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Major Hazard Facilities. Introduction to Safety Report. Some Abbreviations and Terms. AFAP - As far as practicable BPCS – Basic process control system Employer - Employer who has management control of the facility FTA – Fault tree analysis HAZOP – Hazard and operability study

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Major hazard facilities

Major Hazard Facilities

Introduction to Safety Report

Some abbreviations and terms
Some Abbreviations and Terms

  • AFAP - As far as practicable

  • BPCS – Basic process control system

  • Employer - Employer who has management control of the facility

  • FTA – Fault tree analysis

  • HAZOP – Hazard and operability study

  • HSR - Health and safety representative

  • LOPA – Layer of protection analysis

  • MHF - Major hazard facility – as defined in the regulations

  • MA - Major accident

  • OHS -Occupational health & safety

  • QRA – Quantitative Risk Assessment

  • SMS - Safety management system

Topics covered in this presentation
Topics Covered in This Presentation

  • Introduction

  • Key principles and objectives of the MHF regulations

  • Why is a Safety Report needed?

  • What is the Safety Report?

  • What must the Safety Report do?

  • Main components of the Safety Report

  • Hazard identification

  • Safety assessment

  • Risk controls

  • Emergency response plans

Topics covered in this presentation1
Topics Covered in This Presentation

  • Demonstration (of adequacy)

  • What else is in the safety report?

  • MHF regulations versus process

  • Sources of additional information

  • Review and revise

  • Conclusion

  • Examples of major accidents


  • This seminar is a basic introduction to the Safety Report that is required under the MHF Regulations.

  • It has been developed for the following purposes:

    • To provide a simple overview

    • To be suitable for new MHF Employers

    • Outline the reason for a safety report

    • Overview of all parts of a safety report

    • Show examples of major accidents

Key principles of mhf regulations
Key Principles of MHF Regulations

  • Focus on major hazards (catastrophic events i.e. typically high consequence and low frequency)

  • Requires a proactive risk based approach

  • Places the responsibility on the Employer

  • Employer has to actively demonstrate safe operation

Key principles of mhf regulations1
Key Principles of MHF Regulations

  • Consultation with different parties required at all critical stages

  • Facilitate culture change at major hazard facilities

  • Regulator ‘peer review’, tied to a licence

  • Addresses both on-site and off-site safety

Focus of mhf regulations

Focus of MHF Regulations is

high consequence (catastrophic)

but low frequency incidents

Focus of MHF Regulations

Increasing risk



Very high risks

should already

be eliminated

after risk


Relative Frequency of Occurrence

OHS risks



Consequence Severity

Objective of the mhf regulations
Objective of the MHF Regulations

  • The objective of the MHF Regulations is to provide for the safe operation of major hazard facilities to:

    • Reduce the likelihood of an MA occurring

    • Reduce the consequences to health and safety and damage to property in the event of an MA occurring

Mhf regulations
MHF Regulations

Specific parts of the MHF Regulations relevant for this seminar are:

  • Hazard identification (9.43)

  • Risk assessment (9.44)

  • Risk control measures (9.45)

  • Safety management system (9.46)

  • Emergency planning (9.53)

  • Provision of information to the community (9.50)

Why is a safety report needed
Why is a Safety Report Needed?

There is a need for specific control of major hazards due to:

  • Changing scale and complexity of specific facilities

  • Advances/changes in technology - unforeseen hazards

  • Changing community perceptions

  • Range of major accidents that have occurred

  • Prescriptive approach has proven inappropriate

Why is a safety report needed1
Why is a Safety Report Needed?

Some major accidents that have occurred

  • Coode Island, Australia – storage terminal fire, August 1991, 0 dead, 0 injured

  • Longford, Australia – explosion and fire, September 1998, 2 dead, led to the development of Victorian MHF legislation

  • Entschede, Holland – fireworks factory explosion, May 2000, 21 dead, 1,000 injured

  • Texas City, USA – fire and explosion, March 2005, 15 dead, over 170 injured

Why is a safety report needed2
Why is a Safety Report Needed?

