Process Safety Information Research Articles

Process safety management lessons learned from a fire and explosion accident caused by a liquefied petroleum gas leak in an aromatics reforming unit in Taiwan

A severe fire and explosion accident was caused by a liquefied petroleum gas leak in Taiwan in 2019. This accident resulted in the loss of approximately US$3.5 billion in output value due to a one-and-a-half-year shutdown after the accident; however, no casualties were recorded at the accident scene. An analysis of the accident pipelines demonstrated that the pipeline leak had been caused by hydrochloric acid corrosion. Cause analysis based on the accident timeline, fault tree analysis, and causal factor charting indicated inadequacies in five elements of process safety management (PSM) namely mechanical integrity (MI), management of change, emergency planning and response, process hazard analysis (PHA), and process safety information (PSI) as the root causes of the accident. Furthermore, insufficient PSI (i.e., a lack of comprehensive understanding regarding corrosion mechanisms) was deemed to have been the core problem leading to the accident. This accident revealed common shortcomings that are often overlooked in PSM implementation in Taiwan; thus, the present research can serve as a vital reference for improving PSM programs in Taiwan.

Improved management practice and process hazard analysis techniques for minimizing likelihood of process safety incidents in Taiwan

In Taiwan, process safety accidents often occur despite the prior implementation of process hazard analysis (PHA). One of the main reasons for this is the poor quality of the PHA process; with the main hazards not being properly identified, or properly controlled. Accordingly, based on the findings of 86 process safety management (PSM) audits, dozens of post-accident site resumption review meetings, and hundreds of PSM review sessions, this study examines the main deficiencies of management practice and PHA implementation in Taiwan, and presents several recommendations for improved PHA assessment techniques and procedures. The study additionally examines the feasibility for using PSM-related information, such as process safety information and process incident information, as a tool for further enhancing the PHA quality. Overall, the study suggests that, in addition to following the basic rules of PHA and requirements of OSHA (1992),management in Taiwan should also provide training in the enhanced assessment techniques proposed herein and take active steps to incorporate PSM information into the PHA framework in order to improve the general quality of PHA and reduce the likelihood of process safety accidents accordingly.

Process safety management lessons learned from a fire accident caused by the reverse flow of high‐pressure gas in a residual desulfurization process in Taiwan

AbstractIn 2020, a fire and explosion accident occurred in Taiwan because of the reverse flow of high‐pressure recycle gas. This accident resulted in three minor injuries and caused the Taiwanese government to instruct the top three chemical groups in Taiwan to conduct procedural hazard and operability (HAZOP) studies in addition to normal HAZOP studies. The cause analysis based on the accident timeline and cause factor chart indicated that improper control of the protection logic bypass and the lack of four process safety management (PSM) elements, namely mechanical integrity, process safety information (PSI), operating procedures, and process hazard analysis (PHA), were the root causes of the aforementioned accident. The deficiencies leading to accidents are related to planning problems in PSM promotion but unrelated to the implementation of PSM programs. Maintenance processes should be evaluated and developed according to PHA results or equipment structure to guarantee equipment integrity. The incompatibility of process chemicals with pipeline materials should be considered; then, the construction materials mentioned in PSI should be extended to those of pipelines, not just equipment. In addition to the hazards of normal operations, those of non‐routine operations should be identified to ensure the completeness of the PSM program. Protection logic bypass should be appropriately controlled, and a complete safety evaluation must be conducted before resetting the initiated protection logic. A majority of the deficiencies identified in this study exist in most Taiwanese chemical companies, including the leading ones performing PSM. The lessons learned from the aforementioned accident provide advance information that can be used to develop an improved PSM system.

Effectively use metrics as part of process safety feedback and learning systems to monitor and improve performance

AbstractWithout appropriate process safety program metrics and feedback systems, warning signs of problems may be missed and learning opportunities for improving performance can be lost. Ensuring the right things are measured and evaluated, based on process safety program goals, provides information on the current performance level and trends: is performance getting better or worsening? Learning from experience, based on effective feedback systems and the use of organizational learning approaches to collect, analyze, share, and retain critical process safety information, helps promote sensitivity to operations, a sense of vulnerability, and knowledge of past problems and successes to help maintain organizational memory and maintain or improve program performance.

