practice from everyone in the organization?
  • Do you have systems in place to determine if inconsistencies exist?
  • Do people believe that “yes, it can happen here”?
  • Do people believe that “yes, we have similar vulnerabilities”?
  • Have you experienced similar incidents but without consequences (i.e., near misses)?
  • Do you combat organizational overconfidence that can be stimulated by past good performance?
  • Do discussions on potential vulnerabilities take place between operations and senior leadership?

Prevent Normalization of Deviation

Normalization of deviation is defined as… 



“The gradual process through which unacceptable practice or standards become acceptable.   As the deviant behavior is repeated without catastrophic results, it becomes the social norm for the organization."

                                                                                                   Sociologist Dr. Diane Vaughan (The Challenger Launch Decision, 1996)

“A gradual erosion of standards of performance as a result of increased tolerance of nonconformance"

                                                                                                                                                                                                 CCPS Glossary 

Signs of Normalization of Deviations – Does this describe your organization?

  • If a deviation is absolutely necessary, are there defined steps that must be taken (i.e., a written variance procedure)?
  • Do these defined steps (or variance procedure) require a detailed risk assessment and approval from multiple levels within the organization?
  • Are the expectations clear that no one individual alone is permitted to determine whether a deviation is permissible?
  • Do you allow operations outside established safe operating limits without a detailed risk assessment?
  • Are willful, conscious, violations of established procedures tolerated without investiga-tion or without consequences for the persons involved?
  • Can employees be counted on to strictly adhere to safety policies and practices when supervision is not around to monitor compliance?
  • Are you tolerating practices, or conditions that would have been deemed unacceptable a year or two ago?  For example:
    • Do you allow routine bypasses during plant start-up without additional means of managing risk?
  • Are all employees empowered to stop work for any situation deemed unsafe?

Evaluate Your Program

Do you audit your Safeguard Bypass program to ensure the program is yielding the intended results?

Do you review the following items:

• Written Bypass procedures?

• Bypass permits or temporary MOCs?

• Roles and responsibilities of persons involved in Bypass activities?

• Training and competency of persons involved in Bypass activities?

• Compensating measures that should be in place before Bypass activities are conducted?

• Job observations performed on Bypass activities?

Have you evaluated your Bypass audit program?

  • To ensure the quality of the audit process (i.e., protocols, sampling strategies, etc.)?
  • To ensure the competency levels of the auditors?
  • Does your Bypass procedure reflect the desired intent and is this intent adequately de-tailed in procedural instruction?
    • Is the “goal” of your program to complete the permit or to use the permit as a tool to facilitate the execution of safe work?
  • Does the execution of the procedure yield the intended results?  Are you evaluating your program for:
    • Procedural Compliance – are actions and tasks in compliance with procedural requirements?  (Paper Control), and
    • Program Health – is your system providing the intended results?  (Actual Execu-tion)                                                                                                                    
  • Do you know of any site or company incidents related to Bypassing?
    • Have you discussed the results and causes within your organization?
  • Do you know of any site or company near misses related to Bypassing?
    • Have you discussed the results and causes within your organization?

Continually Improve Your Program

Are you considering improvements to prevent future incidents?  Here are some ideas you may want to consider:

• How frequently do you review CSB, Process Safety Beacon and other relevant incident communication having learning potential with all members of the organization?

• Do you track specific bypass-related metrics that can be used to determine program ef-fectiveness and improve performance?

• Have you benchmarked your program against other programs in your industry?

• How often do your senior managers visit the field to inspect bypass status?

• Do you have a requirement to periodically update your program?

• Do your workers (those closest to the work), have an easy method to suggest improvements to your program?

Read More

SWP Element 

Hot Work - Need / Call to Action

Incidents Continue to Happen

Washington DC, August 15, 2016 - An investigative team from the U.S. Chemical Safety Board (CSB) is deploying to the scene of an incident that injured seven workers – including three critically – that occurred Friday August 12 at the Sunoco Logistics Partners, a terminal facility in Nederland, Texas.  According to initial inquiries the incident involved a flash fire during welding – also referred to as hot work - activities at the facility.  Hot work is defined as burning, welding, or similar spark-producing operations that can ignite fires or explosions. Media reports state that all of the injured were contractors engaged in work activities on a crude oil pipeline connection.