Port Kembla Ethanol Tank Fire, NSW, Australia, 28th January 2004

Quote from the Coroner…“not a lack of adequate safety procedures but rather the failure to adhere to them”.

(Welding was carried out in an unsuitable area without a ‘hot work’ permit)

Why is a safety report needed3
Why is a Safety Report Needed?

This has led to Regulations where:

  • The Employer knows what technical and human activities occur

  • The Employer decides on the appropriate means of major hazard control for the facility, and prepares a Safety Report explaining this

  • The Regulator assesses and audits performance adequacy against the safety report

Why is a safety report needed4
Why is a Safety Report Needed?

  • The introduction of regulations were ‘fast tracked’ in Victoria primarily as a result of the Royal Commission into the incident at Longford in 1998.

  • The Victorian MHF regime is now mature and is working well.

What is the safety report
What is the Safety Report?

  • The safety report must address all hazardous events that could result in MAs that pose serious danger or harm to:

    • Persons

    • The community

    • Property

    • The environment

What is the safety report1
What is the Safety Report?

  • A safety report is a detailed document that outlines:

    • The identification and control mechanisms in place to prevent and mitigate all MAs for the facility

    • The types of safety studies undertaken

    • The results obtained for such studies

    • The management arrangements in place

      to ensure the continued safety of the facility and its people and the surrounding community.

  • The safety report must be prepared in consultation with employees and be a true reflection of the state of the safety arrangements for the facility.

What is the safety report2
What is the Safety Report?

The Role of the Safety Report

  • Regulatory role: The primary document used by an approved assessor to verify that the facility is operated safely to support the Employer’s licence application.

  • Information Repository: Contains all information about the safe operation of the facility which contributes to continuous improvement of safety at the facility.

What must the safety report do
What Must the Safety Report Do?

  • Document the state of safety arrangements for the facility

  • Demonstrate to the satisfaction of the Commission, through content and supporting material, that:

    • The employer knows what technical and human activities occur

    • How activities are managed

    • How safety will be managed in the event of an emergency

What must the safety report do1
What Must the Safety Report Do?

Identify methods to be used for monitoring and reviewing all activities for continual improvement of the safety arrangements of the facility over its lifetime.






The safety report should
The Safety Report Should…

  • Reflect the facility safety culture

  • Contain information about the facility and interaction with its surroundings

  • Describe the systems used to achieve safety

  • Identify, assess and show controls for potential major accidents

  • Demonstrate ongoing consultation between the employer and workforce

  • Be integrated into the Employers management systems rather than a collection of separate individual safety studies

Safety report timeline
Safety Report Timeline

Refer Guidance Booklet 4 for this timeline

Main components of a safety report
Main Components of a Safety Report

The main components of the safety report are:

  • Facility description

  • Risk assessment

    • Hazard and MA identification

    • Risk control measures

  • Safety management system description

  • Emergency response plan

  • Demonstration of adequacy

    • Control measures

    • Safety Management System

Facility description
Facility Description

  • History

  • Daily operations

  • Schedule 9 materials and their characteristics

  • Demographic description

  • Facility topography & meteorological data

  • Simplified process flow diagrams

  • Site layout drawings

  • Location plans, surrounding facilities and sensitive neighbours

  • Proposed changes

Risk assessment requirements
Risk Assessment Requirements

  • Hazard identification – for determining MAs

  • Risk assessment studies – for determining controls

  • Risk evaluation - for determining risk acceptability

  • Recommendations and review – for continuous improvement

Hazard and ma identification
Hazard and MA Identification

Process Hazard Studies

(HAZOP/What If)

Past Risk Assessments

Unit Technical Review Input

(Specialist Review)

Hazards that can lead to major accidents are identified. From these, MA scenarios can be developed for further analysis.