Writing in the margins: Considerations for safe operating limits

AbstractWhen learning how to write, school‐age children are often told, “Do not write in the margins.” This guidance is important because it instills in a child the sense of where text is best placed on a piece of paper. The same is true for chemical processes—normal operating limits define the area where a process is best operated. However, processes may occasionally stray into the margins beyond the operating limits. As a result, facilities may need to define safety margins where temporary operation beyond the normal operating limits is tolerable. In this paper, guidance will be provided for understanding and setting operating limits and safety margins for chemical processes. Good practices from the industry for defining and setting limits, as well as documenting and communicating the limits to operational staff, will be discussed. Last, a case study that examines safe operating limits, alarm setpoints, interlocks, and process safety information for a dryer processing a thermally unstable material will be presented to illustrate the concepts of the paper.

A Case Study of Asset Integrity and Process Safety Management of Major Oil and Gas Companies in Malaysia

Asset integrity is closely intertwined with process safety where the latter is often perceived to be equivalent or a subset of the former. In Malaysia, the requirements for offshore process safety are set by Petronas assuming exclusive rights to petroleum in the nation. It imposes and enforces these requirements on oil and gas companies entering into its production sharing contracts via the common law. Process safety management in Malaysia is strongly influenced by the US OSHA 3132 with elements comprising process safety information, process hazard analysis, operating procedures, employee participation, training, contractors, pre-startup safety review, mechanical integrity, hot work permit, management of change, incident investigation, emergency planning and response as well as compliance audits. These elements are largely included in the Mandatory Control Framework of Petronas and the trio of design, technical and operating integrity adopted in the process safety management of other oil and gas companies. These management practices align with the reiterative plan-do-check-act model. Process safety performance is also gauged with indicators suggested by international institutions such as the American Petroleum Institute. On top of the Control of Industrial Major Accident Hazards Regulations 1996 for onshore processes, this study deems that establishing statutory law for offshore installations will be beneficial to propel offshore safety in Malaysia to a greater height.

Guidelines for integrating process safety into engineering projects

AbstractThis article describes a new guideline book that the Center for Chemical Process Safety has published on integrating process safety into engineering projects. Engineering projects in the process industry are temporary endeavors generally undertaken to create a new or modified facility and vary widely in scope and size ranging from large capital projects to small management of change works. The main focus of the guidelines is on proactively implementing process safety activities at the optimum timeframe, while also reactively conducting “cold eyes” reviews to provide assurance that nothing significant has been missed. This approach ensures that if the right process safety activities are conducted at the right time, project leadership will have the right (process safety) information in order to be able to make the right risk management decisions regarding safety. Process safety in engineering projects involves leadership, managers, engineers, operating and maintenance personnel, contractors, vendors, suppliers, and support staff. Therefore, these guidelines were prepared for a wide audience.

Deficiencies frequently encountered in the management of process safety information

Process Safety Information (PSI) provides the fundamental information necessary for developing the elements of Process Safety Management (PSM). We report the PSI management deficiencies found in PSM audits of more than 70 plants. It should be noted that the PSM audits were not limited to OSHA requirements. The deficiencies found were frequently encountered in the management of the PSI element. The chemical hazards information provided on the Safety Data Sheets (SDS) are not sufficient and may not be appropriate for the process condition used; therefore, the chemical hazards information should not be limited to only the SDS. Although the information provided by the SDS satisfies the OSHA requirements, it is suggested that management further develop the chemical hazards information necessary to ensure the safety of the process. Process incidents resulting from undesired reactions are more frequent than from the desired reaction. Therefore, in terms of safety, the process chemistry of the undesired reactions is essential information for the process technology. However, such undesirable reactions are not identified, and their process chemistries are lacking for most processes. The frequently encountered problem for the information of the process equipment is the inconsistency between the piping and instrument diagram and the actual process. Summarily, the necessary information of the PSI should be developed based upon the characteristics of the process.

