Graham Creedy, P.Eng, FCIC, FEIC Senior Manager, Responsible Care® Canadian Chemical Producers’ Association (613) 237-62

1. Process Safety Management: Some Lessons from Recent Incidents Presentation to theIntroduction to Environmental, Health & Safety WorkshopCSChE 2008 ConferenceOttawa, ON, October 21, 2008 Graham Creedy, P.Eng, FCIC, FEIC Senior Manager, Responsible Care® Canadian Chemical Producers’ Association (613) 237-6215, gcreedy@ccpa.ca

2. Origins of this Workshop • Why Process Safety Management? • Knowing (and meeting) the regulations is important; but is not enough – especially in Canada • Need to Know: • How to spot the hazards • Why and How defences fail • How to communicate

3. Personal safety hazards can sometimes be easy to spot; but major hazards are often not obvious • Keep an open mind about hazards – do not assume that if it is important, someone else would have noted it • Know the basic hazard identification & risk assessment techniques and when to use them • If using a contractor for this, know enough to watch for competence

4. Why and How Defences Fail • People often assume systems work as intended, despite warning signs • Examples of good performance are cited as representing the whole, while poor ones are overlooked or soon forgotten • Failure modes and effects analysis (FMEA) should include human and organizational aspects as well as equipment, physical and IT systems

5. Avonmouth, UK 1996 • Although not recent, it is a classic example of a latent failure • Hazard of material known, but lack of awareness of potential system failure mode leads to defective procedure design

6. Ghent, WV 2007 • Hazards well-known and supposedly covered by equipment and procedure design • Latent errors in procedure execution allow actual practice to deviate from assumed

7. Danvers, MA 2006 • Hazards known, but defences compromised by apparently benign change • Latent error in procedure design creates vulnerability to likely execution error

8. Port Wentworth, GA 2007 • Hazard of material not obvious (despite history) • Latent error allowed dust to accumulate, creating conditions for subsequent events

9. James Reason’s “Cheese Model” shows how the layers of protection intended to control hazards are not perfect, but are subject to holes that can increase over time if not monitored carefully. Eventually the holes are such that enough defences fail, leading to a major incident

10. The Process Safety Management Guide • Summarizes CCPS approach in handy, short booklet • Available as free download from CSChE’s PSM division website, in English and French (or as booklet, for nominal fee) • Website:http://psm.chemeng.ca

11. A page from the “HISAT” Site Self-Assessment Tool, available on the PSM Division website http://psm.chemeng.ca

12. Understanding and sizing up the hazards • The US Chemical Safety Board website www.csb.gov has case studies and videos – great for understanding and “Could it happen here?” • Center for Chemical Process Safety (CCPS) guide • Easy to use • Describes hazard evaluation procedures • Explains when and how to use them www.aiche.org/ccps

13. Percent adoption Innovators Laggards Early Majority Late Majority Early Adopters When communicating, remember the New Product Introduction Curve • Categories differ by ability and more importantly, motivation • Where is your org, and your boss, on this curve?

14. Dealing with a Safety (or Engineering) Problem • Finding out who you’re dealing with • Where is the organization on the curve? (generally, and re the specific issue or problem) • Where are the people you’re dealing with on the curve? (generally, and re the issue or problem) • Finding out what to do • “Benchmark” – don’t try to reinvent the wheel unless you’re sure there isn’t one already (or you’ve time and it’s fun to do so) • Find out what others are doing about it • Read the instructions • Identify/define the issue • If it’s likely to be regulated, check with government agencies, trade associations, web, internet • If not regulated but likely good industry practice, check suppliers, other users of same material or item, other users of similar items, other industry contacts – but test the info!!! (cross-check, ask if it makes sense) • Check standard reference works,(Lees, CCPS, etc) • Doing it • Try to think of all situations that are likely to occur (process, eqpt, people) • “KISS”, keep it user-friendly, show basis for decisions if practical to do so • Follow up afterwards to see how it’s working

15. Questions?