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Author Safety), CCPS (Center for Chemical Process
Title Recognizing Catastrophic Incident Warning Signs in the Process Industries
Imprint New York : American Institute of Chemical Engineers, 2011
©2012
book jacket
Edition 1st ed
Descript 1 online resource (260 pages)
text txt rdacontent
computer c rdamedia
online resource cr rdacarrier
Note Intro -- Recognizing Catastropic Incident Warning Signs in the Process Industries -- CONTENTS -- List of Tables -- List of Figures -- Files on the Web Accompanying This Book -- Acknowledgments -- Foreword -- Preface -- 1 INTRODUCTION -- 1.1 Process safety management -- 1.1.1 Identifying process safety management system deficiencies -- 1.2 Normalization of deviance -- 1.3 A strategy for response -- 1.4 Maintaining organizational memory and a healthy sense of vulnerability -- 1.5 Risk Based Process Safety -- 1.6 Our target audience -- 1.7 How to use this book -- 1.8 Case study - Toxic gas release in India -- 2 INCIDENT MECHANICS -- 2.1 Incidents do not just happen -- 2.2 Incident models -- 2.2.1 The difference between incidents and catastrophic incidents -- 2.2.2 The Swiss cheese incident model -- 2.2.3 The bonfire incident analogy -- 2.2.4 The dam incident analogy -- 2.2.5 The iceberg incident analogy -- 2.2.6 Incident trends and statistics -- 2.2.7 Root cause analysis -- 2.2.8 Multiple root cause theory -- 2.3 Case study - Benzene plant explosion in China -- 3 LEADERSHIP AND CULTURE -- 3.1 How does leadership affect culture? -- 3.1.1 Communication -- 3.1.2 Operational discipline -- 3.1.3 Process safety culture -- 3.1.4 Process safety versus occupational safety -- 3.2 The leadership and culture related warning signs -- 3.2.1 Operating outside the safe operating envelope is accepted -- 3.2.2 Job roles and responsibilities not well defined, confusing, or unclear -- 3.2.3 Negative external complaints -- 3.2.4 Signs of worker fatigue -- 3.2.5 Widespread confusion between occupational safety and process safety -- 3.2.6 Frequent organizational changes -- 3.2.7 Conflict between production goals and safety goals -- 3.2.8 Process safety budget reduced -- 3.2.9 Strained communications between management and workers
3.2.10 Overdue process safety action items -- 3.2.11 Slow management response to process safety concerns -- 3.2.12 A perception that management does not listen -- 3.2.13 A lack of trust in field supervision -- 3.2.14 Employee opinion surveys give negative feedback -- 3.2.15 Leadership behavior implies that public reputation is more important than process safety -- 3.2.16 Conflicting job priorities -- 3.2.17 Everyone is too busy -- 3.2.18 Frequent changes in priorities -- 3.2.19 Conflict between workers and management concerning working conditions -- 3.2.20 Leaders obviously value activity-based behavior over outcome-based behavior -- 3.2.21 Inappropriate supervisory behavior -- 3.2.22 Supervisors and leaders not formally prepared for management roles -- 3.2.23 A poorly defined chain of command -- 3.2.24 Workers not aware of or not committed to standards -- 3.2.25 Favoritism exists in the organization -- 3.2.26 A high absenteeism rate -- 3.2.27 An employee turnover issue exists -- 3.2.28 Varying shift team operating practices and protocols -- 3.2.29 Frequent changes in ownership -- 3.3 Case study - Challenger space shuttle explosion in the United States -- 4 TRAINING AND COMPETENCY -- 4.1 What is effective training, and how is competency measured? -- 4.1.1 Three basic levels of training -- 4.1.2 Competency assessment -- 4.2 The training and competency related warning signs -- 4.2.1 No training on possible catastrophic events and their characteristics -- 4.2.2 Poor training on hazards of the process operation and the materials involved -- 4.2.3 An ineffective or nonexistent formal training program -- 4.2.4 Inadequate training on facility chemical processes -- 4.2.5 No formal training on process safety systems -- 4.2.6 No competency register to indicate the level of competency achieved by each worker
4.2.7 Inadequate formal training on process-specific equipment operation or maintenance -- 4.2.8 Frequent performance errors apparent -- 4.2.9 Signs of chaos during process upsets or unusual events -- 4.2.10 Workers unfamiliar with facility equipment or procedures -- 4.2.11 Frequent process upsets -- 4.2.12 Training sessions canceled or postponed -- 4.2.13 Procedures performed with a check-the-box mentality -- 4.2.14 Long-term workers have not attended recent training -- 4.2.15 Training records are not current or are incomplete -- 4.2.16 Poor training attendance is tolerated -- 4.2.17 Training materials not suitable or instructors not competent -- 4.2.18 Inappropriate use or overuse of computer-based training -- 4.3 Case study - Gas plant vapor cloud explosion in Australia -- 5 PROCESS SAFETY INFORMATION -- 5.1 Critical information to identify hazards and manage risk -- 5.2 The process safety information related warning signs -- 5.2.1 Piping and instrument diagrams do not reflect current field conditions -- 5.2.2 Incomplete documentation about safety systems -- 5.2.3 Inadequate documentation of chemical hazards -- 5.2.4 Low precision and accuracy of process safety information documentation other than piping and instrument diagrams -- 5.2.5 Material safety data sheets or equipment data sheets not current -- 5.2.6 Process safety information not readily available -- 5.2.7 Incomplete electrical / hazardous area classification drawings -- 5.2.8 Poor equipment labeling or tagging -- 5.2.9 Inconsistent drawing formats and protocols -- 5.2.10 Problems with document control for process safety information -- 5.2.11 No formal ownership established for process safety information -- 5.2.12 No process alarm management system -- 5.3 Case study - Batch still fire and explosion in the UK -- 6 PROCEDURES -- 6.1 Safe and consistent operation