DADS

We present a novel scheme called Decentralized Attestation for Device Swarms (DADS), which is, to the best of our knowledge, the first to accomplish decentralized attestation in device swarms. Device swarms are smart, mobile, and interconnected devices that operate in large numbers and are likely to be part of emerging applications in Cyber-Physical Systems (CPS) and Industrial Internet of Things (IIoTs). Swarm devices process and exchange safety, privacy, and mission-critical information. Thus, it is important to have a good code verification technique that scales to device swarms and establishes trust among collaborating devices. DADS has several advantages over current state-of-the-art swarm attestation techniques: It is decentralized, has no single point of failure, and can handle changing topologies after nodes are compromised. DADS assures system resilience to node compromise/failure while guaranteeing only devices that execute genuine code remain part of the group. We conduct performance measurements of communication, computation, memory, and energy using the TrustLite embedded systems architecture in OMNeT++ simulation environment. We show that the proposed approach can significantly reduce communication cost and is very efficient in terms of computation, memory, and energy requirements. We also analyze security and show that DADS is very effective and robust against various attacks.

화학물질 취급사업장의 공정안전 통합보고서 작성에 관한 연구

Recently, fire, explosion and environmental pollution caused by leakage of chemical substances are gradually becoming larger, and the amount and risk of chemical substances to be handled are increasing. In 2017, the Ministry of Employment and Labor and the Ministry of Environment compiled and analyzed the results of the PSM, RMP, and ORA. However, the requirements of each system are different from those of the integrated report. Therefore, it is necessary to study the improvement methods of items - Chemical Information, Process Safety Information, Safety Facilities, etc. to meet the requirements of each system and to increase the utilization of the company.

Managing Employee Participation based on OSHA’s Process Safety Management Requirements

A report published on 25 April 2016 stated that OSHA has issued 14 serious violations after an investigation conducted in a variety of industries including manufacturing, water treatment and oil and gas that violated OSHA's Process Safety Management (PSM) standard. One of the violations is related to the 29 CFR 1910.119(c)(2) which is employers did not consult with employees and their representatives on the conduct and development of the OSHA’s PSM elements which are process safety information (PSI), process hazard analyses (PHA), training (TNG), mechanical integrity (MI), management of change (MOC), pre-start up safety review (PSSR), contractors (CON), incident investigations (II), emergency planning and response (EPR), compliance audit (CA) and trade secret (TS). 29 CFR1910.119(c)(2) is one of the requirements in the OSHA’s PSM employee participation element. However, companies are still struggling to comply with this regulation due to unclear coverage and the implementation method for achieving compliance. Thus, this paper presents a framework and work-aid tool developed based on OSHA’s PSM 29 CFR 1910.119(c) which are helpful to the industries as they provide structured technique to plan and implement an employee's participation management system to achieve compliance in implementing the OSHA PSM employee participation element.

Investigating Written Procedures in Process Safety: Qualitative Data Analysis of Interviews from High Risk Facilities

Socio-technical systems, such as those in oil and gas, or the petrochemical and energy industries, are escalating in complexity, a consequence of increasingly advanced technologies, organizational constructs, and business functions that interact and depend on one another. These dynamic social and technological elements, coupled with the high risk inherent in these systems, have generated conditions that can bring about catastrophic failure and the tragic loss of human life, such as the disaster in Bhopal, India (1984) or the explosion in the Houston Ship Channel near Pasadena, Texas (1989). Historically, the perception of such complexities and the struggle to minimize catastrophic failures observed within the petrochemical industry have been attributed to the inherent variability in people. Therefore, process safety regulations associated with the Clean Air Act Amendments of 1990 and the Occupational Safety and Health Administration (OSHA) require employers to develop written process safety information or “procedures” which aim for consistency in plant operations and to help workers at the “sharp-end” of the system cope with unexpected events (OSHA, 2000). However, investigation reports since, such as the BP Texas City incident of 2005, suggest “outdated and ineffective procedures” as significant contributing factors to failure. Evidence from other studies suggest that procedures in complex environments are sometimes misunderstood, outdated, or simply not used (Bullemer & Hajdukiewicz, 2004). While there have been studies on procedural deviations and safety violations (Alper & Karsh, 2009; Jamison & Miller, 2000), employers continue to report a high rate of procedural breakdown as root causes for incidents (Bates & Holroyd, 2012). This warrants a contemporary, systems-oriented inquiry into process safety and behavior surrounding the use of the documents at different individual (e.g. cognitive), task, cultural, organizational, and environmental levels. This perspective appreciates the interdependent nature of these interrelated socio-technical elements and should provide insight into the effectiveness of current procedure systems, thereby informing future work in creating and empirically testing mitigation methods to address potential barriers. This research documents one part of a three part, large-scale project that investigates the issues with procedure forms, usage, adoption, and challenges in a wide range of high-risk industries. As such, the method was framed around first understanding the extent to which these challenges could be generalized between various locations. A grounded theory approach in qualitative data analysis, influenced by the Strauss & Corbin and Charmaz approaches (Bryman 2015) and facilitated by the analysis software MAXQDA-12 was used to examine 72 semi-structured interviews with operators of varying roles and experiences across 6 countries and an offshore drilling vessel. Findings reaffirm previous research, suggesting that the effectiveness of written procedures is limited by an abundance of outdated procedures plagued by information overload. New findings suggest that frequency of the task and the experience level of the worker would impact workers’ procedure use, with participants commenting that the perceived importance of these documents decreases significantly after initial training periods. Other unintended consequences associated with written procedural systems range from complications in using the documents around personal protective equipment (PPE) requirements and harsh weather, reactive organizational behavior surrounding changing procedures, and a general disconnect between the users and the writers of these documents. This is only exacerbated as management imposes pressure to use procedures on personnel despite the issues encountered with the documents, inhibiting valuable feedback within their organizations as personnel withhold information for fear of job security and potential punishment (in the form of 20-day suspension programs or termination). Moving forward, research is in-progress to identify the interdependencies between environmental, cultural, organizational, task, and personal factors unique to each location. This will provide insight regarding the extent to which procedures may not be generalized, after which a holistic view of procedure use in the industry will be offered. The resulting insight will point to recommendations for the future redesign of procedures’ role in promoting safe operations within petrochemical systems. Finally, the third part of this research project will demonstrate the efficacy of using visualizations as tools and methods in qualitative research for modeling complexity in socio- technical systems.

