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In Search of “Perfect Process Safety” In Search of “Perfect Process Safety” How to Ensure Sustainable Continuous How to Ensure Sustainable Continuous Improvement Improvement
L i f th M d D t H i Bl O tLearning from the Macondo Deepwater Horizon Blow OutAugust 21, 2012 Runcorn, UK
Steve Arendt, Vice President, P.E.North America Process Industries
Organizational Performance Assurance [email protected]
Steve Arendt, P.E.30+ years in process safety and risk assessmentVice President, ABS Consulting, NA Process Sector and Organizational Performance Assurance CenterABSC project manager for the Baker Panel PSM reviewsABSC project manager for the Baker Panel PSM reviewsConducted 100s of PSM audits, incident investigations, and best practice reviews, including 20+ offshore facilities60+ articles and books on PSM and risk management
Guidelines for Risk-Based Process SafetyGuidelines for Management of ChangeA Compliance Guide for EPA’s Risk Management Program RuleManager's Guide to Quantitative Risk AssessmentResource Guide to the Process Safety Code of Management Practices
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y gGuidelines for Hazard Evaluation Procedures, Second EditionA Manager's Guide to Implementing and Improving MOC SystemsRisk Communication Guide, Chemical Educational FoundationProSmart - CCPS PSM Performance Metrics System
Center for Chemical Process Safety FellowRecipient of Mary Kay O’Conner PSC Merit AwardCenter for Offshore Safety work group member
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“Perfect Process Safety”
What is it?Is it possible?What are the barriers?
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A Vision For “Perfect Process Safety”
A culture based on proper ownership of HSERisk-informed sensitivity that guides everythingy g y gEffective, fit-for-purpose management systemsPS practices embraced and followed with good operational discipline at ALL levelsLearning from ALL sources – internal, external and outside industry groupoutside industry groupWell-formed/visible performance pyramid; metrics at every level that drive intended behaviorsGoals and actual performance that improves
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Compliance with Existing Regulations Is Not EnoughRegulations provide minimum framework, but industry practices have bypassed regulationsindustry practices have bypassed regulations
Minimum standards may not be enough for all facilitiesWe have not really learned from our experience
Minimalistic compliance approach does not lead to robust future performance
Fragility due to economic cyclesFragility due to economic cyclesCulture challengesOrganizational stressesAging assets and changing people
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The Problem with Some Companies…The Problem with Some Companies…
Accidents
They Are Taught a Lot of Lessons, But They Never Seem to Sustain LearningThey Are Taught a Lot of Lessons, But They Never Seem to Sustain Learning
They either don’t see
Incidents
Precursors
Management System Failures
yhazards below the waterlineOr they don’t
know how to identify and fix root causes
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g y
Unsafe Behaviors and Attitudes
Culture – Individual and Organizational Tendencies
© ABSG Consulting, Inc.
