Safety Management Systems -...

Major Hazard Facilities

Safety Management Systems

2

Overview

The seminar has been developed to provide:

• Context with MHF Regulations

• An overview of what is required

• An understanding of the SMS and why it is important

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• AFAP - As far as (reasonably) practicable

• Employer - Employer who has management control of the facility

• ER or ERP - Emergency response or Emergency response plan

• Facility - any building or structure at which Schedule 9 materials are present or likely to be present for any purpose

• HAZID - Hazard identification

• HSR - Health and safety representative

• LOC - Loss of containment

• LOPA – Layers of protection analysis

• MA - Major accident

• MHF - Major hazard facility

• MOC – Management of change

• OHS - Occupational health & safety

• SR - Safety report

• SMS - Safety management system

Some Abbreviations & Terms

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Topics covered in This Presentation

• Introduction

• Regulations

• What is a safety management system?

• SMS models and standards

• Key elements of the SMS

• The importance of SMS

• What should the SMS do?

• Measurement of performance

• Examples of SMS performance standards

• Emergency planning

• SMS testing

• Items to note

• Critical success factors

• Sources of additional information

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Regulations

Occupational Health and Safety (Safety Standards) Regulations 1994

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What is a Safety Management System?

• An SMS is a comprehensive and integrated system that

ensures that all work at the facility is conducted safely

• It should be fully documented, accessible and

comprehensible to those that need to use it

• It recognises the potential for errors and establishes robust

defences (control measures) which are fully implemented, to

ensure that errors do not result in accidents or near misses

• It is comprises a set of work practices and procedures for

monitoring and improving the safety and health of all aspects

of the operation

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Key Terms Used in Describing the SMS

Comprehensive

• Describes the way that all safety issues including control measures are managed

• Clear link between controls management and the SMS

Integrated

• The structure is logical, systematic

• Logically ties in to other management systems

• Corporate systems do not contradict onsite systems

Comprehensible

• Abbreviations and terms used mean something to employees

• Consideration of language issues

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Key Terms Used in Describing the SMS

Implemented

• Procedures are approved and in circulation

• Evidence is available – completed forms and/or checklists

• Employees are trained and knowledgeable

Accessible

• Employees are aware of how to obtain the most up to date or relevant procedures

• Employees can obtain the SMS information needed to support control measures

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SMS Models & Standards

• Sound management systems are all similar in fundamental terms

• Compliance with the MHF Regulations does not require any particular standard to be used, nor will compliance with an existing management standard ensure compliance with the SMS requirements of the MHF Regulations

• There are a variety of ways in which the SMS can be structured. Most large organisations will have their own structure already

• However, adoption of a proven standard may assist an MHF employer

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Examples of SMS

OH&S Management Systems Model – AS 4801

gg

Safety PolicySafety Policy

PlanningPlanning

Implementation

& Operation

ImplementationChecking

&CorrectivActio

Measurement

& Evaluation

Continual

Improvement

Continual

Improvement

Manageme

ntRevie

ManagementReview

Overall

vision, goals

and

commitment

to improve

• Legal compliance

• Objectives and targets

• Implementation plans

• Resources

• Leadership responsibility

• Training and competency

• Consultation and communication

• Documentation

• Hazard identification, risk assessment

and controls

• Emergency response

• Monitoring and

measurement

• Incident investigation

• Records management

• Audits

Suitable, adequate,

effective

Changes needed?

Opportunities to

improve?

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ISO 14001 Environmental Management Systems

Environmental

Policy

Management

Review

Planning

Implementation

& Operation

Checking &

Corrective Actions

Examples of SMS

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Key Elements of the SMS

From the previous examples, there are common elements

Policy

Planning

Implementing

Assessing

ManagementReview

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Policy

Planning

Implementing

Assessing

ManagementReview

Effective health and safety policies set a clear direction for the organisation to follow

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An effective management structure and arrangements are in place for delivering the policy.

