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The first step in developing or updating a written operating procedure is to ensure that the most knowledgeable people are involved. It has been our experience when starting from scratch, developing the workflow processes for each of the seven operational phases needs to be first. Make sure that steps are provided for each operational phase, even if you do not have temporary operations. The workflow should define the specifics steps, and the order of those steps, with enough detail that a new operator can understand what needs to be done and when. Once the initial workflow has been defined, then send the draft for others to review and provide feedback. In the interim, the next steps are to define the safety systems and their functions. This should be a comprehensive list of all the safety systems, which may include those that are covered in other operating procedures, or you might consider developing a standalone document that is easily accessible by all operators. What needs to be clear is what is the safety system, and how does it function. For example, a facility may have a...more
There has always been an industry debate when it comes to operating procedures on how detailed the procedure needs to be. Of course, the answer will depend on who is asked, an operator, or a process engineer. This is a common question when discussing the operating procedure element. The answer is simple, as detailed as possible. This makes sense when you ask an operator if they use the operating procedures as part of their daily duties or refer to them as needed. The overwhelming majority of operators just refer to them as needed. If a well-trained operator is referring to an SOP only when needed, then it stands to reason that the procedure should be well detailed. Secondly, a new operator MUST be trained on the operating procedures. For an operator to have received sufficient training, the procedures need to have the needed detail. If the facility relies only on other operators to provide new operator training, then you can expect there to be operational deviations as compared to the written operating procedures. We all have bad habits, and without sufficiently detailed...more
In the last article regarding Management of Change, we discussed the three simple questions that can be asked to determine if a proposed change must be handled through your formal change management system, or if it is a replacement in kind. Assuming a change is not a replacement kind, a lack of a well-defined management system is where, in most cases, we see things go in the wrong direction from beginning to end. Most have a process for determining if a change requires an MOC, and if so, will also have a process of getting the MOC approved, Engineering Design process, conducting a PSSR, and how the MOC is closed. What occurs between the approval of MOC and conducting the PSSR is most critical for having a robust and effective management of change system. If your management system involves attaching documents to a MOC document, then you can expect to have failures and gaps in your system. For example, if you go back to the original design, EACH component on your P&IDs must have process safety information readily available. This information is best maintained in equipment...more
I often hear that a management of change (MOC) was not used because the equipment being replaced, was a replacement in kind. A simple example, a process evaporative condenser is being replaced due to Mechanical Integrity issues, the new condenser is a different make and model but meets the definition of “replacement in kind” since it is “a replacement which satisfies the design specification”. This last quote is straight from the regulation itself. However, the process safety information (PSI) will be different no doubt, and based on various RAGAGEPs, the model and serial numbers are considered required process safety information. Too often we debate if the change “satisfies the design specification” when we should be asking three (3) simple questions:
1. Does the proposed change result in manufacture, model, and general specifications changing (Process Safety Information)?
2. Does the proposed change require operating or maintenance procedures to be changed or updated?
3. Does the proposed change have ANY impacts safety...more
When it comes to process safety, one area that is vitally important, yet most still struggle to implement, is management of change (MOC). In fact, the lack of a robust change management process can be traced to the main causal factors in numerous process safety events. There are many ways in which facilities manage change from simple to complex. What is common though in most MOC systems is the failure to complete the basic requirements of a management of change (MOC) system which is to “manage the changes”. For example, most MOC systems, involve completing various checklists and/or attaching documents to the MOC as the change is being completed or even after completion. Some MOC systems are so complex and involve so many levels of approval that they often get bypassed altogether. When the change is simple, engineers, contractors, and other third parties that are involved in the change are more likely to complete the requirements and provide the proper information. Lastly, even when all parties involved understand the process, do the actual equipment files get updated,...more
I came across a social media post several days ago that indicated that it is an order of magnitude (10X) more important to do an investigation on a “near miss”, then on a fatality. I understand the sentiment, but I wholeheartedly disagree. I’m not sure there is any empirical evidence that would support that more can be learned from a near miss, then can be learned from a fatality investigation. Yes, we should be to be conducting many more near miss incidents than fatalities and that conducting investigations on near miss incidents is extremely important to ensure continues improvement in risk reduction.