Their “fixes” don’t stay fixed
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Seems to Be Four Types of Companies
In theory, requirements and enforcement practices should be matched to these various “needs”should be matched to these various needs
Know what to do and do a pretty good jobKnow what to do, but don't do a consistent jobKnow what to do and "intentionally" don't do a good jobDon't really know what to do – ignorant or confused
Difficult to make happen Seems like we want “oneDifficult to make happen. Seems like we want one paint brush” and the “same type of painter” no matter what the need
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Learning from Experience
Outside your industryInside your industryInside your industryInside your company
One BIG problem in industry is that we get taught the same lesson over and over, but don’t truly LEARN so that the problems don’t repeat
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p p
A critical skill is to find something relevant to learn and improve on out of EVERY significant incident
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Simple Lessons Baker PanelSimple Lessons Baker Panel--CSB ReportsCSB ReportsIneffective PSM system with weak performance evaluation, corrective action, and corporate oversight
Lack of follow-up in ALL areaspHuge backlogs in inspections and corrective actionsNot following consensus standards – nor their ownPoor risk awareness and assessmentSuperficial auditsInadequate metricsPoor management review at local levelNot focused on process safety at corporate level
Inadequate corporate safety culture Inadequate corporate safety culture –– had symptoms had symptoms in every PS culture problem areain every PS culture problem area
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in every PS culture problem areain every PS culture problem areaBlind spotsArrogantComplacentSuperficialGlacial, non-agileIn denial
Macondo – Lessons and Potential Impacts
Classes of root causes - plenty to go aroundInadequate process safety culture for DHadequate p ocess sa ety cu tu e oInadequate GOM operating environment cultureComplex offshore operating environmentProcess safety management system failuresInadequate GOM regulatory environment
Potential influences for onshore regulationsgEnhanced reporting and third-party auditsPrescriptive independent verification of safety critical elementsQRA and safety case
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Lessons from Major Learning Sources
Failure to execute – primary lessonWe are not taking advantage of all “internal”We are not taking advantage of all internal sources of learning opportunities
In the U.S., we have incomplete value generation from 20 years of regulatory PSM incidents - inadequate collective analysis, trending, sharing, and learning
Failure to learn from other types of industry accidents Will process safety leading indicators suffer the same fate?We have a culture challenge
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Six Characteristics of a Learning Organization (Harvard Professor David Garvin)
Supports discussion and evaluation of divergent opinions and dataProvides timely feedback and flexibility in the means used to conduct work activitiesStimulates new ideas to promote a step change in risk understanding and operational performanceMaintains an external focus by not automatically discounted outside ideas and waysdiscounted outside ideas and waysTreats errors/mistakes as investments. Learns from them. Encourages proper risk-takingRoutinely updates a learning plan to increase competencies
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Characteristics of a Learning-Disabled Company(Steve Arendt, Armchair Process Safety Psychologist)
Dysfunctional safety culturePeople hide things and kill messengersp g gFail to question; procedures not followed without accountabilityMixed/improper safety/production messagesComplacency, low trust, silo mentalityMisplaced safety ownership, invisible/ineffective leadership
Superficial causal analysis of problemsThings don't get fixedNo company memoryAdd in your own…
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Characteristics of Good Risk ManagementNecessary, but Not Sufficient for Perfect PS
Pervasive understanding of what risk isConsistent practices driven using fit-for-purpose gHSE management systemLife-cycle wide and enterprise deep risk visibilityFlexible tool set and relevant data sourcesCompetent practitionersAppropriate risk tolerance concepts/tools employedAppropriate risk tolerance concepts/tools employedEffective risk reduction issue managementRegular executive review of risk register top issues Risk ownership throughout the organization
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Definition of the Perfect PS Leading IndicatorThe Perfect Risk Model Or…a “Live Risk” Model
Evaluates the risk impact of day-to-day facility changes and circumstances:
U d fi i t th t i f il dUser defines equipment that is failed, disabled, degraded etc.Operational adjustmentsExternal circumstancesEvaluates the increase in risk from these changes
Requires input from risk models (HAZOPsHAZIDs, LOPAs, BTs, QRAs) into risk model
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Operator identifies equipment that is failed or out of service
LIVERISK shows you the increase in risk due to the known equipment failures/outages or operational circumstances
LIVERISK Features
Dashboards forDifferent levels within the organization (facility, Business Unit, g ( yCorporate etc.)Different departments (production, safety, inspection etc.)
