A Roadmap for Effective Process Safety Management

Safety Management

IHS OPERATIONAL EXCELLENCE AND RISK MANAGEMENT

April 2015

A Roadmap for Effective Process

Safety Management
Todd Lunsford

A Fatal and Preventable Lesson

Immense pressure had built in a pipe that was scheduled for routine maintenance.
The worker was new to the job and eager to complete his tasks on time.
Unaware of the risks, he overlooked procedure and loosened the bull plug
without checking the pressure gauge upstream.
The pressure released from the pipe knocked the employee on his back, but
without injury. He had a laugh with his coworker, but they did not report the event.
The companys SOP called for a near miss to be reported and for a risk analysis
to be performed. This would have led to a root cause analysis.
The next month, the same task is performed by a different worker. This time the
pressure release knocks the worker off the maintenance truck, resulting in a
fatality.
Separately, a JSA (Job Safety Analysis) at another plant had already identified
this risk and put a safeguard in place.
As a response to this event, the company implemented a high learning value
event (lessons-learned) process, implemented the known safeguard at all
applicable locations, and launched an initiative to improve its safety reporting
culture.
Similar events and missed opportunities occur on a daily basis within operations.
How do you ensure that lessons-learned from all sources of exposure are identified
and turned into preventive actions to strengthen controls enterprise-wide?
Introduction
Advancements in technology, inherently safe design, and the application of lessonslearned in the Process Safety Management (PSM) domain have led to the reduction in
the number of process safety incidents in recent years. Yet, unforeseen catastrophic
process safety events (PSEs) continue to occur at a disturbing rate and are increasing in
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severity . We must continually improve our efforts to ensure safe, reliable operations -to increase risk visibility, to drive consistent process execution, and to sustain learning.
This is a major challenge today in the midst of lower operating margins, aging equipment,
increasing regulatory pressure, and an ever-changing workforce. IHS and its customers
are working together to improve PSM programs and reduce the likelihood of significant
incidents through a unique combination of software, content, and community.
Increase Risk Awareness & Visibility
In its latest assessment of the top 100 losses in the hydrocarbon industry, Marsh stated
that it was the failure of prevention and mitigation measures that resulted in maximum
property damage and that none of the 100 losses should be considered black swan
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events . This is a blunt reminder that each of these losses could have been avoided, and
it should inspire us to exploit available knowledge about risk in order to avoid future
significant incidents in any industry.
1

American Institute of Chemical Engineers (AIChE; www.aiche.org)

The 100 Largest Losses 1974-2013 Large property damage losses in the Hydrocarbon Industry 23rd Edition
www.marsh.com
2

A Roadmap for Effective Process Safety Management

Safety Management

We gain this risk knowledge from many sources. There are lessons-learned and
corrective actions from external companies, regulatory agency rules and
recommendations, expert opinions and so forth.
Internally, we accumulate risk
knowledge from risk assessments, management of change, incidents, audits,
inspections, and other events planned and unplanned. These events contain valuable
information about known risks, safeguards & controls that are in place or have failed, root
causes, and risk mitigation activity.
Figure 1.
Sources of Risk Knowledge:
Incidents
Near Misses
Risk Assessments
Management of Change
Audits & Assessments
Drills / Exercises
Safe Operating Limit (SOL) Exceedences
Primary Containment Inspections
Testing Results Outside Acceptable Limits
Demands on Safety Systems

Safety Systems Activated

Mechanical Shutdown Systems Activated
Critical Equipment Inspections
Spurious Shutdowns
Process Safety Related Training
Process Safety O&M Procedure Reviews
Reviewed Work Permits
Safety Critical Equipment Inspections
Fatigue Risk Events

Figure 1 lists potential sources of Process Safety risk information. The American
Petroleum Institute recommends many of these as sources of leading and lagging
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process safety indicators. The information from these sources should be integrated and
easily accessible so that learnings can be applied and controls can be continuously
strengthened. Getting your arms around all these risk-related events can seem like a
monumental undertaking, but it doesnt have to be. First-movers in this market have
already accomplished this and paved the way for fast-followers.
What have the First Movers done?
They have integrated the most critical PSM processes and event types onto a
common, company-wide platform;
Theyve used the platform to engage the workforce;
Theyve educated employees and contractors about what should be reported;
Theyve removed the technical and cultural barriers to reporting risks, hazards,
findings, issues, non-conformances, incidents, and near misses; and
Theyve held individuals accountable for the corrective and preventive actions.
Figure 2 shows a visual integration of essential PSM event types: risk assessments;
management of change events; incidents & near misses; high learning value events; and
action items. These event types were identified as the top critical processes in
assessments of IHS customers, and are often prioritized as the most important elements
of a PSM management system. They follow a common risk management pattern from
risk identification to causal analysis and to the strengthening of controls across the
organization. Integrating these onto a single enterprise system increases visibility from
the bottom up and from the top down. An incident at one facility can quickly be turned
into a lesson-learned and preventive action at all others. Multiple hazards identified on
the front lines can build risk control libraries and roll up into a corporate risk register.
Major issues, root causes, regulatory findings, and lapses in workforce engagement can
be highlighted and corrected company-wide. The risk information from multiple sources
can be used to specifically allocate resources to strengthen controls that will prevent
future incidents. All of this activity can be efficiently monitored so that improvements can
be made.
3

