Role of PSM Audits and Lessons Learned for Modernization of … · 2016-05-17 · • API 520:...

Copyright PSRG Inc. 2016

Role of PSM Audits and Lessons Learned for Modernization of OSHA PSM Regulations

Author: Robert J. Weber, P.E.Date: March 29, 2016

GTBRProcess Safety

Roundtable


• Industry Incidents and Lessons Learned• Introduction to PSM Auditing• PSM – Common Deficiencies• Regulatory Update• PSM Key Success Factors• Conclusion

Presentation Outline

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Industry Incidents & Lessons Learned

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“It should not be necessary for each generation to rediscover principles of process safety which the

generation before discovered. We must learn from the experience of others rather than learn the hard

way. We must pass on to the next generation a record of what we have learned.”

~ Jesse C. DucommunVice President, Manufacturing and a Director of American Oil Company; Process Safety Pioneer

[1905-1966]

Industry Incidents & Lessons Learned

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• 28 fatalities; 36 injuries onsite; 53 additional injuries offsite.

• 20” di. Temporary bypass pipe around reactor failed under thermal stress

• Lack of plant modification / change control.

• Lack of design codes for pipework.

• Lack of siting considerations.

Flixborough, UK (1974)Nypro UK(Cyclohexane release & Explosion)

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• Release of a Dioxin, a poisonous and carcinogenic by-product of an uncontrolled exothermic reaction.

• 25 km North of Milan.

• No fatalities. More than 600 people evacuated; 20 people treated for Dioxin poisoning.

• Long term health impacts.

• Led to development of initial EU “Seveso” directive.

Sevesto, Italy (1976)ICMESA (Industrie Chimiche Meda Società Azionaria)(Tetrachlorodibenzoparadiox in release)

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• PEMEX LPG Terminal BLEVE (Boiling Liquid Expansion Vapor Explosion) and fire after Loss of Containment in local sewer system

• Over 650 fatalities, mostly offsite; $20MM damages

• CONTRIBUTING FACTORS:• Plant spacing and layout

• Active / passive fire protection

• Emergency isolation

• Emergency response / spill control

Mexico City, Mexico (1984)

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• Considered the world’s worst industrial disaster.

• Accident was a result of poor safety management practices, poor early warning systems, and the lack of community preparedness.

• 3,000+ fatalities; 100,000+ injured

• Eventually, resulted in the demise of Union Carbide, one of the world’s largest integrated chemical companies.

Bhopal, India (1984)Union Carbide India Limited(UCIL)

(Methyl isocyanate (MIC) tank rupture & release)

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• Occidental Petroleum, Piper Alpha Platform

• 167 fatalities

• $3.4B insured loss

• CONTRIBUTING FACTORS:

• Lack of adequate emergency evacuation and egress

Piper AlphaNorth Sea (1988)

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• Explosion with a force of 2.4 tons of TNT.

• 23 fatalities; more than 130 injured.

• Property damage was $750MM+.

• The evidence showed that more than 85,000 pounds of highly flammable gases were released through an inadvertently open valve.

Pasadena, Texas (1989)Phillips Pasadena Chemical Complex(Vapor Cloud Explosion)

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• Process Safety Management was initiated by U.S. OSHA in 1992 as a way to respond with government regulations/ oversight of industries using highly hazardous chemicals (HHCs).

• PSM emphasizes the management of hazards associated with highly hazardous chemicals and establishment of a comprehensive management program that integrated technologies, procedures, and management practices

History of Process Safety

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PROCESS SAFETYMANAGEMENT

EmployeeParticipation

Process SafetyInformation

OperatingProcedures

TradeSecrets

EmergencyPlanning and

Response

Managementof Change

MechanicalIntegrity

IncidentInvestigation

Pre-StartupSafety Review

Training

ComplianceAudits

Contractors

Process HazardAnalysis

Hot WorkPermit

Elements of Process Safety

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History of Process SafetyIS IT WORKING???

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• 15 worker fatalities and more than 170 others were injured.