Incident History (internal / external)

Dangerous Goods Present and Material Properties

Major Accident Event


Risk assessment

Mitigative Controls

Preventative Controls








Risk Assessment

The information for assessment can be presented as a bow-tie diagram

Example layer of protection analysis
Example: Layer of Protection Analysis

Risk Assessment

Analysing the safety measures and controls that are between an uncontrolled event and the worst potential consequence - risk reduction study

Risk assessment1
Risk Assessment

Example Risk Matrix

Description of the safety management system
Description of the Safety Management System

  • A comprehensive and integrated management system for all aspects of control measures adopted

  • Documented and describes how compliance is to be achieved

  • Site safety philosophy and how it is reflected in the SMS

  • Safety policy and safety objectives

  • Organisation and personnel responsible for the implementation and compliance with the SMS

  • Major features/elements of the SMS

  • SMS performance monitoring processes

  • Consultative processes used to develop and implement the SMS

Oh s management system model as 4801
OH&S Management System Model – AS 4801

Overall vision, goals and commitment to improve

  • Suitable, adequate, effective

  • Changes needed?

  • Opportunities 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

Emergency response plans
Emergency Response Plans

  • Promote preparation

  • Ensure necessary equipment is available

  • Ensure personnel are trained and prepared to respond

  • Identify communication methods

  • Identify community resources

  • Consultation with emergency services, local council & community

Emergency incident scenario plans
Emergency Incident Scenario Plans

  • Analysis of the consequences of specific MA’s to determine fire fighting access and to identify affected areas

  • Determination of firewater and foam requirements for extinguishing the fire and/or protecting affected equipment

  • Available as a resource for training

Demonstration of adequacy
Demonstration of Adequacy

  • The safety report must demonstrate that the Employer is achieving safe operation of the facility by :

    • Use of adequate control measures

    • Satisfactory management systems

Demonstration of adequacy of control measures
Demonstration of Adequacy of Control Measures

  • Controls linked to hazards and proportionate to risk

  • Depth and breadth of control measures

  • Performance indicators defined and performance monitored

  • Risk has been reduced AFAP

  • Standards, industry practices

  • Decisions are documented and justifiable

  • Improvement programs – past and future

  • More information is available in the Comcare guidance Booklet 3 (control measures).

Demonstration of adequacy of sms
Demonstration of Adequacy of SMS

Comprehensive and Integrated

  • Performance standards for the control measures are defined

  • Control measures are monitored and failures are addressed

  • Adequate education and training is provided for employees

  • Processes are provided for review and revision of control measures

  • Sufficient resources are provided, responsibilities, accountabilities defined

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

  • More information is available in Booklet 3 (SMS)

What else is in a safety report
What Else is in a Safety Report?

Detailed Risk Assessment Records

  • Risk analysis of the hazards on site. E.g.

    • LOPA

    • FTA

    • Risk matrix

    • QRA

  • Provides a more detailed analysis of causes/frequency/consequences/controls for each identified MA

  • Assessment of off-site risk

  • Comparison of risk reduction options

What else is in a safety report1
What Else is in a Safety Report?

Occupied Buildings Risk Assessment

  • Analysis of the impact of MAs on occupied buildings

  • Mainly risks (due to flame impingement, explosions, toxic gas) from other buildings/operations

What else is in a safety report2
What Else is in a Safety Report?

Risk Assessment Procedures

  • Details of all the hazard and risk assessment work documented in procedures and referenced

  • Procedures provide step by step guidance on how the assessments were undertaken – enables corporate memory retention

  • Consistency of approach for all assessments

  • Justification for selection of risk assessment processes

  • Resources/guidance for the conduct of future assessments

What else is in a safety report3
What Else is in a Safety Report?

Community Consultation

  • Community consultation philosophy

  • Summary of Safety Report information for community

  • Community bulletins

What else is in a safety report4
What Else is in a Safety Report?

