1. sponsored by
In Search of “Perfect Process Safety”
How to Ensure Sustainable Continuous Improvement
Learning from the M
L i f th Macondo D
d Deepwater H i
t Horizon Bl
Blow O t
Out
August 21, 2012 Runcorn, UK
Steve Arendt, Vice President, P.E.
North America Process Industries
Organizational Performance Assurance Center
sarendt@absconsulting.com
Steve Arendt, P.E.
30+ years in process safety and risk assessment
Vice President, ABS Consulting, NA Process Sector and
Organizational Performance Assurance Center
ABSC project manager for the Baker Panel PSM reviews
Conducted 100s of PSM audits, incident investigations, and best
practice reviews, including 20+ offshore facilities
60+ articles and books on PSM and risk management
Guidelines for Risk-Based Process Safety
Guidelines for Management of Change
A Compliance Guide for EPA’s Risk Management Program Rule
Manager's Guide to Quantitative Risk Assessment
Resource Guide to the Process Safety Code of Management Practices
y g
Guidelines for Hazard Evaluation Procedures, Second Edition
A Manager's Guide to Implementing and Improving MOC Systems
Risk Communication Guide, Chemical Educational Foundation
ProSmart - CCPS PSM Performance Metrics System
Center for Chemical Process Safety Fellow
Recipient of Mary Kay O’Conner PSC Merit Award
Center for Offshore Safety work group member
2
1

2. “Perfect Process Safety”
What is it?
Is it possible?
What are the barriers?
3
A Vision For “Perfect Process Safety”
A culture based on proper ownership of HSE
Risk-informed sensitivity that g
y guides everything
y g
Effective, fit-for-purpose management systems
PS practices embraced and followed with good
operational discipline at ALL levels
Learning from ALL sources – internal, external and
outside industry group
Well-formed/visible performance pyramid; metrics
at every level that drive intended behaviors
Goals and actual performance that improves
4
2

3. Compliance with Existing
Regulations Is Not Enough
Regulations provide minimum framework, but
industry practices have bypassed regulations
Minimum standards may not be enough for all facilities
We have not really learned from our experience
Minimalistic compliance approach does not lead to
robust future performance
Fragility due to economic cycles
Culture challenges
Organizational stresses
Aging assets and changing people
5
The Problem with Some Companies…
They Are Taught a Lot of Lessons, But They Never Seem to Sustain Learning
Accidents They either don’t see
y
hazards below the
Or they don’t waterline
know how to Incidents
identify and fix
root causes
Precursors
Management System Failures
g y
Their “fixes”
don’t stay fixed
Unsafe Behaviors and Attitudes
Culture – Individual and Organizational Tendencies
© ABSG Consulting, Inc.
6
3

4. Seems to Be Four Types of Companies
In theory, requirements and enforcement practices
should be matched to these various “needs”
needs
Know what to do and do a pretty good job
Know what to do, but don't do a consistent job
Know what to do and "intentionally" don't do a good job
Don't really know what to do – ignorant or confused
Difficult to make happen. Seems like we want “one
happen one
paint brush” and the “same type of painter” no
matter what the need
7
Learning from Experience
Outside your industry
Inside your industry
Inside 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
p p
A critical skill is to find something relevant to learn
and improve on out of EVERY significant incident
8
4

5. Simple Lessons Baker Panel-CSB Reports
Panel-
Ineffective PSM system with weak performance
evaluation, corrective action, and corporate oversight
Lack of follow-up in ALL areas
p
Huge backlogs in inspections and corrective actions
Not following consensus standards – nor their own
Poor risk awareness and assessment
Superficial audits
Inadequate metrics
Poor management review at local level
Not focused on process safety at corporate level
Inadequate corporate safety culture – had symptoms
in every PS culture problem area
Blind spots
Arrogant
Complacent
Superficial
Glacial, non-agile
In denial
9
Macondo – Lessons and Potential Impacts
Classes of root causes - plenty to go around
Inadequate process safety culture for DH
adequate p ocess sa ety cu tu e o
Inadequate GOM operating environment culture
Complex offshore operating environment
Process safety management system failures
Inadequate GOM regulatory environment
Potential influences for onshore regulations
g
Enhanced reporting and third-party audits
Prescriptive independent verification of safety critical
elements
QRA and safety case
10
5

6. Lessons from Major Learning Sources
Failure to execute – primary lesson
We are not taking advantage of all “internal”
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
11
Six Characteristics of a Learning Organization
(Harvard Professor David Garvin)
Supports discussion and evaluation of divergent opinions
and data
Provides timely feedback and flexibility in the means
used to conduct work activities
Stimulates new ideas to promote a step change in risk
understanding and operational performance
Maintains an external focus by not automatically
discounted outside ideas and ways
Treats errors/mistakes as investments. Learns from
them. Encourages proper risk-taking
Routinely updates a learning plan to increase
competencies
12
6