– US Chemical Safety Board

 

"We typically hear about hot work accidents weekly.  It has become one of the most significant types of incidents the CSB investigates, in terms of deaths, in terms of frequency."

– CSB Investigations Supervisor Donald Holmstrom, 2010

 

“The CSB has identified over 60 fatalities since 1990 due to explosions and fires from hot work activities on tanks.  Hot work is defined as “work involving burning, welding, or a similar opera-tion that is capable of initiating fires or explosions.”  Hot work also includes other activities with the potential to create a source of ignition such as cutting, brazing, grinding, and soldering.  Workers are potentially at risk not only in the oil and gas industry, where flammables are handled regularly, but also in many other sectors within general industry, such as food production, paper, and wastewater treatment.” 

– Seven Key Lessons to Prevent Worker Deaths During Hot Work In and Around Tanks, CSB 2009 

 

“According to insurance industry statistics, hot work operations are one of the largest causes of fire loss in the workplace.” 

– EMC Insurance Company 

 

“Hot work operations conducted outside of a designated hot work area (a weld shop for exam-ple) are a major cause of fires. Between 2005 and 2009, the United States averaged 3,165 fires, $145 million in property damage, 8 deaths, and 116 civilian injuries per year relating to torch, soldering, and burner equipment.”

– National Fire Protection Association (NFPA), March 2011 

 

Maintain a Sense of Vulnerability

A Sense of Vulnerability Is Healthy – Just because it has not happened yet (or here) does not mean it will not happen in the future! Is a sense of vulnerability a critical part of the mindset of every employee and contractor?

  • Do you require consistency in practice from everyone in the organization?
  • Do you have systems in place to determine if inconsistencies exist?
  • Do people believe that “yes, it can happen here”?
  • Do people believe that “yes, we have similar vulnerabilities”?
  • Have you experienced similar incidents but without consequences (i.e., near misses)?
  • Do you combat organizational overconfidence that can be stimulated by past good performance?
  • Do discussions on potential vulnerabilities take place between operations and senior leadership?

Prevent Normalization of Deviation

 

Normalization of deviation is defined as…

 

“The gradual process through which unacceptable practice or standards become acceptable.  As the deviant behavior is repeated without catastrophic results, it becomes the social norm for the organization.” 

– Sociologist Dr. Diane Vaughan (The Challenger Launch Decision, 1996)

 

 

A gradual erosion of standards of performance as a result of increased tolerance of nonconformance.” 

– CCPS Glossary (iPhone Application)

 

Signs of Normalization of Deviations – Does this describe your organization?

  • If a deviation is absolutely necessary, are there defined steps that must be taken (i.e., a written variance procedure)?
  • Do these defined steps (or variance procedure) require a detailed risk assessment and approval from multiple levels within the organization?
  • Are the expectations clear that no one individual alone is permitted to determine whether a deviation is permissible?
  • Do you allow operations outside established safe operating limits without a detailed risk assessment?
  • Are willful, conscious, violations of established procedures tolerated without investiga-tion or without consequences for the persons involved?
  • Can employees be counted on to strictly adhere to safety policies and practices when supervision is not around to monitor compliance?
  • Are you tolerating practices, or conditions that would have been deemed unacceptable a year or two ago?  For example:
    • Do you allow hot work to start/progress with an LEL reading greater than 2%?
  • Are all employees empowered to stop work for any situation deemed unsafe?

Evaluate Your Program

Do you audit your Hot Work program to ensure the program is yielding the intended results?

Do you review the following items:

  • Written Hot Work procedure?
  • Hot Work permits?
  • Roles and responsibilities of persons involved in Hot Work activities?
  • Training and competency provided to persons involved in Hot Work activities?
  • Hazard assessments performed before Hot Work activities are conducted?
  • Job observations performed on Hot Work activities?

Have you audited your Hot Work permits and discussed the results of the audits? 

Was there evidence that:

  • Permits were not completely filled out (i.e., no LEL reading)?
  • Permits were not signed?
  • Permits showed evidence that the Fire Watch failed to remain on site after job comple-tion?
  • The permit writer was not trained?
  • The fire watch not trained?
  • Permit conditions were not communicated within the subject work team?
  • Work was not coordinated between work groups (permit writing group vs. group(s) that perform the work?
  • Work extended beyond the authorized period of time?
  • The work area covered by the permit was too large?
  • Certain technical provisions of the permit were not followed?
  • Gas detection was not performed properly or continuously?