• Both the BP and the U.S. Chemical Safety and Hazard Investigation Board identified numerous technical and organizational failings at the refinery and within corporate BP.

BP Texas City (2005)(Vapor Cloud Explosion)

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• Considered the largest accidental marine oil spill in the history of the petroleum industry.

• Oil flowed for ~90 days; 134MM-176 MM barrels spilled.

• Eleven workers were never found despite a three-day Coast Guard (USCG) search operation.

Deepwater Horizon (2010)BP / Transocean / Halliburton(Explosion and sinking of the Deepwater Horizon oil rig followed by oil release)

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• 15 people fatalities; more than 160 people injured.

• More than 150 buildings and homes were damaged or destroyed due to blast.

• Investigators have confirmed that ammonium nitrate was the material that exploded.

• USGS recorded the explosion as a 2.1-magnitude.

West, Texas (April 17, 2013)West Fertilizer Company(Ammonium nitrate explosion)

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Regulations have NOT changed since their promulgation, but……

• OSHA Petroleum Refinery Process Safety Management National Emphasis Program (NEP) Directive – 2007

• OSHA’ PSM Covered Chemical Facilities National Emphasis Program (NEP) Directive – 2011

• Executive Order 13650 (August 1, 2013)• More chemicals, lower TQs, more covered facilities

• Stay tuned……

History of Process Safety

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PSM Auditing - Overview

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• Excellent tool to assess your organization’s Process Safety effectiveness – written program and implementation

• Assess compliance; benchmark performance with industry

• Identify and mitigate “early warning signs” before a potential incident

• Integral to “PLAN – DO – CHECK – ACT” cycle of continuous improvement

Compliance Audit – Why?

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• Perform audit every three (3) years (OSHA 29CFR1910.119)

• Conducted by at least one person knowledgeable in the process.

• A Report of the findings shall be developed.• The employer shall document a response to each of

the findings and document corrective actions.• Employer shall retain the two (2) most recent

compliance audit reports.

Compliance Audit – Why?

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Process Safety Management (PSM)

COMMON DEFICIENCIES

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• 350+ audits / assessments performed• 2010 – 2015• Large, major operating companies to smaller, niche

specialty chemical companies and industries

Common Deficiencies BASIS

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• Boundaries of PSM-covered process not well-defined or documented; leading to inconsistent interpretation of PSM boundaries across different departments and incomplete PHA assessment

• Failure to include interconnecting utilities in the PSM-covered process and PHA review process (e.g., steam, nitrogen, cooling water, etc.)

Common DeficienciesDEFINITION OF PSM BOUNDARIES

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• Boundaries of PSM-covered process not well-defined or documented; leading to inconsistent interpretation of PSM boundaries across different departments and incomplete PHA assessment

• Failure to include interconnecting utilities in the PSM-covered process and PHA review process (e.g., steam, nitrogen, cooling water, etc.)

• SOLUTION: Redline/mark PSM-covered process boundaries on your Facility Plot Plan AND process P&ID(s) AND Communicate.

Common DeficienciesDEFINITION OF PSM BOUNDARIES

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• Lack of well-articulated management expectations and defined goals; leading to weak employee morale and decreased employee participation.

• Employees do not know how to access PHAs and other PSM information.

Common DeficienciesEmployee Involvement

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EXAMPLES OF GOOD EMPLOYEE PARTICIPATION:• Assignment of “PSM Champions” (by Element, by Unit, etc.)• Plant safety steering committee• Toolbox safety meetings• Employee participation in PHAs, PSM audits, incident

investigations, development of SOPs, etc.• Regular communication of action items from PHAs, audits,

incidents to affected employees• Employee feedback; suggestion for improvement boxes• Management consultation with operators on the frequency and

content of training• Regularly-planned emergency action plan drills and exercises with

follow-up and response critique• Behavioral-based safety programs (BBS)