Recommendations and Improvements

  • Identification of opportunities to reduce risk via risk assessments

  • Recommendations are assessed and prioritised

Review revision
Review & Revision

  • Employers must review (and revise) the safety report for an MHF to ensure risks remain reduced AFAP:

    • Prior to modification

    • When new information becomes available regarding possible MA hazards previously unknown

    • Upon licence renewal conditions or at least every 5 years

    • At the direction of the Commission

    • After a major accident


  • The safety report must demonstrate adequacy of all Safety Duties required by the MHF regulations

  • Safety Duties are ongoing requirements

  • An Employer at a MHF who fails to comply with the MHF regulations may be subject to civil proceedings or criminal prosecution under the OHS Act.

Sources of additional information
Sources of Additional Information

  • Part 9 of the Occupational Health and Safety (Safety Standards) Regulations 1994

  • Major Hazard Facility Guidance Material – Comcare website

  • WorkSafe Victoria

  • NSW Major Industry Hazard Advisory Papers 1 to 9

  • Centre for Chemical Process Safety

  • UK Health and Safety Executive,

Publicly available data incidents
Publicly Available Data/Incidents

Several examples of incidents are available. These include:

  • Tosco Avon refinery fire incident, Martinez California, 23rd February 1999 (source: U.S. Chemical Safety and Hazard Investigation Board, Report No. 99-014-1-CA, issue date March 200)

  • Buncefield fire, December 2005 (source: UK HSE)

  • Dubai Dry Dock Incident (source: Web site, US Naval Sea Systems Command)

Buncefield incident uk december 2005
Buncefield Incident (UK) – December 2005.

  • In the early hours of Sunday 11 December 2005, 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

Buncefield incident
Buncefield Incident

Off-Site Consequences

  • “Significant damage” to commercial and residential neighbours

  • 2000 people evacuated

  • Sections of M1 Motorway closed

  • Very large smoke plume over Southern England → Air pollution

  • Large quantities of foam and water → contaminated water courses and ground water

Buncefield incident1
Buncefield Incident

  • HSE/EA investigation determined the direct cause (initiating event) as follows:

    • “Tank 912 ……. overflowed at around 05.30 hours …….. while being filled at a high rate”

    • Large vapour cloud formed and flowed off-site

    • First explosion at 06.01 hours

  • There were multiple root causes (failures) identified

  • Many related to management system failures

  • Still some unanswered questions

    • Why was there so much explosive force?

Dubai dry dock incident
Dubai Dry Dock Incident

  • On 27 March, 2002 in Dubai there was a breach and failure in one of the dock gates that caused uncontrolled flooding in the dry dock.

  • Several vessels were set on blocks inside the dry dock at the time of the failure. The vessels included the large vessel "Key Burmuda," a cargo barge and the accommodation barge "SEP 350“.

Dubai dry dock incident1
Dubai Dry Dock Incident

  • The dry dock gates failed at 09.30 during a working day.

  • The dock is 500 metres long by 100 metres wide and 11 metres deep.

Dubai dry dock incident2
Dubai Dry Dock Incident

Everything looks normal!!

Dubai dry dock incident3
Dubai Dry Dock Incident

Moments after the first breach at 09:30 on 27.3.02

Dubai dry dock incident4
Dubai Dry Dock Incident

Larger vessels coming off the blocks

Dubai dry dock incident5
Dubai Dry Dock Incident

Cargo barge getting ready to roll. Many trapped inside, a few on deck getting ready to jump

Dubai dry dock incident6
Dubai Dry Dock Incident

“KEY BERMUDA” coming off blocks. “INDRA-1”

swinging towards rig

Dubai dry dock incident7
Dubai Dry Dock Incident

Accommodation barge “SEP 350” sinking

Dubai dry dock incident8
Dubai Dry Dock Incident

“SEP 350” touching bottom

Dubai dry dock incident9
Dubai Dry Dock Incident

The aftermath. Official reports account for 26

persons killed.