Have you evaluated your Hot Work audit program?

  • To ensure the quality of the audit process (i.e., protocols, sampling strategies, etc.)?
  • To ensure the competency levels of the auditors?
  • Does your Hot Work procedure reflect the desired intent and is this intent adequately detailed in procedural instruction?
    • Is the “goal” of your program to complete the permit or to use the permit as a tool to facilitate the execution of safe work?
  • Does the execution of the procedure yield the intended results?  Are you evaluating your program for:
    • Procedural Compliance – are actions and tasks in compliance with procedural requirements?  (Paper Control), and
    • Program Health – is your system providing the intended results?  (Actual Execution)                                                                                                                    
  • Do you know of any site or company incidents related to Hot Work?
    • Have you discussed the results and causes within your organization?
  • Do you know of any site or company near misses related to Hot Work?
    • Have you discussed the results and causes within your organization?

Continually Improve Your Program

Are you considering improvements to prevent future incidents?  Here are some ideas you may want to consider:

  • How frequently do you review CSB, Process Safety Beacon and other relevant incident communication having learning potential with all members of the organization?
  • How frequently and what methods are used to calibrate the LEL meters?
  • Do you have sufficient LEL meters to support all hot work?
  • Do you track specific hot work-related metrics that can be used to determine program effectiveness and improve performance?
  • Have you benchmarked your program against other programs in your industry?
  • How often do your senior managers visit the field to watch hot work in action?
  • Do you have a requirement to periodically update your program?
  • Do your workers (those closest to the work), have an easy method to suggest improvements to your program?

Organizational Culture

A successful Hot Work program depends on the actions of individuals within the organization.  Do the values and behaviors of your organization determine the manner in which your Hot Work program is managed and executed?

  • Does management and supervision reinforce desired behaviors to ensure they be-come integrated into the group’s values?
  • Are high standards of Hot Work performance clearly established?
  • Is open and effective communication encouraged and supported?
  • Has management established safety as a core value?
  • Does management and supervision provide strong leadership?
  • Has management formalized the safety culture emphasis and approach?
  • Does management work to ensure employees maintain a sense of vulnerability?
  • Are individuals empowered to successfully fulfill their safety responsibilities?
  • Does management ensure open and effective communication exists?
  • Does management support and foster mutual trust?
  • Does management establish and enforce high standards of performance?
  • Does management defer to expertise?
  • Has management established a questioning/learning environment?
  • Does management require timely responses provided to safety issues and concerns?
  • Does management provide continuous monitoring of performance?
Read More

SWP Element 

Energy Isolation - Need / Call to Action

Incidents Continue to Happen

On December 6, 2016, an operations employee had already locked out the suction and discharge valves for pump AC-11. It was discovered that the drain line valve for AC-01 was faulty and could not open to drain hot monomer. A Safe Work Permit that called for a line break using an Unusual Job Permit (UJP) was issued on December 6, 2016 at 7:30 am. The pump jacket was drained of its heat transfer medium (HTM) oil into a black 55-gallon drum, prior to maintenance mechanic splitting open pump AC-11 for the first line break at around 12 noon to drain hot PET monomer. Once the maintenance mechanics had completed the first line break by separating the volute from the pump, hot PET monomer was expected to spill onto the floor around the pump, cool and solidify. Around 12:10 pm, a pressure blast occurred that blew out the right side of the pump about 10-15 feet through the air. The employee was struck by the blast and smashed into the adjacent concrete block wall. The employee was killed from the blast. 

– United States Department of Labor, OSHA Fatality and Catastrophe Investigation Summaries

At approximately 1:30 p.m. on September 6, 2016, an employee was servicing the scissor lift table to fix a leak in the hydraulic hose. The hose fitting broke and the lift table lowered pinning the employee between the table and the floor. The employee received crushing injuries, such as fractured clavicle and ribs with hemorrhaging and was killed.