Generally, not everyone’s definition of a near miss is the same, therefore, many near misses are not investigated at all. In numerous surveys in the past several years, we have posed the questions regarding what is a “Near Miss”. Suffice it to say that there is very little consistency in the definition. Even the consensus standard, API 754, would not classify things as near misses as I believe they should. However, I also see the reasoning behind this. When an...more
As most are aware if we ever picked fruit of any kind, the easiest fruit to retrieve are those that are hanging low on the vine. Speaking from direct experience, this same analogy applies to regulatory compliance officers; they go after those regulatory infractions that are obvious, the employer has a hard time refuting, and are easy to defend in a court of law. Of course, it can also be said, that if we cannot do the easy things, how could we ever really be expected to fully understand and apply process safety principals at all? Even though there is a lot of truth to this last statement, there are legitimate cases where we can honestly forget, get distracted by other larger issues, and lose track of the smaller things. Some of the low hanging fruit in process safety that can get overlooked or forgotten includes such items as updating the emergency contact person in the RMP, revalidating the PHA every five years, conducting a PSM/RMP compliance audit every three years, addressing action items or recommendations in a timely manner, just to name a few. Each of these items...more
I have read several articles lately regarding why employees do not report workplace injuries or illnesses. Perhaps, we sometimes oversimplify the reason why incidents are not reported. Most articles seem to indicate it is the employer’s work environment being toxic or not conducive of reporting incidents, blaming of the employee, fear of losing their job, and trying to maintain company safety goals, as well as many others. For the most part, we can find statistics to support just about anything. For perspective, if we look at non-workplace traffic fatalities, we can start to see that the issue is not as simple as we think, but there are many factors with us humans to be considered, and even if we understood all those things, it will never be perfect. Consider the fact that there are approximately 5,500 workplace and 35,000 traffic fatalities in the US annually. Most indications are that nearly 70% of traffic fatalities are a result of distracted or impaired driving or excessive speed, whether that is due to texting while driving, influence of drugs or alcohol or talking on the...more
In part 2 of this series, I discussed design codes and standards and the importance of documenting those for the individual pieces of equipment or components in the cover process. This information will be the basis in which the hazard analysis and subsequent inspections and tests will need to be completed to ensure that the equipment continues to achieve those minimum requirements. With that, the next area of RAGAGEP is that for mechanical integrity or MI. Again, a list of RAGAGEPs is not what is needed nor required. A specific RAGAGEP must be utilized for inspections and tests that coincide with the RAGAGEP used for design. This may include the original equipment manufacturer’s requirements since the equipment was designed to RAGAGEP, then it would also be acceptable to use that as an MI RAGAGEP. In choosing an MI RAGAGEP, it is important that you understand their application and limitations. For example, it is fairly common for a facility to indicate that they are utilizing a Risk Based Inspection (RBI) protocol such as API 580. However, they have not conducted any previous...more
In part 1 of this series, we discussed what is RAGAGEP and how they are/were developed. In fact, this knowledge will help us to understand a few pitfalls in some of the RAGAGEPs, and why it is important to get the correct knowledge and experience within these codes and standard groups to further enhance the desired goal of improved process safety. We have conducted well over 400 NEP (National Emphasis Program) type PSM inspections in the last 10 years. We track findings in general for each inspection to find common issues to better improve our clients' PSM programs and process safety performance. A common practice, as it pertains to RAGAGEP, is for facilities to have a “RAGAGEP List.” There is nothing wrong with the list itself if it is used by engineering to ensure equipment in the process is manufactured and maintained to those standards, and that there is a connection to the RAGAGEP from the list to a component in the process. For example, a common RAGAGEP for all industries is Section VIII of the ASME Boiler and Pressure Vessel Code (BPVC). This code relates to most pressure...more
A common question posed during compliance audits and training is “what exactly is Recognized And Generally Accepted Good Engineering Practices (RAGAGEP) and how do we determine what is the appropriate RAGAGEP for our PSM covered process?” In this series of articles or posts, I will attempt to answer some of the more prominent questions and misconceptions regarding this important part of the PSM regulation. In the first part of this series, we will look at what is RAGAGEP. In subsequent parts, we will review some of the pitfalls, or concerns, with some industry RAGAGEP(s), how we go about determining the most appropriate RAGAGEP(s) for our facility, PSM regulatory requirements for selecting design codes & standards, misconceptions regarding application of RAGAGEP, and finally discuss RAGAGEP(s) for maintaining equipment in the covered process.