Accounts for the impact of changes in management systemsMechanical integrity: testing & maintenance programs; Project Quality Management (PQM), etc.Health, Safety and Environmental: results of HSE audits, Class surveys etc
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surveys, etc.Integrate HSE/process safety metrics (leading indicators)Integrate safety culture issuesOthers
Accounts for operational profile and external events
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Improvements in Process Safety/HSEat
eTechnologyand standards
HSE managementsystems
Culture• Organizational and
Standards• Engineering improvements• Hardware improvements• Design review• Compliance Management Systems
• Integrated HSE MSR ti
Ris
k/In
cide
nt R
a systems
Improvedculture
• Organizational and individual behaviour aligned with goals
• “Felt” leadership• Personal accountability• Shared purpose & belief
• Reporting• Assurance• Competence• Risk Management
Time
17Adapted from Kiel Centre
Overview of U.S. Industry Process Safety Performance Improvement Activities
Center for Chemical Process SafetyRisk Based Process Safety Guidelines emphasis on Learning fromRisk Based Process Safety Guidelines emphasis on Learning from ExperienceLeading indicator work in late 90’s culminating in new PS metrics guidelinesMember benchmarking project and Vision 2020
APIRP 754API/AFPM Advancing Process Safety Initiative
Center for Offshore SafetyLessons from industry accidents and investigationsIndustry is refocusing attention and leadership away from PSM compliance to PS Performance
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Current PSM/HSE Auditing and RCA Practices Don’t Go Far EnoughPSM/HSE audits generally issue findings and areas for improvement “at the element level” even though the evidence used may point to deeper problemsIncident investigations identify PSM elements as root causes but don’t address safety culture factorsUse of PSM leading indicators are just becoming broadly accepted, but their use for performance management is in the “infant stage”Plenty of learning opportunities; need to adjust our learning and performance improvement approaches
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Center for Chemical Process SafetyCenter for Chemical Process SafetyMade Culture an Official SMS ElementMade Culture an Official SMS Element
Evaluated major organizational accidents and prepared Safetyaccidents and prepared Safety Culture Awareness toolABSC included Process Safety Culture as an element in CCPS Guidelines for Risk Based Guidelines for Risk Based Process SafetyProcess SafetyDefined the twelve essential
2020
Defined the twelve essential features of a good cultureCreated structure for a culture management practice
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What Is Safety Culture?What Is Safety Culture?Our Company and Individual DNAOur Company and Individual DNA
Culture is the tendency in all of us – and our Cu tu e s t e te de cy a o us a d ouorganization - to want to do the right thing in the right way at the right time, ALL the time – even when/if no one is looking – ABS Group definition
Culture is the result of all the actions - and inactions -in institutional/workforce memory
Individual and organizational safety culture is affected
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Individual and organizational safety culture is affected by ethnic culture and off-the-job behavior
Culture is hard to measure and more difficult to change; it will be the “root cause of the decade”
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To Address Unsafe Acts, Some Companies Have Implemented BBS Programs
Industry experience has variedWorked for some; did not work for othersWorked for some; did not work for othersWorked for a while, but then flounderedSome have not tried it because of the resource commitment and negative feedback
Problems with BBS programsLTA management commitment; LTA resourcesPerceived to be a program for employees to “fix themselves” p g p yManagement not viewed as a part of the problem/solutionLack of employee ownershipTrivial/ineffective observations - quotas, improper reward systems, program gets stale, gets nit-pickyEmployees unable to provide/accept constructive peer feedback
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Organizational Accidents and CultureOrganizational Accidents and CultureChallenger & ColumbiaChallenger & ColumbiaPiper AlphaPiper AlphaL f dL f dLongfordLongfordChernobylChernobylFlixboroughFlixboroughTexas CityTexas CityMacondoMacondo
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Process Safety Culture Process Safety Culture –– Essential FeaturesEssential Features
1. Establish safety as a core l
7. Defer to expertisevalue
2. Provide strong leadership3. Establish and enforce high
standards of performance4. Formalize the safety culture
emphasis/approach
8. Ensure open and effective communications
9. Establish a questioning/learning environment
10. Foster mutual trust
5. Maintain a sense of vulnerability
6. Empower individuals to successfully fulfill their safety responsibilities
11. Provide timely response to safety issues and concerns
12. Provide continuous monitoring of performance
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1. HSE/Process Safety As a Core Value1. HSE/Process Safety As a Core Value
Deeply ingrained sense of value for HSE/safetyAt all levels of the organizationAt all levels of the organizationPromoted to an ethical imperative in really strong cultures
Awareness of responsibility to:SelfCo-workersCompany
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CompanySociety
Individual and group intolerance of those in violation of the norm
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2. Strong Leadership2. Strong Leadership
Visible, active, consistent support from all levels of company management
Through communications, actions, priorities, provision of resources, etc.