– U.S. Chemical Safety Board

On April 8, 2004, four workers were seriously injured when highly flammable gasoline components were released and ignited at the Giant Industries Ciniza refinery, east of Gallup, New Mexico. The release occurred as maintenance workers were removing a malfunctioning pump from the refinery’s hydrofluoric acid (HF) alkylation unit. Unknown to personnel, a shut-off valve connecting the pump to a distillation column was apparently in the open position, leading to the release and subsequent explosions.

– U.S. Chemical Safety Board

Workers were attempting to clear a plugged line. The LOTO permit was authorized and locks placed per procedure. Unfortunately, the workers did not verify that all hazardous energy was removed. The residual pressure from blowing out the line remained. As workers opened a flange just below the plug, material was blown out, burning personnel in the immediate area.

– CCPS Safety Alert February 23, 2005

A maintenance technician was investigating a bag-feeding machine because bags were not feeding properly through the roller. He reached into the machine with his left hand while the machine was still running to clear a jam instead, without locking out first. He put his right hand down next to rollers that were running. His right hand slipped into the moving rollers. Investigation showed that all of the operators and maintenance workers routinely reached into the machinery without proper LOTO. He was the one who got unlucky.

– CCPS Safety Alert February 23, 2005

I am convinced that one of the most likely ways to severely injure workers is through not using, or not correctly following, safe work practices, including LOTO, Line Opening, Confined Space Entry and Hot Work. This is one of the topics that I stress the most in audits, and I make particular mention of in Process Hazard Analyses. We read about such incidents all the time. For such practices to not be in place is (unacceptable).

– CCPS Safety Alert February 23, 2005

Our company standards, including LOTO are REQUIRED for all our sites worldwide. LOTO is one of a few inviolable safety rules that will prompt immediate dismissal from the company if violated.

– CCPS Safety Alert February 23, 2005

Maintain a Sense of Vulnerability

A Sense of Vulnerability Is Healthy – Just because it has not happened yet (or here) does not mean it will not happen in the future!

  • Is a sense of vulnerability a critical part of the mindset of every employee and contractor?
  • Do you require consistency in practice from everyone in the organization?
  • Do you have systems in place to determine if inconsistencies exist?
  • Do people believe that “yes, it can happen here”?
  • Do people believe that “yes, we have similar vulnerabilities”?
  • Have you experienced similar incidents but without consequences (i.e., near misses)?
  • Do you combat organizational overconfidence that can be stimulated by past good performance?

Prevent Normalization of Deviation

Normalization of deviation is defined as…

The gradual process through which unacceptable practice or standards become acceptable. As the deviant behavior is repeated without catastrophic results, it becomes the social norm for the organization.

Sociologist Dr. Diane Vaughan (The Challenger Launch Decision, 1996)

A gradual erosion of standards of performance as a result of increased tolerance of nonconformance.

– CCPS Glossary (iPhone Application)

Signs of Normalization of Deviations – Does this describe your organization?

  • If a deviation is absolutely necessary, are there defined steps that must be taken (i.e., a written variance procedure)?
  • Do these defined steps (or variance procedure) require a detailed risk assessment and approval from multiple levels within the organization?
  • Are your expectations clear that no one individual alone is permitted to determine whether a deviation is permissible?
  • Do you allow operations outside established safe operating limits without a detailed risk assessment?
  • Are willful, conscious, violations of established procedures tolerated without investigation or without consequences for the persons involved?
  • Can employees be counted on to strictly adhere to safety policies and practices when supervision is not around to monitor compliance?
  • Are you tolerating practices, or conditions that would have been deemed unacceptable a year or two ago? For example:
    • Do you allow maintenance tasks to proceed without proper Lock out/tag out completed (it will only take a few minutes to complete this task therefore control of hazardous energy is not important)?
  • Are all employees empowered to stop work for any situation deemed unsafe?

Evaluate Your Program

Do you audit your Lock-Out/Tag-Out program to ensure the program is yielding the intended results?

Do you review the following items:

  • Written Lock-Out/Tag-Out procedure?
  • Lock-Out/Tag-Out permits?
  • Proper Lock-Out/Tag-Out of de-energized equipment?
  • Roles and responsibilities of persons involved in Lock-Out/Tag-Out activities?
  • Training for contract personnel involved with Lock-out/Tag-out activities?
  • Training and competency provided to persons involved in Lock-Out/Tag-Out activities?
  • Hazard assessments performed before Lock-Out/Tag-Out activities are conducted?
  • Was equipment specific Lock-Out/Tag-Out procedure available?
  • Job observations performed on Lock-Out/Tag-Out activities including verification that equipment is de-energized?

