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Holding In NOT Holding Up

The familiar Process Safety Management (PSM) Frameworks are typically based on a structural model where elements (pillars) are founded on sound principles:

AIChE CCPS Risk Based Process Safety (RBPS) Framework

However, it is conceivable that several “columns” could be removed (or not constructed) and the PSM “roof” remains intact (albeit weakened). A better model might be an arch which requires all elements (blocks) to be in place:

We believe there is a more accurate model based on containment & control of Hazards i.e. Holding In not Holding Up to prevent Incidents, Major Accidents or Unplanned Events:

_{Move the slider to see the transition from Hazard to Top Event}

LESSONS

Key learning are categorised according to familiar PSM elements:

In the simple model above, it takes several e.g. 2 adjacent elements to fail before the “Beast is out of the Box” (you may be familiar with the Tiger in the Cage model – alternatively consider a Gorilla) but perhaps your PSM system is not so “tight” and failure of a single element is enough to lose control/containment:

TOPICS

Technical subjects, techniques or technologies applied to create & sustain the PSM elements:

SOLUTIONS

Delivered by topic specialists who provide services, software, training & coaching:

OVERVIEW

In simple terms, we aim to provide context by connecting:

WHAT happened (Incidents)
WHY did it happen (Lessons)
HOW can we correct/prevent it (Topics)
WHO can provide support (Solutions)

HOLDING IN NOT HOLDING UP

So, should we be more Hodor than Atlas ?

The full vision is available here:

We want to hear from you – either directly via email or on social media

Langue commune | Lingua Franca

Cela fait exactement une semaine depuis la terrible tragédie de Beyrouth …

It’s exactly one week since the terrible tragedy in Beirut …

202004AugAll DayBeirut Port Explosion 2020Port of Beirut (LB)Industry:WarehouseCountry:LebanonLanguage:ENLoC:Confined explosion Origin: TCE Incident:Explosive decompositionHazards:ExplosiveImpact:HUMAN (Offsite Fatalities)Effects:> 100 FatalitiesMaterial:Ammonium Nitrate

Naturellement, il y a eu une vague d’indignation à propos de l’incapacité d’apprendre des incidents passés et des dangers connus de la manipulation d’un matériau explosif familier, mais parce que nous manquons de temps, notre attention se tourne vers d’autres défis et finalement les seuls intéressés sont ceux qui sont sur le terrain et une poignée de chercheurs spécialisés.

Understandably there has been an outpouring of outrage about failure to learn from past incidents and the known hazards of handling a familar explosive material, however because we are time-poor, our attention drifts to other challenges and eventually the only ones interested are those on the ground and a handful of specialist researchers.

Ceci, comme la majorité des événements de sécurité des procédés, n’est pas un “cygne noir” mythique – jamais vu auparavant et apparaissant comme une surprise totale …

This, like the majority of Process Safety Events, is not a mythical “black swan” – never before seen and appearing as a complete surprise …

Oppau 1921

Grandcamp 1947

Port Neal 1994

**_{Terra International, Port Neal (US-IA)}**

Toulouse 2001

West 2013

Charleville 2014

Tianjin 2015

Beirut 2020

Avons-nous besoin d’une langue commune (lingua franca) pour communiquer des sujets techniques (et non techniques) à un personnel moins informé mais critique.

Do we need a common language (lingua franca) to communicate technical (and non-technical) topics to less informed but critical personnel

Le français est la deuxième langue au Liban – pensez-vous qu’une simple traduction aurait évité cette catastrophe?

French is the second language in Lebanon – do you think that simply translating would have avoided this catastrophe ?

Les propriétés physiques sont bien comprises et sont clairement consignées sur les étiquettes de mise en garde – étaient-elles présentes et importantes?:

The physical properties are well understood and are neatly captured on hazard warning labels – were these present & prominent?:

Nous avons créé cette base de données en ligne pour être facilement accessible, par exemple pour trouver des incidents similaires, rendez-vous simplement sur la page Historique, sélectionnez l’option de filtre, décochez l’option ALL, cochez AMMONIUM NITRATE puis cliquez sur APPLY FILTERS

We’ve created this online database to be easily accessed, for example to find similar incidents simply go to the History page, select the filter option, uncheck the ALL option, check AMMONIUM NITRATE then click APPLY FILTERS

Ou tapez simplement dans le champ de SEARCH:

Or simply type into the SEARCH field:

Les options linguistiques se développent, mais une simple conversion d’une langue à une autre peut ne pas être suffisante pour éviter des événements futurs – nous travaillons pour résoudre ce problème et empêcher l’histoire de se répéter

Language options are developing, however a simple conversion from one language to another may not be enough to avoid future events – we’re working to address that and prevent history from repeating itself

لغة مشتركة | Lingua Franca

مضى أسبوع بالضبط على المأساة الرهيبة في بيروت …

It’s exactly one week since the terrible tragedy in Beirut …

من المفهوم أنه كان هناك فيض من الغضب حول الفشل في التعلم من الحوادث السابقة والمخاطر المعروفة للتعامل مع مادة متفجرة عائلية ، ولكن نظرًا لأننا نفتقر إلى الوقت ، ينجرف انتباهنا إلى تحديات أخرى ، وفي النهاية المهتمون الوحيدون هم أولئك الموجودون وحفنة من الباحثين المتخصصين.

هذا ، مثل غالبية أحداث سلامة العمليات ، ليس “بجعة سوداء” أسطورية – لم يسبق رؤيته من قبل ويظهر كمفاجأة كاملة …

This, like the majority of Process Safety Events, is not a mythical “black swan” – never before seen and appearing as a complete surprise …

هل نحتاج إلى لغة مشتركة (لغة مشتركة) لتوصيل الموضوعات الفنية (وغير الفنية) إلى موظفين أقل معرفة ولكن مهمين

Do we need a common language (lingua franca) to communicate technical (and non-technical) topics to less informed but critical personnel

اللغة العربية هي اللغة الأولى في لبنان – هل تعتقد أن مجرد الترجمة كانت ستجنب هذه الكارثة؟

Arabic is the first language in Lebanon – do you think that simply translating would have avoided this catastrophe ?

الخصائص الفيزيائية مفهومة جيدًا ويتم التقاطها بدقة على ملصقات التحذير من المخاطر – هل كانت موجودة وبارزة؟:

The physical properties are well understood and are neatly captured on hazard warning labels – were these present & prominent?:

لقد أنشأنا قاعدة البيانات هذه على الإنترنت ليتم الوصول إليها بسهولة ، على سبيل المثال للعثور على حوادث مماثلة ، ما عليك سوى الانتقال إلى صفحة السجل ، وتحديد خيار التصفية ، وإلغاء تحديد الخيار ALL ، والتحقق من نترات AMMONIUM ، ثم النقر فوق تطبيق عوامل التصفية

أو اكتب ببساطة في حقل البحث:

Or simply type into the SEARCH field:

تتطور خيارات اللغة ، ولكن التحويل البسيط من لغة إلى أخرى قد لا يكون كافيًا لتجنب الأحداث المستقبلية – نحن نعمل على معالجة ذلك ومنع التاريخ من تكرار نفسه

Mission Impossible?

Most of us use Google daily, but how many actually know or think about their vision or mission?

Our mission is to organise the world’s information and make it universally accessible and useful.

Google

We endeavour to do the same in our way in your industry – quite simply we aim to organise the world’s Process Safety information and make it universally accessible and useful.

Organise

Collating key messages (lessons to be learned) from incidents and connecting them to familiar frameworks and technical topics via intelligent categorisation.

Information

Curating the wealth of information (not limited by location or language) from existing databases, investigations reports & competent contributors.

Accessible

Free and easy to access with interactions to/from social media in languages & visual formats that offer learning opportunities to the many not just the few.

Useful

Knowledge is nothing without action (ideally proactive rather than reactive) and we aim not just to highlight problems but offer solutions.

Our goal is to Inform the next generation of Leaders & Duty-Holders, Remind the current generation of Industry veterans and Engage all Stakeholders through …

Hindsight

Past ACCIDENTS (unplanned events) from a variety of sources are presented chronologically and geographically to highlight the diversity of time & place when & where incidents have occurred.

Insight

Current MEDIA (including social media posts, incident videos, podcasts and bulletins) provides context via PSM Framework Lessons and Technical Topics. We also use intelligence and innovators to communicate and inspire.

Foresight

Future EVENTS (including webinars, online training and physical meetings) are also linked to/from each Incident via related Lessons & Topics to help focus learning & action.

Is this Mission Impossible? – it’s certainly not easy and we can never claim to have all the facts on all the accidents, incidents, near-misses or close calls.