There is a planned and systematic approach to implementing the health and safety policy

Policy

Planning

Implementing

Assessing

ManagementReview

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The policies and procedures are put in place to manage all aspects of the control measures that ensure safe operation of the facility

Policy

Planning

Implementing

Assessing

ManagementReview

16


Performance is measured against

agreed standards to reveal when and where improvement is needed.

Policy

Planning

Implementing

Assessing

ManagementReview

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The organisation learns from all relevant experience and applies the lessons.

Policy

Planning

Implementing

Assessing

ManagementReview

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The Importance of SMS

• In reviews of accidents, a common thread throughout is the inadequacy of management systems that might have prevented the accident from occurring

• Examples of some issues identified are

– Lack of hazard review and risk assessment to predict and prevent incidents

– Insufficient investigation and follow up after previous incidents

– Inadequate training of staff

– Failure to implement effective mechanical integrity programs

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Causes Expressed in Broad Management System Categories

29%

32%

12%

27%

Engineering & Design

Procedures & Practices

Management & Oversight

Training & Communication


The following information provides broad details on some US incidents and contributing causes

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Management System Categories Contributing Causes

0

2

4

6

8

10

12

Emer

genc

y Pre

para

tion

Qua

lity Ass

uran

ce

Oth

er T

raining

Indu

stry

Guida

nce

Incide

nt In

vestigat

ion

Employ

ee P

artic

ipat

ion

Facility S

iting

Intern

al A

uditing

and

Ove

rsight

Safe

Wor

k Pra

ctices

Man

agem

ent o

f Cha

nge

Enginee

ring

Des

ign & R

eview

Mainten

ance

Pro

cedu

res

HAZC

OM

Ope

rato

r Tra

ining

Ope

ratin

g Pro

cedu

res

Proce

ss H

azar

d Ana

lysis

Proce

ss S

afety In

form

ation

Management System

Cau

se

Breakdown of management system categories identified as contributing causes in incident investigations

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• Flixborough 1974

– Management of modification failure

– Inadequate experience

– Overstretched resources

• Piper Alpha 1988

– Failures in shift handover

– Permit to work

– Training

– Communications

– Auditing

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• Pasadena 1989

– Maintenance

– Permit to work errors

– Failure to follow-up on audits

• Longford 1998

– Inadequate knowledge of hazards

– Absent personnel

– Poor procedures

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• Corporate safety oversight, including the safe management of sites obtained through mergers and acquisitions

• Corporate safety culture

• Corporate and site SMS

• Near miss reporting and investigation programs

• Mechanical integrity programs

• Hazard analysis programs

• Change management

BP America Refinery Explosion Texas City, 23 March 2005

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The Importance of SMS - Exercise

Buncefield Explosion, UK, 11 December 2005

• In the early hours on Sunday a number of explosions occurred at Buncefield Oil Storage Depot, Hemel Hempstead, Hertfordshire

• At least one of the initial explosions was of massive proportions and there was a large fire, which engulfed a high proportion of the site

• Over 40 people were injured; fortunately there were no fatalities

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What control measures

• Were in place?

• Could have been in place?

• Were they effective?


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Control Measure Effectiveness?

Level meter & alarm Failed before alarm

Independent HLA & Trip Flow continued

Auto tank gauge system Did not prevent overflow

Pre

ventive

Operator surveillance Did not prevent overflow

Ignition source control Vapour cloud went off site

Fire water system Pump house destroyed

Mitig

ative

Bunding Penetrations / joints failed

Common theme – failure to manage the control measures

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• What SMS elements were needed to ensure that the control measures worked when required?


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Control Measure Supporting SMS

Level meter & alarm Testing and inspection

Independent HLA & Trip Critical safety function testing

Auto tank gauging system Preventative maintenance program

Pre

ventive

Operator surveillance Operating procedures and training

Ignition source control Design standards, purchasing specs

Fire water system Design standards

Mitig

ative

Bunding Maintenance and integrity inspection

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The Importance of SMS – Australian Experience

• Feedback from regulator site visits to Australian MHFs, together with examination of incident data has revealed the following issues are likely to be the weakest links within an SMS

– Management of 3rd parties

– Maintenance procedures and systems

– Hazard identification and analysis

– Engineering design and review

– Operating procedures

– Management of change

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The Importance of SMS – Australian Experience

Other issues to note:

• There are always fundamental failings in the “system”

• Complacency and safety versus production conflicts

• Deficiencies in practice with adherence to application of the SMS rather than system standards

• Failure to accept and prepare for emergencies

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What Should the SMS Do?