Committed to what is rightVisionary and inspiringOpen and honestFi b t fl ibl
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Firm but flexibleAlert and responsive to modify strategies to meet safety goalsHSE/safety as line responsibility
3. Consistent Accountability to High3. Consistent Accountability to HighPerformance StandardsPerformance Standards
I di id l d i ti lIndividual and organizationalStandards established, reinforced, and updated in a controlled fashionConsistency in accountability and transparency at all organizational strata – no “double standards”
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Avoidance of normalization of devianceZero tolerance for willful violations of safety standards, rules, or procedures
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4. Formalize a Culture Approach4. Formalize a Culture Approach
Culture cannot be designed or manufactured, but ...Document key principles or activities that support orDocument key principles or activities that support or maintain its safety cultureRecord basic safety tenants, such as in a company policy or mission statementFormalize a culture evaluation, monitoring, and learning activities that are expected to be carried
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learning activities that are expected to be carried out by someone or some group on a periodic basis
5. Sense of Vulnerability5. Sense of Vulnerability
Preoccupation with failureConstant vigilance for indications of systemConstant vigilance for indications of system weaknesses
Attention to “weak signals”Avoidance of complacency
“Past performance not a guarantee of future success”Avoidance of putting excessive reliance on
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safety systemsAwareness of need for resilience (multiple lines of defense)
Burden of proof for safety rather than "un-safety
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6. Individual Empowerment6. Individual Empowerment
Clear delegation of, and accountability for, responsibilitiesresponsibilitiesProvision of requisite authority and resources to staff to allow success in assigned rolesManagement expectation and tolerance of disparate opinionsPersonal responsibility for safety
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Personal responsibility for safety
7. Deference to Expertise7. Deference to Expertise
High value placed upon training and development of individuals and groupsdevelopment of individuals and groupsAuthority for decisions migrates to proper people based upon their knowledge and expertise
Rather than rank or positionIndependent and unassailable role for safety experts
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expertsImperative for maintaining the “critical mass” of expertise required for safe operations
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8. Open and Effective Communications8. Open and Effective Communications
Vertical communications (both up and down)Management hearing as well as speakingManagement hearing as well as speaking
Horizontal communicationsAll have the information they need to identify and respond to the unexpected
Emphasis on observation and reportingRedundant and/or non traditional
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Redundant and/or non-traditional communications channelsMonitoring of communications for effectiveness
9. Questioning/Learning Environment9. Questioning/Learning Environment
Enhancing risk awareness and understanding as means to continuous safety improvementmeans to continuous safety improvement
Appropriate and timely hazard/risk assessmentsThorough and timely incident investigationsLooking beyond site or company for applicable learnings
Reluctance to simplify interpretations or seek the
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p y psimple solutions
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10. Mutual Trust10. Mutual Trust
Employees for managersTrust that managers will do the right thing in supportTrust that managers will do the right thing in support of safety
Managers for employeesTrust that employees will shoulder their share of responsibility for safety performance
Peers for peers
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pConfidence in a just system where honest errors can be reported without fear of reprisals
11. Responsiveness to Safety Concerns11. Responsiveness to Safety Concerns
Awareness of safety as a dynamic non-eventA “properly tuned controller”A properly tuned controller
Rapid, but not reckless, response to the unexpected in order to maintain the safety setpoint
Timely response to implement learnings from audits and investigationsTimely resolution of mismatches between
ti d d t t li ti
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practice and procedure to prevent normalization of devianceTimely reporting of, and response to, employee safety concerns
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12. Continuous Monitoring of12. Continuous Monitoring ofPerformancePerformance
Curiosity/anxiety for ”How are we doing?”Curiosity/anxiety for How are we doing?Sensitivity to operations
Process Management system Interpersonal
Pertinent, clear metrics addressing both leading
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, g gand lagging indicators
DefinedCreatedTracked
Examples of Culture Influencing EventsExamples of Culture Influencing Events