Common DeficienciesEmployee Involvement

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Role

PSM Activity

CO

O

HSS

E

Engi

neer

ing

&

Con

stru

ctio

n

Ope

rati

ons

PSM

Sup

ervi

sor

Ope

rato

rs

Mai

nten

ance

All

Empl

oyee

s

Con

trac

tors

Applicability - (a) A R C C C I I I I

Employee Participation - (c) C C I A R I I I I

Process Safety Information - (d) I C R/A C C I I I i

Process Hazards Analysis - (e) I A I R C I I I I

Operating Procedures - (f) I C C A R C I I

Training - (g) I C A R C I I I

Contractors - (h) A R C C C C C I I

Pre-Startup Safety Review - (i) I R C A C C I

Mechanical Integrity - (j) I C C R/A C C C

Hot Work Permit - (k) A R C C C C I I

Management of Change - (l) A C I R C C C I

Incident Investigation - (m) A R I C C C I I

Emergency Preparedness & Response - (n) A R C C I I I

Compliance Audits - (o) A R C C C I I I I

Trade Secrets - (p) A C C R C C i I I

RACI Matrix

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• Hazardous effects of inadvertent mixing of different chemicals that could foreseeably occur not addressed

• Lack of complete Electrical Area Classification documentation and field survey

• Design basis information for emergency relief/PSV and flare systems incomplete (e.g., API RP520/521 RV sizing “contingency analysis ” and flare analysis)

Common DeficienciesProcess Safety Information

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• Design basis information for safeguards, which prevent or mitigate a potential release, incomplete (e.g., fire water systems).

• Materials of construction information not on file for all equipment in the “covered process”.

• Lack of reference Plant design codes and standards identified (“RAGAGEP”).


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MOST FREQUENTLY REFERENCED RAGAGEPs IN RECENT OSHA INSPECTIONS• API 520: Sizing, Selection & Installation of Pressure-

Relieving Devices in Refineries• API 521: Pressure-Relieving and Depressuring

Systems• API RP752: Management of Hazards Associated with

Location of Process Plant Permanent Buildings• API RP753: Management of Hazards Associated with

Location of Process Plant Portable Buildings


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MOST FREQUENTLY REFERENCED RAGAGEPs IN RECENT OSHA INSPECTIONS• API 510: Pressure Vessel Inspection Code – In-service

Inspection, Rating, Repair and Alteration• API 570: Piping Inspection Code – In-service Inspection,

Rating, Repair and Alteration of Piping• API 574: Inspection Practices for Piping System

Components• ANSI/ISA S84.01: Functional Safety – Safety

Instrumented Systems for the Process Industry Sector


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• PHA fails to comprehensively identify all hazards of the process because:• Selection of the wrong methodology based on

complexity of the process• Incomplete set of Guidewords + Parameters

(“Deviations”) utilized• Failure to review Startup / Shutdown issues,

Abnormal Operations

Common DeficienciesProcess Hazards Analysis

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• Safeguards not independent of the initiating event / cause. Failure to perform Layer of Protection Analysis (LOPA) to assess effectiveness of safeguards.

• Consequences not based on failure of engineering controls, but taking into account safeguards. Failure to assess consequences to “ultimate” loss event assuming safeguards are non-existent or ineffective as designed.


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Common DeficienciesProcess Hazards Analysis• Failure to address/update FACILITY SITING

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API RP 752 (2009) API RP 753 (2012)

API RP 756 (2014)


• Previous incidents, including “near misses”, not considered or documented by the PHA team.

• Overdue PHA recommendations with no managed schedule for resolution, completion.

• Incomplete compilation of Process Safety Information prior to performing the PHA.


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• SOPs not written for ALL phases of operation (esp., non-routine operations, e.g., purging, cleaning, sampling, temporary operation, emergency operation, etc.)

• Safe operating limits and consequences of deviation from these limits not well-defined. Steps to correct/avoid deviations not documented.

• No written procedures for Shift Change / Handover operations.

• Lack of annual certification.

Common DeficienciesOperating Procedures

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• No documented Equipment-specific procedures for LOTO, Confined Space.

• Lack of periodic training for LOTO, Confined Space

Common DeficienciesSafe Working Practices

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• Missing records of initial training for qualified operators.