First, what is RAGAGEP? In various industries, there are typically groups of individuals with significant knowledge and experience that formally get together to collaborate and/or share “best practices” on how to manufacture,...more
In most PSM Covered Processes, the predominate training method is some form of blended learning whereby the training is a combination of classroom combined with hands on or on-the-job training (OJT). In fact, blended learning, in most cases, is the most effective. However, what is also fairly evident from incident investigations, is that this training can be inconsistent on what is delivered to the trainee. If the same person was the one providing the OJT instructions, then evaluations of understanding of the training provided was also consistent, whether good or bad. To determine the effectiveness of training we need to ensure we have a good basis for that evaluation and that begins with a consistent method of delivery. Secondly, the resources used in the training need to be consistent and more importantly, accurate. For example, training must be provided on the operating procedures. If the operating procedures are lacking in sufficient detail, then so will the training, or it will be based on the person’s knowledge providing the training. Most operators do not have...more
In the first and second parts of this series on Operating Procedures (OP), I discussed the required detail and the various operating phases. In this part, I will address operating limits, common errors, and best practices to make operating limits useful and appropriate. First, a common error is to confuse process “Safe Upper/Lower Limits” with “Operating Limits”. To be clear, there is NOT a PSM element in regulation entitled “Safe Operating Limits”. Operating limits should be inherently safe since they should be well within any process “Safe Upper/Lower Limits”. If your operating limits have a consequence of deviations defined as fire/explosion, release of a toxic, or potential exposure of personnel, then you need to seriously rethink your operating philosophy. If your operating limits are well defined, then any deviation from normal operating parameters should include an alarm (consequence of deviation) with steps to avoid the alarm to begin with, or to correct the deviation once it has occurred. When any operating parameter has more process safety risks (loss of primary...more
In the first part of this series on Operating Procedures (OP), I discussed how detailed an OP should be. In this part I will discuss the different operating phases. The most misunderstood parts of the operating procedure element are the Initial Startup, Temporary Operations, and Emergency Operations. Not specifically mentioned in any of the operating phases, is Normal Startup.
Initial Startup refers to the initial “commissioning” of the process in which the procedure is being written. The initial startup procedure should be extremely detailed and include the initial startup of all the various process components. This procedure can and should involve detailed checkout (prior to introduction of chemicals) and should also include the actual first addition of chemicals into the process. Initial startup may take several hours, days, or weeks in some cases depending on the complexity of the process. It is perfectly acceptable to use this procedure as part of your Pre-Startup and Safety Review (prior to adding chemicals). Once the process has been started and stable, then move...more
When it comes to Operating Procedures, how detailed the procedure needs to be has always been an industry debate. Of course, the answer will depend on who you are; an operator or a process engineer. This is also the most common question when discussing the PSM operator procedure element during PSM Compliance Training. The answer is simple, the procedure needs to be as detailed as possible! If you ask the operator if they use the operating procedures as part of their daily duties or just refer to them as needed during an interview, the overwhelming majority response is to just refer to them as needed. If a well-trained operator is referring to a procedure only when needed, they better be well detailed. Secondly, the new operator MUST be trained on the operating procedures, and they should be a major source of their operations training. If we rely on seasoned operators to provide on-the-job training of new operations, then you can expect there to be operational deviations as compared to the written operating procedures. We all have bad habits and without good detailed...more
Ideally the Management of Change element is implemented to ensure that a change in the process is managed in such a way to ensure that process safety risks of the change are addressed…not to create more “paperwork”. If we are completely honest, a lot of facilities complete the “MOC” after the change is already completed, and others use the MOC as the process to make sure everything was updated or addressed. When an MOC is done after the change is completed, the risk of the change itself is never fully evaluated until after the change is implemented making it even harder to revert back to the original design. Another common issue seen during compliance audits is the failure to update Process Safety Information (PSI). This may not seem like a significant issue if all the other items have been addressed but consider the cumulative effects over time. The Process Hazard Analysis (PHA) should be based on accurate and complete PSI, the lack thereof can result in hazards either missed or not evaluated properly which can lead to catastrophic failures. Lastly, there are still way too...more
Process Safety Management or PSM, is all about managing process risks, so it would stand to reason that we need to manage changes since any change can pose significant risks both new and latent. If we follow the Occupation Safety and Health Administrations (OSHA) PSM regulation, we should be very familiar with the Management of Change or MOC element. However, the language of the regulation is unclear and ambiguous. This ambiguity, or lack of clarity in the regulatory language, is evident in the hundreds of PSM program MOC policies and procedures reviewed as part of PSM compliance audits and incident investigations. Analysis obtained from audits and incident investigations would indicate that industries handling highly hazardous materials have room for improvement to fully implement a robust management of change process. Continuous improvement of safety and health management systems, require that we continue to look at policies and procedures and make the necessary corrections and updates. The same process of review and updates should be applied to our MOC policy and...more
There have been a number of articles and discussions recently regarding the United States Court of Appeals for the 10th Circuit decision regarding PSM coverage. It would seem from the many posts, comments, and related articles that this decision expands PSM coverage. However, this is simply not the case, but rather this decision affirms the plain language and intent of the regulation itself.