6.2 The procedure related warning signs -- 6.2.1 Procedures do not address all equipment required -- 6.2.2 Procedures do not maintain a safe operating envelope -- 6.2.3 Operators appear unfamiliar with procedures or how to use them -- 6.2.4 A significant number of events resulting in auto initiated trips and shutdowns -- 6.2.5 No system to gauge whether procedures have been followed -- 6.2.6 Facility access procedures not consistently applied or enforced -- 6.2.7 Inadequate shift turnover communication -- 6.2.8 Poor quality shift logs -- 6.2.9 Failure to follow company procedures is tolerated -- 6.2.10 Chronic problems with the work permit system -- 6.2.11 Inadequate or poor quality procedures -- 6.2.12 No system for determining which activities need written procedures -- 6.2.13 No established administrative procedure and style guide for writing and revising procedures -- 6.3 Case study - Nuclear plant meltdown and explosion in the Ukraine -- 7 ASSET INTEGRITY -- 7.1 Systematic implementation -- 7.2 The asset integrity related warning signs -- 7.2.1 Operation continues when safeguards are known to be impaired -- 7.2.2 Overdue equipment inspections -- 7.2.3 Relief valve testing overdue -- 7.2.4 No formal maintenance program -- 7.2.5 A run-to-failure philosophy exists -- 7.2.6 Maintenance deferred until next budget cycle -- 7.2.7 Preventive maintenance activities reduced to save money -- 7.2.8 Broken or defective equipment not tagged and still in service -- 7.2.9 Multiple and repetitive mechanical failures -- 7.2.10 Corrosion and equipment deterioration evident -- 7.2.11 A high frequency of leaks -- 7.2.12 Installed equipment and hardware do not meet good engineering practices -- 7.2.13 Improper application of equipment and hardware allowed -- 7.2.14 Facility firewater used to cool process equipment
7.2.15 Alarm and instrument management not adequately addressed -- 7.2.16 Bypassed alarms and safety systems -- 7.2.17 Process is operating with out-of-service safety instrumented systems and no risk assessment or management of change -- 7.2.18 Critical safety systems not functioning properly or not tested -- 7.2.19 Nuisance alarms and trips -- 7.2.20 Inadequate practices for establishing equipment criticality -- 7.2.21 Working on equipment that is in service -- 7.2.22 Temporary or substandard repairs are prevalent -- 7.2.23 Inconsistent preventive maintenance implementation -- 7.2.24 Equipment repair records not up to date -- 7.2.25 Chronic problems with the maintenance planning system -- 7.2.26 No formal process to manage equipment deficiencies -- 7.2.27 Maintenance jobs not adequately closed out -- 7.3 Case study - Refinery naphtha fire in the United States -- 8 ANALYZING RISK AND MANAGING CHANGE -- 8.1 Risk management -- 8.1.1 Hazard identification and risk analysis -- 8.1.2 The definitions of hazard and risk -- 8.1.3 Management of change -- 8.1.4 What is your role in risk management? -- 8.2 The risk analysis and management of change related warning signs -- 8.2.1 Weak process hazard analysis practices -- 8.2.2 Out-of-service emergency standby systems -- 8.2.3 Poor process hazard analysis action item follow-up -- 8.2.4 Management of change system used only for major changes -- 8.2.5 Backlog of incomplete management of change items -- 8.2.6 Excessive delay in closing management of change action items to completion -- 8.2.7 Organizational changes not subjected to management of change -- 8.2.8 Frequent changes or disruptions in operating plan -- 8.2.9 Risk assessments conducted to support decisions already made -- 8.2.10 A sense that we always do it this way -- 8.2.11 Management unwilling to consider change
8.2.12 Management of change item review and approval lack structure and rigor
This book provides guidance on characterizing, recognizing, and responding to warning signs to help avoid process incidents and injuries before they occur. The guidance can be used by both process safety management (PSM) professionals in evaluating their processes and PSM systems as well as for operators who are often the frontline defense against process incidents. Warning signs may consist of process deviations or upsets, instrumentation warnings or alarms, past operating history and incidents, observable problems such as corrosion or unusual odors, audit results indicating procedures are not being followed, or a number of other indicators. Filled with photos and practical tips, this book will turn anyone in a process plant into a hazard lookout and will help prevent potential incidents before they turn into catastrophic events
Description based on publisher supplied metadata and other sources
Electronic reproduction. Ann Arbor, Michigan : ProQuest Ebook Central, 2020. Available via World Wide Web. Access may be limited to ProQuest Ebook Central affiliated libraries
Link Print version: Safety), CCPS (Center for Chemical Process Recognizing Catastrophic Incident Warning Signs in the Process Industries New York : American Institute of Chemical Engineers,c2011 9780470767740
Subject Chemical engineering -- Safety measures.;Chemicals -- Accidents -- Prevention.;Warnings
Electronic books
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