David Buzzelli, a vice president of the Dow Chemical Company, openly stated …

For an industry so proud of its technical safety achievement it is humbling to have to admit that most of our significant safety improvements were developed in response to plant accidents

D.T. BUZZELLI

We can’t capture & communicate all the problems, and we certainly don’t state that we have all the solutions, however we have a growing network of providers who offer services, software, coaching & training.

Process Safety is certainly not a religion (a particular system of faith and worship – although we often have blind faith that our protection measures are always present and performing) so we’re not looking for Missionaries in the strict definition of the word (a person sent on a religious missions) because we aren’t crusading or trying to convert “non-believers”.

The best definition is perhaps Evangelists (zealous or enthusiastic advocates of a particular cause)

If you are a Process Safety Evangelist who can promote their research, share their teaching and/or deliver solutions – please join us because this Mission matters:

contact@processsafety.events

We believe it’s Mission Difficult not Mission Impossible!

Thanks for the Memory

In 2008, Trevor Kletz was interviewed by the CSB and offered (amongst many) the following provocative and memorable observation:

“The major problem with the chemical industry and indeed, with other industries, is that the way accidents are investigated; reports are written, circulated, read, filed away and then forgotten. And then ten years later, even in the same company, the accident happens again. There is a saying that organizations have no memory; only people have memory and once they leave the plant, the accident that occurred there is forgotten about.“

Neatly summarised (and immortalised) as “Organisations have no memory – only people do“, the indisputed (god)father of Process Safety has, over half a century, provided us with a wealth of short quotes and lengthy considerations to remind us that ‘Safety never Sleeps’, that we must always be on our guard and avoid complacency while controlling & containing the hazards which generate revenue or reward.

It is inevitable that we become dulled by the messages and insensitive (both technically & emotionally) to past events so it’s vital that his simple truths stay with us so we can maintain our respect and vigilance.

We’ve created a growing collection of quotes from Trevor and other respected members of the Process Safety community as well as some general anecdotes & comments from less technical sources which are nevertheless intended to evoke some mindfulness that we can apply ourselves and share with others.

Entitled Process Safety Intelligence, it is not aimed at intellectuals but more broadly to all stakeholders with the basic definition of intelligence as the:

Ability to acquire and apply knowledge and skills
Collection of information of value

Trevor himself (as his books will testify) was not averse to employing humour to reinforce and retain the key messages:

_{IChemE Computer Control and Human Error}

And we can see similar styles aimed at management:

As well as directly towards frontline personnel:

Whatever the message, Joseph Pulitzer reminds us to:

“Put it before them briefly so they will read it, clearly so they will appreciate it, picturesquely so they will remember it, and, above all, accurately so they will be guided by the light“

Serious subjects like Process Safety can be “taught” or shared in a way that is relevant and respectful – in fact renowned comedian and self-proclaimed actor, writer and tall-person John Cleese developed a training company (Video Arts) with the simple aim to “help your learning last longer”.

If we don’t learn, we won’t remember and we can’t act !

Providing Solutions

It is simply not enough to ACKNOWLEDGE (I now know that my facility is vulnerable to this type of event) or APPRECIATE (I now understand WHY it relates to my assets/activities) the Lessons to be Learned from previous Incidents – we must ACT (Corrective action to deal with an incident that has occurred) and ANTICIPATE (Preventive action to address the potential for the same or similar incident from occurring here or elsewhere in the future) to literally prevent history repeating itself.

We use the event database to connect Incidents (Major Accident Events) to Lessons based upon PSM Elements that are constructed and sustained using industry standard techniques and technologies which are presented as Topics.

Technical specialists provide solutions around these topics to help dutyholders meet their regulatory obligations and commercial expectations and offer assistance to address deficiencies in PSM elements including:

• Incomplete or Incorrect assessments/analyses (Poor Inputs, Limited Scope or Actions not Addressed)
• Inadequate or Inactive controls/protection (Degraded, Defeated or Deleted barriers)
• Inappropriate, Irrelevant or Impractical processes/procedures (Out of Date or Unrealistic)
• Inaccurate documentation/drawings (“As-Is” ≠ “As-Built” ≠ “As-Designed”)

We offer solution providers a platform to promote their portfolio which may include Services (including Consulting and Classroom & Online Training) and Products (including Software):

To showcase your company and the topics you cover, which we will connect to Lessons and Incidents to provide context and value e.g. this is relevant because its errors or omissions contributed to this or this type of incident, then please email us via the link below:

DataBasics

There are many ways we use the Database to connect past Incidents, current Media and future Events.