• The SMS is the tool with which the Employer meets the overall goal of the Regulations

• The SMS should cover the following

– Define safety roles and responsibilities

– Ensure adequate skills, information, tools and decision-making are present in day to day and abnormal operations

– Maintain awareness of hazards and risks

– Plan, implement, measure and evaluate MA controls and the SMS

– Develop performance requirements

– Set targets for improvement of safety at the facility

– Manage change

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• Manage and maintain knowledge

• Instigate HAZID and risk assessments

• Manage adequate human resources

• Provide performance information to all levels of organisation

• Review and improve the SMS itself

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• Manage safe operation at the facility, including MAs, specifically focusing on:

– Prevention

– Reduction

– Mitigation

• It is not just documentation - it is the actual implementation of processes, procedures and practices at the facility

• Include and reflect the safety culture at the workplace

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• Some companies, in particular employers of multiple sites, may apply corporate standards for an SMS

• These may prescribe the entire SMS, or only common high-level components such as the overall policies and procedures

• In other cases corporate SMS requirements may be very limited, and the site will then need to develop its own systems

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• Many corporate systems specify that local regulations override corporate requirements if they are more stringent

• Other companies may employ integrated management systems for the business as a whole

• It is entirely up to the Employer to choose how the SMS is structured and developed

• However, in all cases the SMS must provide a management focus on the specific control measures required for safe operation of the particular facility

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Accidents

Haz

ard

s

Cau

ses

Con

seq

uen

ces

Local procedures and practices (design, maintenance & operation)

Prevention

Controls

Mitigation

Controls

Corporate Safety Management System

MA Potential

Level 1

Level 2

Level 3

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• The SMS should not just be seen as satisfying MHF requirements

• It should be used as a performance management tool to assist in managing the entire operation, including other performance based regulatory requirements

• Most modern management system “standards” or "models" feature a set of generic elements, forming a continual improvement cycle

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Measurement of Performance

• Performance standards/indicators must be developed and implemented as part of the SMS (e.g. measure the effectiveness of SMS) to support the MHF safety objectives

• The following principles apply in defining performance standards: Make them SMART

• Specific

• Measurable

• Achievable

• Realistic

• Targeted

• The purpose of performance standards/indicators for the SMS is to enable the objective measurement of its target and (subsequently) effective maintenance and improvement of performance

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• Standards and systems need to be practical

• Should not place an unworkable burden on employees

• Ensure open, comprehensive and accurate reporting of errors or problems

Is an absence of evidence of problems really indicating high performance?

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• Performance indicators need to be meaningful and contribute to the overall evaluation of the SMS effectiveness

• If a control is stated to be in place for prevention of an MA, then:

– Is it implemented?

– Is it effective?

– Is it audited?

– Are the results used for improving the effectiveness of controls management?

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• Performance indicators should be established covering (as a minimum):

– How often audits are to be undertaken

– Scope of the audits

– Are the controls implemented?

– Are the controls functional?

– % compliance, partial compliance and non compliance

• Performance indicators should be sufficiently detailed and transparent to enable the effectiveness of the SMS to be apparent from the documentation

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• The audits need to be evaluated against criteria developed by the MHF

• They should include steps to continually improve the SMS, so there needs to be processes and measures designed to identify and implement improvements to the system itself

• Three main types of audits– First audit: Self audit

– Second party: audit of suppliers

– 3rd party: external agencies e.g. regulator, certification bodies.