• Refresher training not conducted at least every three (3) years.

• Lack of verification of personnel comprehension of training program.

Common DeficienciesTraining

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• No written proof that operators consulted on frequency or content of refresher training.

• Refresher training too much focused on “normal” operations.

Common DeficienciesTraining

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• Lack of due diligence qualification, certification records for contractor employees who perform “specialized skill or craft work”, e.g.,• Crane and rigging work• Forklift driving, mobile lifts/JLGs• Certified welding• Instrument calibration• Other

• Lack of periodic surveillance of contractors post-selection; contractors only disciplined when something goes wrong

Common DeficienciesContractors

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• PSSR not performed and documented for new plant facilities or process modifications prior to introduction of highly hazardous chemicals

• PSSR not performed and documented for each MOC• Weak, short-form PSSR checklist used for major

changes

Common DeficienciesPre-Startup Safety Review

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• “FIX IT WHEN IT BREAKS” mentality• Failure to identify “critical equipment” relative to the

PSM-covered process• Lack of written deficiency management program for

non-conformances identified during inspection and testing activities

• Overdue inspections• Failure to identify and implement RAGAGEP for

inspections and tests

Common DeficienciesMechanical Integrity

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• Failure to review PHA and include all “safeguards” in Mechanical Integrity program (e.g., positive pressurization systems for control rooms, etc.)

• Focus on stationary equipment; less emphasis on Rotating Equipment and Instrumentation & Controls.

• Lack of “fitness for service” documentation for aging process equipment.

• MOC process not used for changes to inspection frequency.

Common DeficienciesMechanical Integrity

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• Hot work permit does not clearly identify “object on which hot work being performed”.

• Pre-job Hot Work Checklist not completed.• Missing signature authorizations on hot work permit

form.• No documentation of fire watch training/qualifications.• Hot work training not performed annually.• Permit-required hot work areas inconsistent with

definition of electrically classified area.

Common DeficienciesHot Work

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• MOC process not applied for: Installation of temporary equipment Decommissioning or taking equipment out-of-

service Changes to alarm setpoints Procedural-only changes (e.g., conversion from

paper-based to electronic systems) Changes in shift work; workforce reductions

Common DeficienciesManagement of Change

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• MOC process not institutionalized – may be strong in Operations; but weaker by Maintenance.

• PSI, SOPs, M.I. not updated when affected by the MOC.

• MOC forms completed and signed off before PSSR completed.

Common DeficienciesManagement of Change

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• “Near misses” not documented; possibly due to:• Lack of good, uniform

understanding of what the definition of a “near miss”

• Lack of positive culture that promotes reporting of “near misses”

• Focus on reporting and investigation of personnel safety incidents (“lagging”) versus “near misses” (leading indicator)

Level 1Incidents of

greater consequenc

eLevel 2

Incidents of lesser consequence

Level 3 Challenges to safety system

Level 4Operating Discipline & Management System

Performance Indicators.(Not reported yet in RCI)

Common DeficienciesIncident Investigation

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• Incident investigations not commenced within 48 hours of the incident.

• Incident investigation team composition does not include a contractor employee for incidents involving the work of a contractor.

• Failure to identify “root causes” leading to repeat of incidents.

• Failure to communicate the findings and action items resulting from incident investigations.

Common DeficienciesIncident Investigation

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• Emergency action plan not up-to-date.• Emergency evacuation maps with routes and safe

distances not visibly posted.• No written process for testing and servicing plant

alarms; no documentation that alarm testing was completed.

• Lack of documented drills and exercises.• Lack of coordination of EAP with local community,

responders.

Common DeficienciesEmergency Preparedness& Response

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• Compliance audits performed; but not certified in writing.

• Audits incomplete (i.e., not representative of the entire facility for multi-Unit operations).

• Audit action items not tracked or completed in a timely manner.