Bulletins

The AIChe CCPS Process Safety Beacons often cite incidents from CSB investigations, for example:

202001JulAll DayProcess interruptions: a threat to process safetyProcess Safety Beacon | Pay attention to all equipment containing chemicals, even if it is “shut down“Lessons:Asset integrity,Control of Work,Emergency Preparedness,Operating Procedures,Operational Integrity,Risk Assessment,Stakeholder EngagementLanguage:EN Origin: CCPS Document Type:BulletinTopics:Chemical Reaction,Pressure Systems,Occupied Buildings

Summary

An explosion on October 13, 2002, propelled large fragments of debris offsite, some landed near crude oil storage tanks. Three people were injured, but fortunately, no fatalities occurred.

Steam leaking through manual block valves heated crude Mononitrotoluene (MNT) inside a vacuum distillation column, which was shut down and thought to be isolated. The column contained about 1,200 gallons (4.5 m³) of MNT, an energetic and reactive material which can decompose violently when heated. The material decomposed over several days, resulting in a runaway reaction and explosion. Debris from the explosion caused a storage tank fire and numerous smaller fires both onsite and offsite.

Low product demand delayed start up, but the MNT column was kept in total reflux, until the plant-wide shutdown was completed. A fire elsewhere caused operators to isolate heat sources to all columns including the MNT column by closing manual steam block valves and control valves. However, the valves on the MNT column were leaking through, and the temperature of the material in the MNT column did not drop but continued to rise, exceeding 450°F (232 °C) in about 8 days. There was no alarm, and there is no evidence that Operations personnel actively monitored the column temperature control system.

Learn More

Origin

CCPSCenter for Chemical Process Safety

200213OctAll DayFirst Chemical Reactive Chemical Explosion 2002First Chemical Corp. Pascagoula (US-MS)Lessons:Asset integrity,Control of Work,Emergency Preparedness,Risk Assessment,Stakeholder EngagementIndustry:PetrochemicalsCountry:United StatesLanguage:ENLoC:Confined explosion Origin: CSB Incident:Runaway reaction explosionHazards:ReactiveContributory Factors:Loss of Process ControlImpact:HUMAN (On Site Injuries)Effects:< 100 InjuriesMaterial:MononitrotolueneTopics:Chemical Reaction,Pressure Systems,Occupied Buildings

Summary

The rupture of a 145-foot-tall distillation column (C-501) used to refine mononitrotoluene (MNT) caused the October 13, 2002, explosion and fire at the First Chemical Corporation (FCC) facility in Pascagoula, Mississippi. The column was thought to be isolated and in standby mode at the time of the explosion (approximately 5:25 am) though it contained a significant amount of MNT.

Debris from the explosion, including metal fragments and packing from the column, was scattered throughout the facility and propelled offsite. One large fragment of the distillation column punctured a nearby para-MNT storage tank and ignited its contents, which burned for almost 3 hours. A 6-ton column segment was hurled 1,100 feet and landed near a crude oil storage tank at a refinery across the highway. Flying glass injured three FCC employees, who were in the unit control room at the time of the explosion. All three employees received first-aid, and one required additional medical treatment.

The FCC fire brigade fought the onsite fires, including the large para-MNT storage tank fire and numerous fires initiated by burning material on ejected column packing. Local community emergency responders provided backup and firefighting support for numerous small fires outside the facility. The sheriff’s department provided traffic control. FCC personnel, the U.S. Environmental Protection Agency (EPA), and the U.S. Coast Guard monitored the air around the facility.

KEY ISSUES:
• EVALUATION OF REACTIVE HAZARDS
• APPLYING LESSONS LEARNED
• LAYERS OF PROTECTION
• WORK PRACTICES
• FACILITY SITING
• COMMUNITY NOTIFICATION

ROOT CAUSES:
1. The FCC Pascagoula facility did not have an adequate system for evaluating the hazards of processing mononitrotoluene (MNT) in its continuous process and did not apply lessons learned from hazard analyses conducted on similar processes in the plant.
2. FCC did not have a system to ensure that the #1 MNT column (C-501) was equipped with sufficient layers of protection to prevent a catastrophic release.
3. The Pascagoula facility had no effective system for ensuring consistent work practices when isolating equipment.
4. FCC did not have an adequate program to prevent leakage from isolation valves in the steam line connected to the #1 MNT column (C-501).