A co-worker does not object when an operator writes an “armchair permit”Supervisors consistently support workers who shut down a process they believe to be unsafe – even if they were wrongAn operations manager extends a unit shutdown to await definitive evidence that a thin-walled vessel is safe to operateA plant manager does not wear appropriate PPE when
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A plant manager does not wear appropriate PPE when walking to the control room to eat lunch with a unit crewA corporate EHS Director persists in her efforts to justify staffing resource commitments to support process safety in spite of company cost-cutting edictsRed = Negative Green = Positive
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Examples of Culture Influencing EventsExamples of Culture Influencing Events
A VP pressures the plant manager to defer the plant turnaround through the busy seasonA company SVP focuses on problem solving rather than affixing blame during a management review of a serious incident investigationA company Director eliminates corporate engineering and process safety staff positions without any management of organizational changeA CEO makes an acquisition without addressing
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A CEO makes an acquisition without addressing EHS/process safety in due diligence reviewsA Board subcommittee spends significant time reviewing EHS/process safety performance metrics and questions the company’s 3rd-quartile performanceRed = Negative Green = Positive
Connecting the Dots Connecting the Dots –– Process Safety Process Safety Performance Assurance Review (PAR)Performance Assurance Review (PAR)©© StrategyStrategy
Mapping of ESH Technical Process Safety/ESH Culture
Evaluation SourcesPerformance and Culture Evidence to Process Safety Culture Factors
Surveys and interviews
Work observations
PSM/EHSleading indicators
Process Safety/ESH
Incidents and investigation results Process Safety/ESH Culture
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Safety/ESH Performance Information Sources
Essential FeaturesCausal Factors
Tenets of Operation
Audits and assessments
Action item completion history
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PAR Process Safety Performance vs. Culture MapPAR Process Safety Performance vs. Culture MapCulture survey results and other sourcesare sorted into the 12 essential features
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Analysis of all process safety performance data (e.g., audit actions) is sorted into the 12 essential features
Cultural Causal Factor – Decreasing Frequency
Ranking of Cultural Causal Factors Present Ranking of Cultural Causal Factors Present –– Summary Summary of Study Results of Study Results
Cultural Causal Factor – Decreasing Frequency
1. Normalization of deviance2. Non-responsiveness to safety concerns3. Lack of a questioning/learning environment4. No performance monitoring/pursuit of
improvement
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improvement5. Lack of sense of vulnerability6. Lack of trust – unsafe reporting environment
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How to Change How to Change PS/HSE PS/HSE CultureCultureEmbracing the idea that YOU affect cultureEmbracing the idea that YOU affect cultureUnderstanding potential root causesDetermining ways to improve culture weaknessesFollow-thru throughout an organization
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How Leaders Influence Beliefs/Values
What leaders pay attention to, measure, or controlReactions to critical incidents or crisisCriteria used to allocate scarce resourcesDeliberate attempts at role modeling, teaching, and coachingand coachingCriteria for reinforcement and disciplineCriteria used to select, promote, or terminate employees
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Small Group/Individual Mentoring and Coaching
Workshops and role playExamples of accidents that occurred due to safety culture problemsExamples of accidents that occurred due to safety culture problemsCCPS 12 essential features of a good safety cultureTaking personal responsibility for evolving your Process Safety and Occupational Safety (Total Safety) behavior and cultureUnderstanding potential historical root causes for culture problemsSoliciting ideas for improving cultureDecide which culture elements you are going to addressDecide who in management is needed to support your effortsDevelop a plan for the next month, the next six months, the next year, and the next three yearsDetermine what metrics will be used to monitor progress
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Some Culture Improvement Lessons
If you have poor culture, marked by mistrust or needs large improvement, the worst thing you can g p , g ydo is too just start “talking” about it at the topThe “top” needs to first start “behaving” better to address culture weaknessesThen, the talk will build up from the bottomIf you survey do it anonymous and voluntary; you
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If you survey, do it anonymous and voluntary; you should commit to sharing the results – quicklyAny education/training, etc. should extend to ALL of the workforce, including contractorsBUILD OWNERSHIP
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Sense, Learn, and Fix at Every LevelSense, Learn, and Fix at Every Level
Put sensors, not censors, at every level