7. Characteristics of a Learning-Disabled Company
(Steve Arendt, Armchair Process Safety Psychologist)
Dysfunctional safety culture
People hide things and kill messengers
p g g
Fail to question; procedures not followed without
accountability
Mixed/improper safety/production messages
Complacency, low trust, silo mentality
Misplaced safety ownership, invisible/ineffective
leadership
Superficial causal analysis of problems
Things don't get fixed
No company memory
Add in your own…
13
Characteristics of Good Risk Management
Necessary, but Not Sufficient for Perfect PS
Pervasive understanding of what risk is
Consistent practices driven using fit-for-purpose
g
HSE management system
Life-cycle wide and enterprise deep risk visibility
Flexible tool set and relevant data sources
Competent practitioners
Appropriate risk tolerance concepts/tools employed
Effective risk reduction issue management
Regular executive review of risk register top issues
Risk ownership throughout the organization
14
7

8. Definition of the Perfect PS Leading Indicator
The Perfect Risk Model Or…a “Live Risk” Model
Evaluates the risk impact of day-to-day
facility changes and circumstances:
User d fi
U defines equipment th t i f il d
i t that is failed,
disabled, degraded etc.
Operational adjustments
External circumstances
Evaluates the increase in risk from
these changes
Requires input from risk models
(HAZOPsHAZIDs, LOPAs, BTs,
QRAs) into risk model
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
15
LIVERISK Features
Dashboards for
Different levels within the organization (
g (facility, Business Unit,
y
Corporate etc.)
Different departments (production, safety, inspection etc.)
Accounts for the impact of changes in management systems
Mechanical integrity: testing & maintenance programs; Project Quality
Management (PQM), etc.
Health, Safety and Environmental: results of HSE audits, Class
surveys, etc.
surveys etc
Integrate HSE/process safety metrics (leading indicators)
Integrate safety culture issues
Others
Accounts for operational profile and external events
16
8

9. Improvements in Process Safety/HSE
Technology
and standards
HSE management Culture
ate
systems • Organizational and
Risk/Incident Ra
individual behaviour
aligned with goals
Standards
• “Felt” leadership
• Engineering improvements
• Personal accountability
• Hardware improvements
• Shared purpose & belief
• Design review
• Compliance Management Systems Improved
• Integrated HSE MS culture
• R
Reporting
ti
• Assurance
• Competence
• Risk Management
Time
Adapted from Kiel Centre 17
Overview of U.S. Industry Process Safety
Performance Improvement Activities
Center for Chemical Process Safety
Risk Based Process Safety Guidelines emphasis on Learning from
Experience
Leading indicator work in late 90’s culminating in new PS metrics
guidelines
Member benchmarking project and Vision 2020
API
RP 754
API/AFPM Advancing Process Safety Initiative
Center for Offshore Safety
Lessons from industry accidents and investigations
Industry is refocusing attention and leadership
away from PSM compliance to PS Performance
18
9

10. Current PSM/HSE Auditing and RCA
Practices Don’t Go Far Enough
PSM/HSE audits generally issue findings and areas
for improvement “at the element level” even though
the evidence used may point to deeper problems
Incident investigations identify PSM elements as root
causes but don’t address safety culture factors
Use 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
19
Center for Chemical Process Safety
Made Culture an Official SMS Element
Evaluated major organizational
accidents and prepared Safety
Culture Awareness tool
ABSC included Process Safety
Culture as an element in CCPS
Guidelines for Risk Based
Process Safety
Defined the twelve essential
features of a good culture
Created structure for a culture
management practice
20
10

11. 21
What Is Safety Culture?
Our Company and Individual DNA
Cu tu e is t e te de cy in a o us – a d ou
Culture s the tendency all of and our
organization - 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
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”
22
11

12. To Address Unsafe Acts, Some Companies
Have Implemented BBS Programs
Industry experience has varied
Worked for some; did not work for others
Worked for a while, but then floundered
Some have not tried it because of the resource commitment and
negative feedback
Problems with BBS programs
LTA management commitment; LTA resources
Perceived to be a program for employees to “fix themselves”
p g p y
Management not viewed as a part of the problem/solution
Lack of employee ownership
Trivial/ineffective observations - quotas, improper reward systems,
program gets stale, gets nit-picky
Employees unable to provide/accept constructive peer feedback
23
Organizational Accidents and Culture
Challenger & Columbia
Piper Alpha
L f d
Longford
Chernobyl
Flixborough
Texas City
Macondo
24
12

13. Process Safety Culture – Essential Features
1. Establish safety as a core 7. Defer to expertise
value
l 8. Ensure open and effective
2. Provide strong leadership communications
3. Establish and enforce high 9. Establish a
standards of performance questioning/learning
environment
4. Formalize the safety culture
emphasis/approach 10. Foster mutual trust
5. Maintain a sense of 11. Provide timely response to
vulnerability safety issues and concerns
6. Empower individuals to 12. Provide continuous
successfully fulfill their monitoring of performance
safety responsibilities
25
1. HSE/Process Safety As a Core Value
Deeply ingrained sense of value for HSE/safety
At all levels of the organization
Promoted to an ethical imperative in really strong
cultures
Awareness of responsibility to:
Self
Co-workers
Company
Society
Individual and group intolerance of those in
violation of the norm
26
13