Process Safety Performance Indicators for the Refining and Petrochemical Industries, ANSI/API RECOMMENDED PRACTICE
754 FIRST EDITION, APRIL 2010

High learning value

events include any events
-- planned or unplanned,
internal or external to the
company -- that contain
valuable lessons or risk
information that could be
used for preventive
actions in multiple
additional areas.

A Roadmap for Effective Process Safety Management

Safety Management

Figure 2.

Improve Process Execution

Expanded risk visibility is a foundational step on the journey to effective process safety
management, but integration alone is not enough. Engaging the workforce to capture a
broad set of risk data on a common platform increases the quantity and efficiency of
data, but the quality will be lacking in many areas if our efforts stop there. To support
effective decision-making, we need complete and reliable information about these allimportant risk processes and the way they are being performed. This is accomplished
by using the platform to drive consistency in the way these processes are executed.
Indeed, if the processes from our PSM management system, such as process hazard
analysis (PHA), management of change, and incident investigation, were correctly and
consistency executed throughout our organizations, the world would be a safer place.
The reality is that many management systems are well-defined and certainly wellintentioned, but they are poorly implemented and executed. The agreed-upon rules,
activities, and behaviors set forth in binders and on websites are never fully brought to
life in field operations. Training, communications, and publications are not enough to
successfully implement and sustain management system, especially for a workforce that
is ever-changing. A well-executed management system can transform a business, yet
there is no business transformation without a system implementation to sustain it. The
management system must be embedded in the organizations culture and underpinned
by an information system that organizes, enables, drives, and sustains the related
activities at the local levels.
Figure 3 shows the cascade from management systems to local behaviors. The
management system defines the framework that will be used to complete the
organizations objectives. Standard operating procedures (SOPs) are the how-to guides
that describe the activities necessary to complete those objectives, the responsibilities of
those involved, and the rules and regulations that apply.

There is no business
transformation
without a system
implementation.

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The business process information is closely related to the SOP, and includes the steps,
business rules, and systems that must be followed and used when completing the
activities. Local practices refer to the facility or field-level interpretations of the business
processes. They represent how these important directions are actually carried out
throughout the organization.
Figure 3.

For instance, a common objective is to perform critical equipment changes without

incident. This objective is defined in the management of change (MOC) element of the
management system. For this objective to be realized, the local practice of managing
changes should correctly and consistently adhere to the MOC SOP and business
process definition. As an example, Figure 4 shows a summary view of an MOC process.
Each step in this process was designed for a reason to ensure safe changes and that
reasoning flows from the management system to the SOP to the process. The challenge
is to ensure that the workforce fully adopts the process and performs it with appropriate
discipline each time a change is made. The right information system can help to achieve
this by applying automation that engages the right people to perform the right steps at the
right time every time. Automation systematizes the process and embeds it into the
local culture, and relieves the pressure from the workforce to memorize process steps,
responsibilities, and business rules.

A strong, safetyoriented culture will

execute the process
consistently well.

Now, imagine if each critical PSM process was enabled in this way, and executed and
reflected in the system in real-time. New workers can step into a process and get up to
speed quickly. If activities are bypassed, cut short, never closed, or completed by the
wrong people, the system will highlight these issues as opportunities for process
improvement. Over time, this process information provides insights into the behaviors
and the culture of the sites using the process. A strong, safety-oriented culture will
execute the process consistently well. A weaker culture may only comply with certain
aspects, such as documentation, but view the end-to-end process as unnecessary or
burdensome. By monitoring risk processes in this way, metrics from the processes can
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be studied and used as leading indicators of future process safety performance.
Figure 4.