Develop learnings at every level
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Take corrective action at every level
Strategy for Process SafetyPerformance Management
Monitor PSM healthMonitor PSM healthFor ALL PS learning opportunities:
Evaluate PSM failure modesDetermine PSM failure culture causal factorsEnsure sustainable PSM/HSE performance improvementimprovement
Avoid organizational warning signsEmbrace critical success factors for PSM
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Evaluating PSM Element Failure Modes
Determine basic element stepsReview element written programReview element written programIdentify life-cycle activities completed and current status• Design and development• Implementation and rollout• Operation• Monitoring and improvement• Monitoring and improvement
Develop workflow diagram of element work processReview relevant incident root causes for elementReview relevant element metrics - leading and lagging indicators
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Evaluating PSM Element Failure ModesReview previous two audit cycle results for elementAssign incident, root causes, audit findings andAssign incident, root causes, audit findings and observations, and metrics indicator performance to:• Life cycle phase during which the element performance issue
occurred• Workflow process point where element breakdown occurred
Highlight element life-cycle phase where performance issues are greatestperformance issues are greatestHighlight work process point where most element performance issues have occurred
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Evaluating PSM Element Failure ModesDetermine corrective and preventive actions to reduce chance of element performance failure poccurring again
Implement/redo life-cycle phase in a more reliable fashionImprove element work process designCreate better leading indicators to monitor element performance areaImprove use of existing relevant metrics to monitor element performanceIncrease management review scrutiny on element performance area
All of this may not be enough51
Evaluating PSM Element Failure Culture Causal Factors
Map element performance issues to cultural featuresCompare performance to known culture weaknessesIdentify which culture features appear to beIdentify which culture features appear to be contributing to element performance lapses
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Ensuring Sustainable PSM/HSE Performance Improvement
Make technical corrections to PSM element performanceImplement culture improvement activities to address culture weaknessesMonitor culture change and improvement
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Guidelines forGuidelines forManagement of Change for Process SafetyManagement of Change for Process SafetyRecognizeClassifyEvaluate hazards and risksApprove (or not) or modifyGet ready for the change
Communicate/train
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Update documentation200 pages. April 2008, US $95ISBN: 978-0-470-04309-7
http://www.wiley.com/WileyCDA/WileyTitle/productCd-0470043091.html
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MOC Program Life-Cycle Phases
Design and developmentImplementation and rolloutOperationMonitoring and improvement
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MOC System Design/Development Failure Modes
Inadequate workforce involvementInadequate design basis wrong change typesInadequate design basis - wrong change types, inadequate review/authorization protocolsMOC use rate not considered when establishing MOC resourcesInadequate MOC resources designatedMOC protocol complexity inappropriate for change types, resources, or workforce cultureMOC system roles and responsibilities inadequateScope of application of MOC program inadequate
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MOC System Rollout Failure Modes
Inadequate workforce involvementInadequate awareness training of workforceInadequate awareness training of workforce, including contractorsInadequate detailed training of MOC system participantsInsufficient MOC system tools/forms/resources providedprovidedInsufficient pilot-testing
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MOC System Operation Failure Modes
Failure to identify a proposed change - system circumventedChange classified as an emergency change when it did not meet established criteriameet established criteriaMistakenly included a RIK in the MOC review processProposed change improperly classified - type or review pathMOC origination information inadequateMOC initial review not completed or inadequateInadequate MOC reviewersWrong MOC review method usedMOC hazard review path step missed, out of order, incompleteMOC hazard evaluation inadequate - hazards missed or risks improperly evaluated
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MOC System Operation Failure Modes
Emergency MOC review procedure not finishedMOC authorization inadequate - wrong, missing or risks accepted are inappropriatePSI not updated based upon changePersonnel not informed of changePersonnel not trained on changeWrong communication or training provided to personnel Temporary change left in place too long without further reviewTemporary change left in place too long without further reviewFailure to restore system to original condition after a temporary changeMOC review records inadequate or missingMOC delayed or lost in the system