Have you audited your Lock-Out/Tag-Out permits and discussed the results of the audits?  Was there evidence that:

  • Permits were not completely filled out (i.e., Lock or tag numbers not documented)?
  • Permits were not signed?
  • Permits showed evidence that equipment specific Lot-out/tag-out procedure was not used?
  • The permit writer was not trained?
  • The personnel performing the task was not trained properly in Lock-Out/Tag-Out procedures?
  • Permit conditions were not communicated to and within the affected work team(s)?
  • Work was not coordinated between work groups (permit writing group vs. group(s) that perform the work?
  • Work extended beyond the authorized period of time?
  • Group performing the task did not install proper locks/tags on the equipment?
  • Verification that equipment was de-energized was not completed?
  • Locks/tags were not removed by personnel performing work when the job was completed?

Have you evaluated your Lock-Out/Tag-Out audit program?

  • To ensure the quality of the audit process (i.e., protocols, sampling strategies, etc.)?
  • To ensure the competency levels of the auditors?
  • Does your Lock-Out/Tag-Out procedure reflect the desired intent and is this intent adequately detailed in procedural instruction
    • Is the “goal” of your program to complete the permit or to use the permit as a tool to facilitate the execution of safe work?
  • Does the execution of the procedure yield the intended results?  Are you evaluating your program for:
    • Procedural Compliance – are actions and tasks in compliance with procedural requirements?  (Paper Control), and
    • Program Health – is your system providing the intended results?  (Actual Execution)                                                                                                       
  • Do you know of any site or company incidents related to Lock-Out/Tag-Out?
    • Have you discussed the results and causes within your organization?
  • Do you know of any site or company near misses related to Lock-Out/Tag-Out?
    • Have you discussed the results and causes within your organization?

Continually Improve Your Program

Are you considering improvements to prevent future incidents?  Here are some ideas you may want to consider:

  • How frequently do you review CSB, Process Safety Beacon and other relevant incident communication having learning potential with all members of the organization?
  • Do you update your equipment specific Lock-Out/Tag-Out procedure based on the task to be performed?
  • Do you have sufficient number of locks to support all Lock-Out/Tag-Out work, especially during a major turnaround?
  • Do you update the lock-out/tag-out procedure based on the near misses and incidents that occurred?
  • Do you track specific Lock-Out/Tag-Out-related metrics that can be used to determine program effectiveness and improve performance?
  • Have you benchmarked your program against other programs in your industry?
  • How often do your senior managers visit the field to watch Lock-out-tag-out in action?
  • Do you have a requirement to periodically update your program?
  • Do your workers (those closest to the work), have an easy method to suggest improvements to your program?

Organizational Culture

A successful Lock-Out/Tag-Out program depends on the actions of individuals within the organization.  Do the values and behaviors of your organization determine the manner in which your Lock-Out/Tag-Out program is managed and executed?

  • Does management and supervision reinforce desired behaviors to ensure they become integrated into the group’s values?
  • Are high standards of Lock-Out/Tag-Out program performance clearly established?
  • Is open and effective communication encouraged and supported?
  • Has management established safety as a core value?
  • Does management and supervision provide strong leadership?
  • Has management formalized the safety culture emphasis and approach?
  • Does management work to ensure employees maintain a sense of vulnerability?
  • Are individuals empowered to successfully fulfill their safety responsibilities?
  • Does management ensure open and effective communication exists?
  • Does management support and foster mutual trust?
  • Does management establish and enforce high standards of performance?
  • Does management defer to expertise?
  • Has management established a questioning/learning environment?
  • Does management require timely responses provided to safety issues and concerns?
  • Does management provide continuous monitoring of performance?

 

Read More

SWP Element 

Line Opening - Need / Call to Action

Incidents Continue to Happen

 

Washington DC, November 23, 2016 – A three-person investigative team from the U.S. Chemical Safety Board (CSB) is deploying to the scene of an incident that injured six workers – including four critically – on Tuesday, November 22 at the ExxonMobil Refinery in Baton Rouge, Louisiana. 