For background, a typical crude oil refinery will have multiple process “units” where each process unit performs a specific process step for producing finished or intermediate hydrocarbon products. One of those processes is a Fluidized Catalytic Cracker (FCC). The FCC is a significant process operation in most refineries and is the key to profitability of the facility since it converts heavy oils or long chain hydrocarbons into more valuable lighter end petroleum products. The FCC reactor is operated at an extremely high temperature and requires significant amounts of steam. When the heavy oils are fed...more
When it comes to Operating Procedures or SOPS, opinions differ widely on at least two items. The first is how much information or detail should be included, and the second the “Operating Limits”. As for the amount of detail, most will agree that the written SOP’s are not something that the operator will carry around with them, or refer to continuously while operating the process, but will more likely refer to them as needed. This would infer then, that the SOP is mainly used as a training document in most cases, therefore, they should be written in fine detail, and should be updated as operating philosophies, procedures, and steps change. If there is not enough detail, then training will most likely be with little detail as well, and we all know that the outcome of having poorly trained operators can be catastrophic. Whether we want to admit it or not, we all have bad habits. Without detailed SOPs, training may include some of those bad habits. If we assume that the trainee will also add their own bad habits, it would stand to reason than that operational tasks will differ in...more
The Process Hazard Analysis (PHA) is what most believe is the most important element of PSM. If true, then the analysis should reflect that level of emphasis. In order for the PHA to deliver the results desired, there needs to be a good understanding of the hazards that may exist and what risks they pose to employee safety and health. Often, PHA teams do not have the hazard and severity knowledge they need to conduct the proper hazard analysis. For example, is there a difference between the hazard and severity associated with a vessel liquid full at 500 PSIG, and one that is filled with a vapor or a gas at the same pressure. Yes, the “knock-on” hazard might be different when the chemical or material in the vessel is released (fire explosion, toxic exposure), but the hazards associated with a catastrophic vessel failure are much different. Once the severity of the hazard is different, based if the difference in energy between an essentially incompressible liquid and the compress gas/vapor, then it is possible to address hazards and the subsequent severity more succinctly....more
The Process Safety Information (PSI) element within PSM has three different categories that include: Information pertaining to the hazards of the highly hazardous chemicals, Information pertaining to technology, and Information pertaining to the equipment in the process. PSI, in this person’s opinion next to employee participation, is the most important element in process safety management, and in many cases has the most gaps in compliance and understanding.
It is important to understand the three distinct process safety information requirements. To help understand these categories better, it is best to think of the steps that are typically taken in the development of a new or a major process revision. Every new process design starts with some very simple basic concepts to achieve a specific objective. The first item that is normally considered in the design, no matter what the process, is what chemical or material will be involved. Even a simple process, such as a closed loop refrigeration system, will use some type of chemical (refrigerant). The decision on which...more
It is important to know, that the order of the PSM elements in the OSHA Process Safety Management Regulation is relevant. Understanding some reasoning for the order is important from an overall management system standpoint, but also in helping us to better understand PSM in general. Immediately following the scope, application, and definitions within the PSM regulation, is the first of the traditional fourteen (14) “elements” entitled “Employee Participation”. Before delving into this element, it is important to take a step back and see these first elements in the context of a safety and health management system (SHMS).