Common DeficienciesCompliance Audits

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Mechanical Integrity 202Process Safety Information 189Process Hazard Analysis 188Operating Procedures 184Management of Change 92

Incident Investigation 71Compliance Audits 47Contractors 33Training 29

855 79%

Common DeficienciesOSHA Refinery NEPEnforcement Statistics2007-2011

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Emergency Planning and Response 17Employee Participation 15Pre-Startup Safety Review

13

Hot Work Permits 8Trade Secrets 0

Total PSM Citations 1088

Common DeficienciesOSHA Refinery NEPEnforcement Statistics2007-2011

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Mechanical Integrity 156Process Safety Information 140Operating Procedures 114Process Hazard Analysis 106Management of Change 44

Compliance Audits 35Training 21Incident Investigation 19Employee Participation 16

516 76%

Common DeficienciesChemical NEP PSMEnforcement Statistics2011-2015

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Contractors 14Emergency Planning and Response 7Pre-Startup Safety Review

5

Hot Work Permits 1Trade Secrets 0

Total PSM Citations 678

Common DeficienciesOSHA Chemical NEPEnforcement Statistics2007-2015

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Regulatory Update

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• AUGUST 2013: President Obama signed Executive Order 13650 ordering OSHA, EPA and DHS to improve the safety and security of the chemical industry in the U.S.

• DECEMBER 2013: OSHA published in the Federal Register a Request for Information (RFI) for comments on 17 areas of possible revision to the PSM Standard.

• JULY 2014: EPA published in the Federal Register a RFI for comments on 19 areas of possible revisions to the RMP Rule.

Modernization of OSHA PSMStandard - Background

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• MAY 2014: EPA, OSHA and DHS issued a report to President recommending:

• Modernize PSM and RMP

• Promote safer technology and alternatives

• Develop guidelines on best practices for process safety

• Increase civil fines

• Serious: $7,000 to $12,744

• Repeats/willfuls: $70,000 to $125,428

Modernization of OSHA PSMStandard - Background

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• Eliminating the PSM Exemption for Atmospheric Storage Tanks• Oil and Gas-Well Drilling and Servicing• Resuming Enforcement for PSM-Covered Oil and Gas Production Facilities• Expanding PSM Coverage and Requirements for Reactive Hazards• Updating the List of Highly Hazardous Chemicals in Appendix A of the PSM Standard• Revising the PSM Standard to Require Additional Management-System Elements• Re-evaluation of Equipment Based on Evolving RAGAGEP• Defining RAGAGEP for Employers

• Expansion of Mechanical Integrity to Any Safety-Critical Equipment• Clarifying Paragraph (l) of the PSM Standard with an Explicit Requirement that Employers Manage Organizational

Changes• Requiring Coordination of Emergency Planning with Local Emergency-Response Authorities• Overhauling the Auditing Requirements in Paragraph (o) of the PSM Standard • Expansion of 1910.109 to Cover the Dismantling and Disposal of Explosives, Blasting Agents and Pyrotechnics• Updating the Flammable Liquid and Spray Finishing Standards• Updating the Regulations Addressing the Storage, Handling and Management of Ammonium Nitrate• Application of PSM Standard to Retailers that Sell Large or Bulk Quantities of Highly Hazardous Chemicals• Changing Enforcement Policy for Highly Hazardous Chemicals Listed in Appendix A of the PSM Standard without

Specific Concentrations

KEYYellow: Changes by MemoBlue: Changes by CourtGreen: Changes by EPA

PSM Modernization:17 Topics Listed in OSHA’s RFI

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1. Eliminating the PSM Exemption for Atmospheric Storage Tanks

2. Oil and Gas-Well Drilling and Servicing3. Resuming Enforcement for PSM-Covered Oil and Gas

Production Facilities4. Expanding PSM Coverage and Requirements for Reactive

Hazards5. Updating the List of Highly Hazardous Chemicals in

Appendix A of the PSM Standard6. Revising the PSM Standard to Require Additional

Management-System Element


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7. Re-evaluation of Equipment based on evolving RAGAGEP8. Defining RAGAGAEP for Employers9. Expansion of Mechanical Integrity to any Safety-Critical

