(89c) Impact of Human Performance on Process Safety Management

As I recall, during the early days of my career, as a young engineer I was moved to project construction site where I was part of the team assigned to develop Safe work practices including pre-commissioning procedures and Permit to Work (PTW) system. The procedures being followed at one of the Middle Eastern companies was taken as reference for the same.

The responsibility of communicating the requirements of the procedures to the commissioning workforce lied with us. We understood that the best way to communicate something is through impactful visuals. So, we made a sign board in the Furnace area, that read “NO PERMIT, NO WORK”. This was way back in 1992, and frankly, I was unaware of the larger implication of this message on the project schedule.

History of Process Safety:

Health and Safety has a long but not a very noble history. It is understood that, the term Safe Work Procedure (SWP) originated in Victoria, Australia, and is predominantly used as a risk management tool by industries throughout Australia, particularly in the mining sector.

According to the Institute of Chemical Engineer’s database, out of 5000 recorded incidents, approximately 700 were related to maintenance of the equipment. The UK HSE reports that 30% of the accidents that occur in the chemical industry are related to maintenance issue. These incidents occurred majorly either due to implementation gaps in the Control of Work system or due to not following the process.

Major accident hazard industries typically use a documented system to control hazardous work. Such systems may be known as “permit-to-work system”; “safe system of work”, or “control of work system”. In this article, all such systems are referred to as “Control of Work System”, abbreviated to CoW.

CoW is a process which details out the steps from planning the jobs to safe execution of the job to the closure of Permit to Work. It is a formal system stating the WHAT, WHEN, WHERE and HOW exactly any activity in the facility is performed. Even though the permit to work process is implemented and followed extensively in the industry, incidents involving failure of permit to work continue to occur.

There are enough incidents reported within and outside RIL which occurred due to failures in adhering to Safe work Practices or CoW.

A careful look into these incidents surfaces the following common issues:

• Perception amongst workforce: The PTW system is perceived to be a burden on the workforce (e.g. it involves paperwork, many required signatures, or unavailability of the required personnel at the right times which may delay the activity )
• Workload: Higher workload on key PTW authorities, which prevent them from checking worksite conditions or other key aspects of Permits before issuing the permits

Independent verification of available controls not applied before issuing the permit

• Improper Hazard Identification: The hazards and control measures recorded on the Permit do not reflect at the location of work ;

Controls identified for incorrect piece of equipment and not pertaining to the equipment covered by the issued permit;

Conflicting activities and SIMOPS are not identified

• Hazardous work conducted with no CoW
• Communication failure

The above issues clearly show the heavy dependency of the entire Control of Work process on humans and hence the importance of Human Factor onto the success of Process Safety Management.

In the past, we have seen catastrophic events occurring due to Absence or failure of CoW process:

• Piper Alpha Disaster:
  • Killed 167 people
  • There was no cross-referencing of PTWs; the work carried out under one permit affected the work under another
• A major vapour cloud explosion at a Chemical complex in Pasadena, USA in 1989:
  • Killed 23 people and injured 300;
  • Lack of an effective system led to a miscommunication between Company supervisor and the contractor performing the activity and work was conducted on un-isolated plant.

Deep analysis of above incidents indicate that there exists a confusion on the intent and implementation of the PTW system throughout the industry. The common confusion among people is that it increases the workload and involves a lot of paperwork, but the above mentioned incidents, when investigated indicate the failure of implementation of the PTW system.

To bring clarity to the existing confusions about the intent of implementing the PTW, organisations should focus on the basics and ensure Operational Discipline at different stages of CoW. Organisations need to focus on Human performance shaping factors for potential errors and violations by establishing a system giving real time feedback to the leadership on the health of the following:

• Competent CoW roles, understanding of the hazards and the integrity of isolation arrangements.
• CoW roles including approvers are empowered to reject the jobs / work activity if they identify unsafe work environment.
• Planning realistic work schedules - including managing competing demands e.g. between maintenance and operation, contract work and operation, shutdown modifications and maintenance - and providing adequate resources for the work
• Well-designed isolation tasks : Use of WCD (work clearance document) wherever isolations are necessary
• Improved communication between operations, planning group, maintenance personnel and work crew.
• Zero tolerance on Violations of PTW systems

To sustain economic development, plants need to be operated at highest efficiencies. This can be effectively and safely achieved by implementing new improvement ideas and maintaining reliability of assets.

Every industry in its ordeal to overcome the challenges faced in achieving HSE Excellence, should emphasize the importance of application of appropriate proactive and reactive strategies. The basic rule that the Control of Work system eases the implementation of activities simultaneously and in a safer manner, when followed to the intent , needs to be percolated through our organization. Management should further introduce the concept of ZERO TOLERANCE for serious violations in CoW processes.