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MOC System Monitoring Failure Modes
MOC metrics not properly developed or usedInadequate management review/oversight ofInadequate management review/oversight of MOC systemMOC not addressed sufficiently in PSM audit
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Top MOC Operating Phase Failure Modes
Failure to identify a proposed change
% of MOCIssues
61 %- system circumventedTemporary change left in place too long without further review or failure to restore system to originalPersonnel not informed of change
61 %
43 %
35 %gMOC delayed or lost in the systemMOC hazard evaluation inadequate -hazards missed or risks improperly evaluated
23 %
18 %
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MOC Failure Example –Offshore Gas Compressor Module
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Unrecognized Change Led to Release
Original position Modified position
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Gas Release Resulted in a “Lucky Explosion”
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Company PS Metrics Related to Incident
Number of open MOCsMOC action item agingMOC action item agingProcess piping inspection aging
None of these metrics addressed monitoring the technical performance aspects of MOC th t t ib t d t th i id tthat contributed to the incident
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Top MOC Cultural Causal FactorsTop MOC Cultural Causal Factors
1. Establish process safety as a l
7. Defer to expertisecore value
2. Provide strong leadership3. Establish and enforce high
standards of performance4. Formalize the process safety
culture emphasis/approach
8. Ensure open and effective communications
9. Establish a questioning/learning environment
10. Foster mutual trust
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5. Maintain a sense of vulnerability
6. Empower individuals to successfully fulfill their safety responsibilities
11. Provide timely response to safety issues and concerns
12. Provide continuous monitoring of performance
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MOC Failure Was a Root Cause
Several MOC failures occurredDevelopment – failure to account for change typeDevelopment – failure to account for change typeRollout – precursors occurred during periodOperation – failure to recognize, failure to evaluate
Several safety culture issues were uncovered that contributed to the MOC system failures
Lack of a sense of vulnerabilityLack of a sense of vulnerabilityFailure to empower individualsLack of a questioning/learning environmentNormalization of deviance
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Conclusions from ExampleMOC is a critical PSM elementMOC performance management (audits) oftenMOC performance management (audits) often don't provide sufficient improvement informationWe must examine MOC failure modes to support continuous improvementMOC failure prevention must consider "life-cycle improvements
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Culture and behavior issues MUST be addressed for sustainable improvementLeading indicators supported by frequent management review are needed
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Strategy for Process SafetyPerformance Management
Evaluating PSM failure modesEvaluating PSM failure modesDetermining PSM failure culture causal factorsEnsuring sustainable PSM/HSE performance improvementAvoiding organizational warning signsCritical success factors for PSM
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How Does a Company Tell If It Is:
In a process safety ditchO th d f dit hOn the edge of a ditchGetting closer to a ditchMoving away from a ditchMaintaining proper distance from a ditch
AVOID loss of visibility or fidelity in performance evidence sources – maintain
a well-shaped and complete pyramid70
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Example of a Faulty PyramidExample of a Faulty Pyramid
Accidents
Incidents
Precursors
Management System Failures
Unsafe Behaviors and Attitudes
Culture – Individual and Organizational Tendencies
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Recognizing Catastrophic Incident Warning Signs in the Process Industries
ISBN: 978-0-470-76774-0264 ppDecember 2011US $125 00US $125.00http://www.wiley.com/WileyCDA/WileyTitle/productCd-047076774X.html
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Monitor Warning Signs – Company
Organizational change/stress without sufficient HSE impact evaluation and mitigationp g
External-induced• Regulations, enforcement, economics, disasters, M&A
target, etc.Internal-induced• Competency, memory, resources, focus loss, initiative
overload M&A leadership instability demographicsoverload, M&A, leadership instability, demographics shift, turnover, absenteeism
Loss of visibility/fidelity in performance evidence sources – maintain a good pyramid
Poor reporting, trending, sharing, monitoring73
Metrics Layered within the PyramidMetrics Layered within the Pyramid
Accidents# of PS incidents
# f fi t idIncidents
Precursors
Management System Failures
Number of Near Misses Reported
HSE/PSM audit scoreNumber of Overdue Action ItemsCorrective Actions Generated Safety Meeting Attendance, %Training Completed, %
# of first aidsSeverity rate
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Unsafe Behaviors and Attitudes
Culture – Individual and Organizational Tendencies
© ABSG Consulting, Inc.