According to initial inquiries, flammable vapors were released during unplanned maintenance around a pump. Although there was no explosion, the release ignited and caused a large fire.

U.S. Chemical Safety Board, 2016

 

On February 23, 1999, 4 people were killed and 1 injured during maintenance work on a naphtha line.  U.S. Chemical Safety Board concluded in their investigation report:

“…..job planning procedures did not require a formal evaluation of the hazards of replacing the naphtha piping.  The pipe repair work was classified as low risk maintenance. Despite serious hazards caused by the inability to drain and isolate the line – known to supervisors and workers during the week prior to the incident – the low risk classification was not reevaluated nor did management formulate a plan to control the known hazards.”

U.S. Chemical Safety Board, 2001

 

A sulfuric acid spill on February 12, 2014, burned two workers in the refinery’s alkylation unit, who were transported to the nearest hospital burn unit by life flight. The incident occurred when the operators opened a block valve to return an acid sampling system back to service. Very shortly after this block valve had been fully opened, the tubing directly downstream of the valve came apart, spraying two operators with acid.

U.S. Chemical Safety Board, 2016

 

An explosion/fire occurred when opening a valve in the line between a quench vessel and the Phosphorus acid storage tank. The cause is due to the decomposition of Phosphorus acid in the line and exposure to air when the valve was opened. We were not aware of the chemistry related to phosphorus acid and the MSDS did not give enough detail as to the hazards associated with degradation.

Health and Safety Executive (HSE), 2005

 

During the mechanical isolation of an Acetic Acid final product storage tank in readiness for internal inspection a release of between 0.9 and 1.5tes of Acetic Acid occurred.

Health and Safety Executive (HSE), 2005

 

Release of gases from refinery slop system header occurred due to inadequate isolation of a section of line that was removed to enable a heat exchanger to be dismantled. At the time of removal, the line had become plugged with heavy oil residues and no release occurred. The plug melted when the steam tracing was reinstated later in the shutdown and the release occurred.

Health and Safety Executive (HSE), 2005

 

Maintain a Sense of Vulnerability

A Sense of Vulnerability Is Healthy – Just because it has not happened yet (or here) does not mean it will not happen in the future!

  • Is a sense of vulnerability a critical part of the mindset of every employee and contractor?
  • Do you require consistency in practice from everyone in the organization?
  • Do you have systems in place to determine if inconsistencies exist?
  • Do people believe that “yes, it can happen here”?
  • Do people believe that “yes, we have similar vulnerabilities”?
  • Have you experienced similar incidents but without consequences (i.e., near misses)?
  • Do you combat organizational overconfidence that can be stimulated by past good performance?
  • Do discussions on potential vulnerabilities take place between operations and senior leadership?

 

Prevent Normalization of Deviation

 

Normalization of deviation is defined as…

 

The gradual process through which unacceptable practice or standards become acceptable.  As the deviant behavior is repeated without catastrophic results, it becomes the social norm for the organization.                                                       

Sociologist Dr. Diane Vaughan (The Challenger Launch Decision, 1996)

 

A gradual erosion of standards of performance as a result of increased tolerance of nonconformance.

CCPS Glossary (iPhone Application)

 

Signs of Normalization of Deviations – Does this describe your organization?

  • If a deviation is absolutely necessary, are there defined steps that must be taken (i.e., a written variance procedure)?
  • Do these defined steps (or variance procedure) require a detailed risk assessment and approval from multiple levels within the organization?
  • Are your expectations clear that no one individual alone is permitted to determine whether a deviation is permissible?
  • Do you allow operations outside established safe operating limits without a detailed risk assessment?
  • Are willful, conscious, violations of established procedures tolerated without investigation or without consequences for the persons involved?
  • Can employees be counted on to strictly adhere to safety policies and practices when supervision is not around to monitor compliance?
  • Are you tolerating practices, or conditions that would have been deemed unacceptable a year or two ago?  For example:
    • Opening a line to unplug it without a safe work permit?
    • Not installing a blind flange when equipment in hazardous service such as a pump is taken out of service for maintenance?
    • Not using a line opening permit when working on steam lines?
  • Are all employees empowered to stop work for any situation deemed unsafe?