Image Credit: CSB

Learn More

Origin

CSBUS Chemical Safety Board

The Key Issues from the investigation reports can be used to categorise Lessons to be Learned according to familiar PSM Frameworks:

Bulletins are available in a variety of languages:

Topics

Planned events are associated with techniques or technologies that address deficiencies in PSM Frameworks – for example a webinar on Bowties provides information on the Risk Assessment element :

Missing Event Data

Related Events

The RELATED EVENTS feature hyperlinks connect Incidents to other Incidents, Media e.g. from the IChemE or relevant Events:

198806JulAll DayPiper Alpha Explosion 1988Occidental UK North Sea (GB)Lessons:Commitment & Culture,Control of Work,Emergency Preparedness,Management of Change,Operational IntegrityIndustry:OffshoreCountry:United KingdomLanguage:ENLoC:Maintenance error Origin: HSE Incident:VCEHazards:FlammableImpact:HUMAN (On Site Fatalities)Effects:> 100 FatalitiesMaterial:Hydrocarbons

Maps

Incidents are also mapped geographically:

Animated or live videos associated with Incidents e.g. from the CSB or the IChemE Safety Centre are also mapped to Major Accidents:

Classification

The Industry in which the Incident occurred, the Hazard(s) associated with the process/activity where the Incident occurred and the Consequences of the Incident are classified as follows:

Intelligence

The site also provides inspiration from historic Thought Leaders including Trevor Kletz and Albert Einstein:

It also offers insight from current Industry Leaders including Andrew Hopkins:

Trish Kerin and Fiona Macleod:

Technical art created by talented engineers; Ramin Abhari, Rachael Cowin & Cesar Puma:

Contact

For regular updates, please follow the link to Subscribe. To showcase your Event, promote your Services or share your Research, please email us:

Hindsight Insight Foresight

Welcome to a free-to-access online relational database that applies the Hindsight from previous Incidents (i.e. LoPC/LoC Process Safety Events), the Insight from current Media and the Foresight from future Events to facilitate more effective Learning from and Acting upon the negative & positive experiences from Major Accidents.

We aim to Inform the next generation of Leaders & Duty-Holders, Remind the current generation of Industry Veterans & Engage all Stakeholders by Curating, Collating & Connecting the wealth of publicly available Process Safety data, information & knowledge to create and sustain Operational Wisdom.

At the heart of the database are Lessons aligned with internationally recognised Process Safety Management (PSM) frameworks that can be applied through the use of technologies or Topics.

The key areas of the site are summarised below:

Incidents from existing databases and published research presented Historically, Geographically and on their Anniversary. They are classified by Industry, Hazards & Consequences and grouped by LoC Cause as well as captured as scenario Summaries.
Media including Podcasts, Incident Videos, Webinar Recordings and a variety of posts & publications such as the IChemE Safety Centre Safety Lore & Case Studies.
Events including Classroom Training, Conferences, Live Webinars, Online Training and Workshops & Meetings with face-to-face events mapped by location.
Lessons aligned to familiar PSM framework elements.
Topics related to Lessons.
Bulletins and Alerts including the CCPS Process Safety Beacon, EPSC Learning Sheets, IChemE Loss Prevention Bulletin, ICI Newsletters and HSE Safety Alerts.
Intelligence to inform & guide with insights from current illustrators & story-tellers and inspiration from thought leaders such as Trevor Kletz. Process Safety research, education, software & support is also shared.

Incidents, Media & Events are all presented as calendar (event) entries – simply click on LEARN MORE for details (hyperlink) of the event and/or click on RELATED EVENTS for associated events. Use the Search or Filter icons to focus on specific events or types of events.

Help on navigating and interpreting the site is available as well as details About our initiative.

Please stay in touch – we welcome feedback (particularly corrections & suggestions) & ongoing engagement.

We’ve developed a neutral platform to provide unbiased promotion of Process Safety solutions, so please contact us if you wish to showcase your Event, Education, Services or Software or simply share your Research.

You can also follow us via the following social media channels:

Incident Timeline ‘On this day in History’ @majoraccidents

Media & Event Updates @processevents

LESSONS

TOPICS

SOLUTIONS

OVERVIEW

HOLDING IN NOT HOLDING UP

Summary

Summary

Learn More

Origin

Related Events

References

Summary

Summary

Learn More

Origin

Related Events

References

Organise

Information

Accessible

Useful

Hindsight

Insight

Foresight

Summary

Summary

Learn More

Origin

Related Events

Summary

Summary

Learn More

Origin

Related Events

Summary

Summary

Learn More

Origin

Related Events

Lessons

References

Maps

Classification

Contact