RC ContactsSafety Inspections Completed, %BBS at-risk observations
Trend incident and management system technical and cultural
root causes as learning opportunities occur
Conceive of cultural weakness metrics to
collect across company
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Process Safety Metrics Process Safety Metrics –– Arendt Arendt SuggestionsSuggestions
1. Process Safety incidents – ANSI/API RP 754 Tiers 1 and 22 Process Safety incident precursors – RP 754 Tier 32. Process Safety incident precursors RP 754 Tier 33. Failure to follow procedures/SWPs – BBS at-risk
observation rate4. Failure to fix identified process safety problems – action
item backlogs or aging, equipment deficiencies backlogs5. Failure to identify process safety deficiencies– inspection
(all sources) backlog, failure to identify/report incidents or do adequate RCA
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do adequate RCA6. Failure to assess risk– MOC circumvention or low quality,
PHA schedule backlog, PHA quality review7. Safety culture weaknesses – Map RCs of incidents to
cultural causal factors
Emerging Challenges with PS Metrics
Don’t pick too manyMake sure they roll up properlyMake sure they add valueDon’t just pick things you can measure; make certain they affect accident riskThink through how you will use them; anticipate
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Think through how you will use them; anticipate unintended behaviorsMake them visible – positive culture influence
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Characteristics of Good Process Safety CompaniesNot blind or arrogant – willing to look into the mirrorSafe questioning/learning environmentProper safety ownership and leadershipEffective, fit-for-purpose management systemsDisciplined in execution - low/decreasing backlogsEffective action prevention not just correctionEffective action - prevention, not just correction
Action at multiple levels of the pyramidBuilds better ownership and fosters a better culture
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Characteristics of Good Process Safety Companies (cont’d)Learns lessons cheaply taught from all sources -p y gavoids repeat teachingPursues effective continuous improvement – seeks out better practicesHigh quality incident investigationsProper process safety metrics and discerningProper process safety metrics and discerning auditsEffective management review
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Keys to Future Process Safety SuccessTo pursue zero or perfect PS – you’ve got to change the ways you are doing some things that served you okay to get you to where you are atget you to where you are atFit-for-purpose PSM/HSE system that is well-executedNurture culture and operating disciplineCreate an effective learning organization
Apply root cause thinking to everythingMaintain an effective corrective action processHigh quality incident investigationsProper process safety metricsDiscerning auditsEffective management review
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Teaching, Learning, and Remembering
Go back to your plant, company, or organization and pick a notable incident and find out:
What was done to keep it from happening againDo people remember it and the lessonsWhat have you done to embed it in your "lore"What effective approaches still exist to prevent itWhat do you have to protect against PS Alzheimers
Pick a notable event from another company or industry - and do the sameGo up your chain-of-command and see how far the “remembering” goes
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“Perfect Process Safety”
Is a worthy and valuable goalCan only be pursued by highly reliableCan only be pursued by highly reliable organizations that embody effective learning patternsSustainable process safety does not allow learning to evaporate or “retire”Should be the stretch goal for all companies andShould be the stretch goal for all companies and organizations
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Swiss Cheese Model for Accident Causation
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Time for QuestionsTime for Questions
sponsored by
In Search of “Perfect Process Safety” In Search of “Perfect Process Safety” How to Ensure Sustainable Continuous How to Ensure Sustainable Continuous Improvement Improvement
L i f th M d D t H i Bl O tLearning from the Macondo Deepwater Horizon Blow OutAugust 21, 2012 Runcorn, UK
Steve Arendt, Vice President, P.E.North America Process Industries
Organizational Performance Assurance [email protected]
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