 

Evaluate Your Program

Do you audit your Line/Equipment Opening program to ensure the program is yielding the intended results?

Do you review the following items:

  • Written Line/Equipment Opening procedure?
  • Line/Equipment Opening permits?
  • Roles and responsibilities of persons involved in Line/Equipment Opening activities?
  • Training and competency provided to persons involved in Line/equipment Opening activities?
  • Hazard assessments performed before Line/Equipment Opening activities are conducted?
  • Job observations performed on Line/Equipment Opening activities?
  • Personal protective equipment requirements for Line/Equipment Opening?
  • Proper isolation techniques including double valves or blinds?
  • Proper draining and cleaning of lines or equipment before opening?
  • Verification procedure that the line or equipment is empty?
  • Line/Equipment properly locked out?
  • Is there a program in place that elevates the authorization level of the Line/Equipment Opening permit based on the assessed risk of the activity?

 

Have you audited your Line/Equipment Opening permits and discussed the results of the audits?  Was there evidence that:

  • Permits were not completely filled out (i.e. last hazardous material contained in the line not identified)?
  • Permits were not signed?
  • Proper PPE requirements were not identified?
  • The permit writer was not trained?
  • Line/equipment not properly cleaned or drained?
  • Line or equipment not properly isolated?
  • Lockout/Tagout (LOTO) procedure not followed?
  • Permit conditions were not communicated to and within the affected work team(s)?
  • Work was not coordinated between work groups (permit writing group vs. group(s) that perform the work?
  • Work extended beyond the authorized period of time?
  • Area was not inspected for possible ignition sources if flammables were being handled?
  • Location of closest safety shower(s) not identified?
  • Isolation valves not locked out properly to prevent operation?

 

Have you evaluated your Line/equipment Opening audit program?

  • To ensure the quality of the audit process (i.e., protocols, sampling strategies, etc.)?
  • To ensure the competency levels of the auditors?
  • Does your Line/Equipment Opening procedure reflect the desired intent and is this intent adequately detailed in procedural instruction?
    • Is the “goal” of your program to complete the permit or to use the permit as a tool to facilitate the execution of safe work?
  • Does the execution of the procedure yield the intended results?  Are you evaluating your program for:
    • Procedural Compliance – are actions and tasks in compliance with procedural requirements?  (Paper Control), and
    • Program Health – is your system providing the intended results?  (Actual Execution)                                                       
  • Do you know of any site or company incidents related to Line or Equipment Opening?
    • Have you discussed the results and causes within your organization?
  • Do you know of any site or company near misses related to Line or Equipment Opening?
    • Have you discussed the results and causes within your organization?

 

Continually Improve Your Program

Are you considering improvements to prevent future incidents?  Here are some ideas you may want to consider:

  • How frequently do you review CSB, Process Safety Beacon and other relevant incident communication having learning potential with all members of the organization?
  • Do you track specific line or equipment-related metrics that can be used to determine program effectiveness and improve performance?
  • Have you benchmarked your program against other programs in your industry?
  • How often do your senior managers visit the field to watch line opening activity?
  • Do you have a requirement to periodically update your program?
  • Do your workers (those closest to the work), have an easy method to suggest improvements to your program?

 

Organizational Culture

A successful Line/Equipment Opening program depends on the actions of individuals within the organization.  Do the values and behaviors of your organization determine the manner in which your Line Opening program is managed and executed?

  • Does management and supervision reinforce desired behaviors to ensure they become integrated into the group’s values?
  • Are high standards of Line/equipment Opening performance clearly established?
  • Is open and effective communication encouraged and supported?
  • Has management established safety as a core value?
  • Does management and supervision provide strong leadership?
  • Has management formalized the safety culture emphasis and approach?
  • Does management work to ensure employees maintain a sense of vulnerability?
  • Are individuals empowered to successfully fulfill their safety responsibilities?
  • Does management ensure open and effective communication exists?
  • Does management support and foster mutual trust?
  • Does management establish and enforce high standards of performance?
  • Does management defer to expertise?
  • Has management established a questioning/learning environment?
  • Does management require timely responses provided to safety issues and concerns?
  • Does management provide continuous monitoring of performance?
Read More

SWP Element 

Subscribe to Need / Call to Action