For those of us who have been involved in project design and installation within the process industry can more fully understand these first six elements and the design process in general. For example, most all process designs, no matter the type or size, go through similar design process steps. The first step, though not always apparent, is the need to have employees participate. The best process designs will always result from utilizing the best from...more
In December 22, 1944, the allies (American troops) were sent a letter from the commander of German forces located outside of the town, demanding “the honorable surrender” of the town within two hours. General McAuliffe, the commander of the American troops reply was brief and to the point:
“To the German Commander:
N U T S!
The American Commander”
We, however, are obviously not in as severe a life or death situation (though it may seem that way), but occasionally we are asked or expected to do things that seem so utterly ridiculous that you can only say, this is NUTS! There are several of those when it comes to ammonia refrigeration systems. You have to wonder if those that developed the requirements have actually had to do this work in the field. This is not to be an indictment against those that developed the standards, but more so in the process at getting input from those that actually carry out the majority of the tasks. This goes to the heart of PSM...more
Most of us, I’m sure, have seen OSHA statistics regarding the most cited elements of the PSM regulation. In the past 10 years, I have conducted well over 250 compliance audits and either led or participated in another 25 plus incident investigations. Based on that experience, I have come to realize that the OSHA data is not an accurate reflection of where the problems lie in process safety. As many of you may know, I spent five (5) years with OSHA as a PSM specialist. During that time, I experienced first-hand the strengths and weaknesses within the agency from a PSM perspective. One of the major weaknesses, in my opinion, is that many of the compliance officers that deal with PSM do not have a process safety, engineering, or process industry background. Without this background knowledge and experience, it is extremely difficult to understand and apply the PSM element’s intent to engineering design principals and then to process safety. Even when it comes to simple processes such as ammonia refrigeration, understanding key engineering concepts is important in applying process...more
We’re all in this together…most of us have undoubtedly heard this repeated over and over in the last couple of months. While it is true that we may be in this together, we are all facing this battle under different circumstances. Some have had their hours extended, while others have been sent home and continue to get their normal paychecks, while others have had to file for unemployment, and face the uncertainty of being able to return to the job they loved. Some have had to become teachers and day care providers, while also trying to work a full-time job from home. Teachers have been plunged into distant learning instructors within a matter of days. Some restaurants have become carry-out or delivery only, some groceries store shelves are bare, while others allow purchases online only. Every one of our businesses, whether an industrial manufacturing facility, restaurant, grocery store, hair salon, or department store, relies on the other in some form to stay in business. As we begin to emerge from this pandemic, now more than ever, we need to assist each other in getting up...more
There is no doubt that right now we are living in a time of a lot of uncertainty. Many are faced with the loss of a job, cut back on the number of hours allowed to work, the potential for illness, and the concern for family and friends. For the most part, these things are out of our own personal control.
However, each of these concerns can weigh heavily on every one of us and can also result in less focus on those risks we can control. Perhaps those of us in process safety management, understand this more so than others. We understand to control risk we must focus on those things that we can control, and not let distractions render our risk reduction efforts mute.
We cannot take a break from process safety. In fact, the last thing any of us need right now is a catastrophic event that results in major injuries, or worst yet, fatalities. Most of us have seen that the EPA has relaxed some of its enforcement activity during this time....more
One important aspect of the OSHA process safety management (PSM) standard that we must keep in mind, is that it was developed and promulgated in the early 1990s, and has not really changed any since then, but our industry has changed a lot.
However, the same principles of process safety management are just as relevant today as they were over 25 years ago. The 14 elements of the PSM standard constitute the framework of a safety and health management system (SHMS). As is the case in all effective management systems, the standard contains the continuous improvement model elements: plan, do, check, and act (PDCA).
The 14 elements of PSM are the “plan” portion, and when implemented, the “do” portion, achieves risk management or process safety. The “check” portion is the OSHA compliance audit element, and the “act” is implementing the recommendations from the compliance audits, incident investigations, and...more
Unfortunately, it is all too common for “good” companies to be lulled into a false sense of security by their past performance in personnel safety and health. They may not realize how vulnerable they are to a major incident, until it happens.
Subsequent investigations of incidents at these “good” companies has typically shown that there were multiple causal factors, and many were known long before the event occurred. In many cases, the company often assumed process safety systems worked as intended, despite the warning signs. They will find examples of “good” performance and assume they represent the whole, while poor examples are overlooked or soon forgotten, rather than digging deeper to understand what is really happening.