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• Likewise, 100% compliance is a desirable objective - but realistically not practical

• Setting a tiered acceptability criteria could be an option

Item Compliance Partial Compliance

Non-compliance

Audit frequency for controls met

90% 10% 0%

Audit time frame achieved

90% 10% 0%

Controls implemented

100% 0% 0%

Controls functional

95% 5% 0%

Example only:

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Examples of SMS Performance Indicators

Permit to work

Management of change

Operating procedures

Auditing

Number of accidents or near misses caused by a failure of this system% permits audited compliant with procedure

Number of accidents or near misses caused by a failure of this system% of MoC forms completed in compliance with procedures% temporary changes beyond their time limit

% of new procedures completed % of procedures reviewed

% audits completed to scheduleNumber of non conformances closed out/month

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Items to Note - Emergency Planning

• The MHF must prepare an emergency plan addressing the on-site/off-site consequences

• Must consult with employees and emergency services

• Plan should consider

– Accident type (e.g. major/minor, environmental, personal safety, on-site, off-site, property damage)

– Command hierarchy and contact information

– Equipment required

– Contingency plans

• Plan should be tested, reviewed, updated

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Items to Note - Management of Change

• Management of change needs to be considered very carefully within the safety report

• An issue often discussed is:

– When is a change really a change?

– When is a change not a change?

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Items to Note - When is a change really a change?

• Any change to an MHF needs to be evaluated in the context of the safety report

• Examples of this include but are not limited to:

– Organisational change

– Addition of a new unit

– Closure of a unit

– Any modification to a potential MA

• Desired Outcome: Demonstrate that at least the same level of risk or lower is achieved after the change and that all the processes within the safety report are followed and transparent

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Items to Note - When is a change not a change?

• Any change to an MHF that involves swapping like for like is not considered to be a change

• This assumes the equipment or systems being changed are fit for purpose

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Items to Note - Incident Investigations

• Incidents that occur or could have occurred at an MHF are a valuable source of information

• As with good practice, all incidents at a facility should be reviewed for lessons learned and their findings implemented for prevention in the future

• For an MHF, investigation of MAs is of particular importance as it will provide insight into the mechanism of occurrence

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SMS - Critical Success Factors

• Adequate resources for both development and improvement

• Personnel are aware of their responsibility and accountability

• Personnel are trained/competent

• Consistent with the understanding of risk gained from the risk assessment

• There should be sufficient focus on MAs, from planning through to operations

• The Employer must document the basis for the facility's SMS, and the SMS itself

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SMS – Critical Success Factors

• Adequate resources for both development and improvement

• Responsibilities & accountabilities defined

• Adequate education and training is provided for employees

• Covers the whole facility as defined in the safety report

• Employees know how to access it and understand it

• Performance indicators & standards for the control measures and the SMS as a whole are defined

• Planning, implementation and monitoring processes are provided for control measures and the system as a whole and failures are addressed

• Processes are provided for review and revision of control measures and the SMS

More information is available in Booklet 3 on the SMS

Comprehensive and Integrated

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Review and Revision

• The SMS needs to be reviewed on a regular basis to ensure it is fit for purpose for management of an MHF

• Over a period of time the lessons learned together with results of performance reviews should enable improvements to be documented

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Sources of Additional Information

• Safety Management, Hazardous Industry Planning Advisory Paper No. 9, Guidelines for the Development of Safety Management Systems, Department of Urban Affairs and Planning, 1995

• AS/NZS 4801:2001, Occupational Health and Safety Management Systems

– Specification with Guidance for Use, Standards Australia,15 November 2001

– General Guidelines on Principles, Systems and Supporting Techniques, Standards Australia,15 November 2000

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• AS/NZ ISO 9001:2000, Quality Management Systems

• AS/NZ ISO 14001:2004, Environmental Management Systems

• API Recommended Practice 750, Management of Process Hazards

• API Publication 9100, Model Environmental Health and Safety Management System and Guidance


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• UK Health and Safety Executive HSG65, Successful Health and Safety Management

• US Department of Labour. OSHA Standard CFR 29 1910.119, Process Safety Management

• AIChE, CCPS, Guidelines for Implementing Process Safety Management Systems

• Management System Failures Identified in Incidents Investigated by the U.S. Chemical Safety and Hazard Investigation Board, Angela S Blair PE Chemical Incident Investigator, Process Safety Progress, December 2004, Volume 23, No.4


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