Unlocking the Value of Operational Data - Introducing Progressive Leading Indicator, Dr. Mei-Li Lin, Sr. Director Operational
Excellence Solutions, IHS, Inc.
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A Roadmap for Effective Process Safety Management

Safety Management

Enhance & Sustain Learning

When critical PSM processes are consistently performed enterprise-wide on a common
platform, a broad, deep, and high-quality set of data is inherently generated. This
presents a tremendous opportunity for learning. If learning is then fully embraced and
utilized, it can become the driver for continuous improvement, and thus, operational
excellence.
Give People the Permission and Support to Learn
People want to learn, and learning unlike training is often initiated by individuals.
Make information available to these individuals, and endorse their time spent learning.
This may involve an update to their job responsibilities to allow more time for learning.
One of the benefits of enabling key processes via enterprise software is the time that is
saved when certain tasks are automated. For example, a recent IHS Spectrum
Excellence award winner reduced their time of creating enterprise-wide reports from 15
5
days to about 15 minutes. This made time available that could be used for learning.
Step into opportunities like these and designate learning responsibilities. Give people
the permission and possibility to explore the available information. Recognizing that this
information can be complex and scattered over many sources, it is also critical to
provide intelligently built overviews in dashboards or prebuilt reports, with the ability to
further investigate and drill-down from these predefined reports.
When you begin to identify the learning-minded individuals in your organization and
provide them the support and tools they need, you can focus their efforts on closing the
information gaps that typically exist between risk assessments, audits, MOCs, incidents,
external events, and other activities.
Risk registers, risk control libraries, and
investigation results can be leveraged to identify trends and thematic issues. Risks
identified and controls implemented at some locations, but not others, can be
addressed. PSM processes can be monitored to ensure the proper risk reduction steps
are consistently being taken.
Implement a Lessons-learned Process
Turning a lesson-learned into a corrective or preventive action doesnt happen
automatically. Start by defining what a lesson-learned is to your company, and create
the criteria that can be used to identify one. Assign responsibilities to review events and
apply these criteria. Create a process for sharing, distributing, and implementing the
needed improvements from lessons-learned. Identify roles at the facility and site level
that will receive lessons-learned, and hold them accountable for reviewing them and
taking action where required. Learning-minded sites and departments will review the
lessons-learned when they receive them, and create preventive actions to implement
the controls at their locations. If the lesson-learned is not applicable, they can decline it
with an explanation. Unlike email alerts or lessons-learned that are posted on a wiki or
document management site, this is a process that can be monitored and improved.
Implementing a lessons-learned process could literally be a life-saving practice.
Engage Leadership to Assess Process Quality
Finally, an important learning & continuous improvement activity is to assess the quality
of a process or processes. This can be done by applying a process quality
questionnaire to a sampling of events that have followed a process, such as the ones
described above. The information system gives leaders visibility to the process
resources and activities performed, and seamlessly enables this assessment so they
can review and validate the process steps taken. Leaders are automatically notified via
email, can link directly to a record, and can complete their review of the process using
a simple checklist, which produces a calculated score for the process. This not only
5

Total Petrochemicals Unifies Global EHS Reporting to Drive Down Operational Risks, Drive Up
Excellence, IHS SPECTRUM EXCELLENCE AWARD WINNER
5

produces high value content for learning, but provides a means for leaders to get
involved, provide feedback, and improve the process and the way its executed. The
workforce in turn realizes the importance of the process when they see leaders
monitoring and reviewing in this manner. Engaging leadership in this activity has also
been proven through IHS studies to be a significant performance predictor. Business
units that performed well on process quality assessments conducted by appropriate
leaders had fewer significant incidents when compared to their peers 6.
Closing
Improving process safety is a journey, certainly not a destination. With that in mind, this
roadmap is not intended to be used as a silver bullet to solve all problems. The
recommendations are designed to come alongside other efforts you are making to
ensure safe, reliable operations. At IHS, weve observed that some best-laid plans
never achieve the desired results due to poor implementations, and ultimately, a lack of
proper execution in the field. Limited risk visibility, poor process execution, and a lack of
learning activity can leave your organization exposed to significant risks. IHS solutions
are embedded with risk concepts that can be used to improve process execution, help
drive the discovery of possible failure points, and enable improvements in controls
across the organization to prevent incidents.

IHS OE&RM Advisory Services Group conducted a multiple-company study using its proprietary tools and
analytic approach. The study examined multiple companies in the energy industry covering over 1.2 billion
work hours with more than 84,000 incidents.

IHS Operational Excellence &

Risk Management
Email:
operationalexcellence@ihs.com

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