Equipment10.Clarifying Paragraph (l) of the PSM Standard with an

Explicit Requirement that Employers Manage Organizational Changes

11.Requiring Coordination of Emergency Planning with Local Emergency-Response Authorities

12.Revamp the Audit Requirements in 1910.119(o)


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13.Expansion of 1910.119 to Cover the Dismantling and Disposal of Explosives, Blasting Agents and Pyrotechnics

14.Updating the Flammable Liquid and Spray Finishing Standards

15.Updating the Regulations Addressing the Storage, Handling and Management of Ammonium Nitrate

16.Application of PSM Standard to Retailers that sell Large or Bulk Quantities of Highly Hazardous Chemicals

17.Changing Enforcement Policy for HHCs listed in Appendix A of the PSM Standard without Specific Concentrations


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PSMKey Success Factors

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1. Process Safety Leadership2. Process Safety Competency3. Process Safety Culture4. Clearly Defined Expectations and

Accountability5. Leading and Lagging Indicators6. Audit and Continuous Improvement7. Community Outreach

PSM Key Success Factors

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• The executive leadership must provide and demonstrate effective leadership and establish clear process safety goals and objectives.

• Management and leadership must clearly demonstrate their commitment to process safety by articulating a consistent message on the importance of process safety.

• Policies and actions should match that message.

Process Safety Leadership

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• Company must establish and implement a system to ensure that its executive management, its line management, and all employees – including managers, supervisors, workers, and contractors – possess the appropriate level of process safety knowledge and expertise to prevent and mitigate accidents.

• Avoid falling subject to the “Peter Principle”. [Dr. Laurence J. Peter, 1968.]

Process Safety Competency

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Peter Principle

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• Company must involve employees at all levels in order to develop a sustainable, positive, trusting, and open process safety culture.

• Company must promote a culture of individual ownership of the Process Safety program.

• Process Safety should be EVERYONE’s responsibility; not just the responsibility of the Process Safety Manager or HSE Department.

Process Safety Culture

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• Company must clearly define expectations and strengthen personnel accountability for process safety.

• At all levels of the organization – the executive leadership, management, supervisors, line employees, contractors, etc.

Clearly Defined Expectations & Accountability

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• Company should develop and implement an integrated set of Key Performance Indicators (KPIs), including leading and lagging metrics for more effectively monitoring the performance of the process safety management system.

• KPIs should be realistic and measurable.• KPIs should also be regularly monitored and periodically

updated to reflect industry changes, best practices, and lessons learned around the world.

Leading & Lagging Indicators

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• Company must establish and implement an efficient and effective system to periodically audit and continuously improve process safety performance relative to regulatory requirement and international peers.

• Plan-Do-Check-Act• Documentation Documentation Documentation

Audit & Continuous Improvement

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• Company should out and work closely with local community leaders to promote its Process Safety image.

• Will lead to increased reputation and goodwill, improved safety and quality performance of workers and suppliers.

• More adequate preparedness and response in case of a catastrophic emergency,

• Part of corporate social responsibility.

Community Outreach

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REALIZE THE BENEFITS: SEVEN (7) KEY STEPS1. Assign personnel who will be accountable.2. Adopt a personalized Company philosophy of

process safety.3. Learn more about process safety.4. Take advantage of strong synergy process safety has

with your other business drivers.5. Set achievable process safety goals.6. Track your performance.7. Revisit your process safety program / continuous

improvement.

Path Forward

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Thank you!

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PSRG PSM Forum“Facility Siting Challenges and

Blast-Resistant Design and Retrofit of Buildingsat Refinery and Petrochemical/ Chemical Facilit ies”

Speakers: Mr. Charles J. King, P.E. - PSRGMr. Paul B. Summers, P.E., S.E., CPEng, F.ASCE -

Simpson Gumpertz & Heger

• April 20, 2016 – East Houston • April 21, 2016 – West Houston• June 1, 2016 – Baton Rouge• June 2, 2016 – Lake Charles

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