Lessons in process safety management learned from a pesticide plant explosion in Taiwan

A massive explosion in Taichung, Taiwan, in 2016, which was attributed to the thermal decomposition of o,o‐dimethyl phosphoramidothioate, resulted in one fatality and one injury. This accidental explosion stemmed from certain elements being absent from process safety management (PSM), including process safety information, the management of change, process hazard analysis, mechanical integrity, operating procedures, training, and the pre‐startup safety review. Problems encountered during the promotion of PSM were also identified, such as the hazards associated with highly hazardous chemicals at normal temperatures and pressure as outlined in the safety data sheet and the fact that these may be different from those under the conditions of the process. © 2017 American Institute of Chemical Engineers Process Process Saf Prog 37:104–109, 2018

Benefits of simple consequence modeling for Burner Management Systems

The current approach used to analyze fired heaters during a Process Hazard Analysis (PHA) is inefficient and outdated. Fired heaters can be one of the more complex systems evaluated in a PHA, however they certainly aren't anything new. In fact, they are one of the most common pieces of process equipment throughout industry, and have been for quite some time. Why then is such a large amount of PHA team time still needed to analyze them? Why, when using the same Process Safety Information (PSI), methodology, and risk criteria, can the results still be inconsistent? The obvious answer is the PHA team; different teams yield different results. Since the results of a PHA can impact several facets of a facility and its operation, including driving the Safety Integrity Level (SIL) for the heater's Burner Management System (BMS), inconsistencies between analyses can have significant safety and financial impacts. If the consequence estimation is over conservative the selected SIL may be too high, which will result in an over designed and a very costly Safety Instrumented System (SIS). Conversely, if the consequence estimation is too low, the facility's risks may not be adequately reduced by the selected SIS. Therefore a means to efficiently and consistently determine the consequence is critical. This paper will describe how simple consequence modeling can solve this problem, its inherent benefits, and the cost savings it provides.

Chinese process safety management core elements and control measures

With the popularization and application of chemical process safety management (PSM) systems in the chemical industry, the use of such systems in China has become the focus of a large volume of research. In this article, 12 elements included in the current Chinese PSM system are divided into four stages from a structural point of view. This division will be helpful in the follow‐up analysis. After a careful analysis of the evaluation results for one PSM pilot study in Nanjing, some correlations have been found between the results of the elemental evaluation. Small‐ and medium‐sized chemical plants make up a large proportion of Chinese chemical plants and many chemical accidents take place in these plants, so a simplified PSM system in practical operation need to be found. Based on a previous PSM structural analysis, the secondary elements of the PSM system can be removed. This allows researchers to avoid the traditional method of analyzing PSM elements individually. In the concrete analysis process, a theoretical analysis of the correlation degree between elements can be combined with the results of accident investigations. The simplified Chinese PSM system consists of four core elements: Process safety information, process hazard analysis, training, and emergency management. Based on the current applications of these four core elements in China, a consideration of correlations between these elements is used to make several suggestions for improving China's PSM systems. © 2017 American Institute of Chemical Engineers Process Saf Prog 36: 378–381, 2017