A process hazard analysis of failure modes and effects should go beyond the equipment, physical, and information technology systems, and must include human and organizational aspects as well. Recognition of the seriousness of...more
If you look at Bureau of Labor Statistics (BLS) data across the various industries prior to the promulgation of OSHA process safety management (PSM) and EPA risk management plan (RMP) regulations, it will show that oil and gas, refining, and petrochemical industries were much better as an industry than other industrial sectors such as machinery manufacturing, logging, commercial fishing, and food production, from a purely injury and illness standpoint.
If we look at the current BLS data for the same industries today, there has not been near the improvement you would expect. There are a lot of reasons that keep us as a process industry, from achieving a paradigm shift in process safety. One reason is that when a team is given more than one objective to achieve, they fail to achieve any of them in the manner we would like or should expect. It does not mean...more
Unfortunately, it is very common for “good” companies to be lulled into a false sense of security by their performance in personnel safety and health goals. They may not realize how vulnerable they are to a major incident until it happens. Subsequent investigations of incidents at these relatively “good” companies have typically shown there were multiple causes, and many of these causes were known long before the event occurred.
In many cases, people often assume systems work as intended, despite the warning signs. They will find examples of “good” performance and will assume they represent the whole, while poor examples are overlooked or soon forgotten, rather than digging deeper to understand what is really happening.
One of the main causes for a lax process safety culture, is the failure to provide a well-defined “management system” that incorporates the teaching and training that is so crucially needed. For example, how many people in...more
How many times have you heard this statement regarding a major release or fire? “If they would have only implemented or adhered to process safety management (PSM) this would not have happened.” Basically, this comment says “we” do not understand the purpose of PSM very well.
Proper process safety management never has, nor will it ever, result in “zero” incidents. This is because PSM or risk management plans (RMP) are not designed to eliminate risks, but rather it creates programs and systems that must be in place to “manage” the risks associated with facilities that handle highly hazardous chemicals (HHC).
I know that some will say that our goal should be to eliminate incidents and not just manage risk. However, this is not only unrealistic, but most likely not practical either. It would be downright impossible to find anything that we do that does not have...more
Ever wonder how your local grocery store keeps all their produce, meats, drinks, and bread fresh by the time it gets distributed for your weekly grocery run?
Suppliers must refrigerate all food and drinks once the product is made to the time it is delivered to your local HEB or Trader Joe’s. Most people think of freon as a refrigerant, but ammonia is actually the most commonly used commercial refrigerant in the food and beverage industry today.
Ammonia has replaced the more popular use of freon for two essential reasons:
Unlike freon, or otherwise known as chlorofluorocarbons (CFC), ammonia has an ozone depletion rating of 0. Throughout the years, it has been discovered that CFCs have a huge contribution to greenhouse gases that destroy the ozone layer.
In addition to being earth-friendly, ammonia...more
If you work with highly hazardous chemicals at a gas plant or ammonia facility, you may have heard someone mentioning PSM. But what is PSM and why should you care?
PSM stands for process safety management and is a regulation (29 CFR 1910.19) created by OSHA in 1992 due to a rise in catastrophic events.
In 1984, one of the worst incidents in the industry occurred where over 2000 people died due to a chemical release in Bhopal, India. Five years later in 1989, an explosion at a petroleum facility in Pasadena, TX resulted in over a hundred injuries and 23 fatalities. Just a few years later, two deaths occurred from an explosion in Cincinnati, OH in 1990 and eight fatalities due to a chemical release in Sterlington, LA in 1991.
PSM consists of 14 elements intended to help eliminate and/or mitigate the hazards at a facility to ensure a safe...more
A violation of the OSHA 1910.119 standard is considered serious in nature, and therefore can result in a fine ranging from $13,494 to $134,937 each.
A violation of the EPA section 112(r) of the 1990 Clean Air Act standard can result in a penalty as much as $37,500 per violation, per day.
Process & Safety Solutions LLC (PSS) is a veteran-owned process safety consultant based in Pearland, TX, though we serve clients across the country. Our extensive industry and regulatory knowledge are essential for evaluating PSM and RMP programs.
Our lead auditor brings this...more