염산취급시설의 사고시 사업장외에 미치는 영향평가

위험물인 염산을 취급하는 사업장에서 발생할 수 있는 사고를 알아내고 사고시 인근에 미치는 영향을 평가하여 어느 정도 위험이 있는지 알아보며 이에 대한 대비책을 적용하고자 하였다. 취급 화학물질 정보와 공정정보로부터 사고 시나리오를 선정하고 염산 누출시 사업장외로 영향을 미치는 사고 시나리오를 선정하여 환경부의 지침에 따라서 ALOHA를 활용하여서 평가하였다. 최악의 사고 시나리오를 비롯한 사고 시나리오를 평가하였으며 이들의 사고시 피해완화대책도 살펴보았다. 평가결과 염산생산시설은 현재의 안전조치가 충분하여서 추가의 개선대책이 필요하지 않은 것으로 판명되었다. Chloric acid is a toxic chemical and the risk of facility handling chloric acid was assessed from the list of accident scenario to provide countermeasure to keep the vicinity safe. Accident scenarios were listed by using MSDS and process safety information. The scenarios having effect to the off-site were selected and assessed further according to guideline provided by Korea government. Worst case and alternative scenarios including other interested scenarios were evaluated using ALOHA. Each evaluated scenario was assessed further considering countermeasures. The results showed that the facility handling chloric acid is safe enough and needed no further protections at the moment.

June 2016 Safety and Health News Summer 2016

June 2016 Safety and Health News Summer 2016

Lessons in process safety management learned in the Kaohsiung gas explosion accident in Taiwan

A series of explosions attributed to leakage of propylene from an underground pipeline resulted in 32 fatalities and 321 injuries in Kaohsiung, Taiwan, in 2014. An analysis of this gas explosion indicated that such an accident could have been prevented, or the consequences might not have been as severe if certain elements of process safety management (PSM) had been applied. Proper execution of PSM, including management of change, mechanical integrity, process hazard analysis (PHA), process safety information (PSI), and training, can prevent the occurrence of such explosion accidents. The impact of this explosion could have been reduced had these PSM elements, particularly PHA, operating procedures, training, PSI, and emergency planning and response, been executed. © 2016 American Institute of Chemical Engineers Process Saf Prog 35: 228–232, 2016

Chemical interaction matrices

Despite the promulgation of the “PSM Standard” by OSHA in 1992, chemical accidents continue to occur at an alarming rate. As part of the process safety information element of the standard, OSHA requires reactivity data on the chemicals in the process. One piece of this reactivity data is a chemical interaction matrix. Several software programs provide simple approaches to generating these interaction charts for common materials using assigned reactive groups. If your process involves materials not included, you are left to determine the reactivity and incompatibilities on your own. This paper will explain a process for assigning reactive groups using chemical classification and structural analysis. This process can be used for less commonly understood materials such as additives, lubricants, mixtures, products, etc. that may come into contact with process chemicals. © 2015 American Institute of Chemical Engineers Process Saf Prog 34: 368–372, 2015

Managing process chemicals, technology and equipment information for pilot plant based on Process Safety Management standard

Injuries, accidents or even fatalities while working in pilot plant are reported worldwide. The OSHA Laboratory Standard and Hazard Communication Standard have been used as a guideline to manage safety of laboratories and pilot plant. In spite of the implementation of these standards, incidents which result in injuries and property loss are continuously occurring. The implementation of OSHA Process Safety Management (PSM) Standard in pilot plant is expected to further reduce the risks of accidents. This paper presents a new system for managing process chemicals, technology and equipment information in pilot plant and the concept is developed based on Process Safety Information (PSI) element of PSM 29 CFR 1910.119(d). It provides organized strategies to manage documentations, communicate information, and written program for maintaining, revising and updating related information. Process and Instrumentation Diagram (P&ID) is used as a foundation for data management. Implementation of this system at the CO2 Hydrocarbon Absorption System pilot plant as a case study is examined and discussed.