14. 2. Strong Leadership
Visible, active, consistent support from all levels
of company management
Through communications, actions, priorities,
provision of resources, etc.
Committed to what is right
Visionary and inspiring
Open and honest
Firm b t fl ibl
Fi but flexible
Alert and responsive to modify strategies to
meet safety goals
HSE/safety as line responsibility
27
3. Consistent Accountability to High
Performance Standards
Individual d
I di id l and organizational
i ti l
Standards established, reinforced, and updated in
a controlled fashion
Consistency in accountability and transparency at
all organizational strata – no “double standards”
Avoidance of normalization of deviance
Zero tolerance for willful violations of safety
standards, rules, or procedures
28
14

15. 4. Formalize a Culture Approach
Culture cannot be designed or manufactured, but ...
Document key principles or activities that support or
maintain its safety culture
Record basic safety tenants, such as in a company
policy or mission statement
Formalize a culture evaluation, monitoring, and
learning activities that are expected to be carried
out by someone or some group on a periodic basis
29
5. Sense of Vulnerability
Preoccupation with failure
Constant 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
safety systems
Awareness of need for resilience (multiple lines of
defense)
Burden of proof for safety rather than "un-safety
30
15

16. 6. Individual Empowerment
Clear delegation of, and accountability for,
responsibilities
Provision of requisite authority and resources to
staff to allow success in assigned roles
Management expectation and tolerance of
disparate opinions
Personal responsibility for safety
31
7. Deference to Expertise
High value placed upon training and
development of individuals and groups
Authority for decisions migrates to proper people
based upon their knowledge and expertise
Rather than rank or position
Independent and unassailable role for safety
experts
Imperative for maintaining the “critical mass” of
expertise required for safe operations
32
16

17. 8. Open and Effective Communications
Vertical communications (both up and down)
Management hearing as well as speaking
Horizontal communications
All have the information they need to identify and
respond to the unexpected
Emphasis on observation and reporting
Redundant and/or non traditional
non-traditional
communications channels
Monitoring of communications for effectiveness
33
9. Questioning/Learning Environment
Enhancing risk awareness and understanding as
means to continuous safety improvement
Appropriate and timely hazard/risk assessments
Thorough and timely incident investigations
Looking beyond site or company for applicable
learnings
Reluctance to simplify interpretations or seek the
p y p
simple solutions
34
17

18. 10. Mutual Trust
Employees for managers
Trust that managers will do the right thing in support
of safety
Managers for employees
Trust that employees will shoulder their share of
responsibility for safety performance
Peers for peers
p
Confidence in a just system where honest errors
can be reported without fear of reprisals
35
11. Responsiveness to Safety Concerns
Awareness of safety as a dynamic non-event
A “properly tuned controller”
properly controller
Rapid, but not reckless, response to the unexpected
in order to maintain the safety setpoint
Timely response to implement learnings from
audits and investigations
Timely resolution of mismatches between
practice and procedure t prevent normalization
ti d d to t li ti
of deviance
Timely reporting of, and response to, employee
safety concerns
36
18

19. 12. Continuous Monitoring of
Performance
Curiosity/anxiety for ”How are we doing?
How doing?”
Sensitivity to operations
Process
Management system
Interpersonal
Pertinent, clear metrics addressing both leading
, g g
and lagging indicators
Defined
Created
Tracked
37
Examples 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
wrong
An operations manager extends a unit shutdown to await
definitive evidence that a thin-walled vessel is safe to
operate
A plant manager does not wear appropriate PPE when
walking to the control room to eat lunch with a unit crew
A corporate EHS Director persists in her efforts to justify
staffing resource commitments to support process safety
in spite of company cost-cutting edicts
Red = Negative Green = Positive
38
19

20. Examples of Culture Influencing Events
A VP pressures the plant manager to defer the plant
turnaround through the busy season
A company SVP focuses on problem solving rather than
affixing blame during a management review of a serious
incident investigation
A company Director eliminates corporate engineering
and process safety staff positions without any
management of organizational change
A CEO makes an acquisition without addressing
EHS/process safety in due diligence reviews
A Board subcommittee spends significant time reviewing
EHS/process safety performance metrics and questions
the company’s 3rd-quartile performance
Red = Negative Green = Positive
39
Connecting the Dots – Process Safety
Performance Assurance Review (PAR)© Strategy
Process Safety/ESH Culture
Mapping of ESH Technical Evaluation Sources
Performance and Culture PSM/EHS
Surveys and Work
Evidence to Process interviews observations leading
indicators
Safety Culture Factors
Incidents and
investigation
Process results Process Safety/ESH Culture
Safety/ESH
Performance Audits and
Essential Features
Information assessments Causal Factors
Sources Action item Tenets of Operation
completion
history
40
20

21. PAR Process Safety Performance vs. Culture Map
Culture survey results and other sources
are sorted into the 12 essential features
Analysis of all process safety
performance data (e.g., audit actions)
is sorted into the 12 essential features
41
Ranking of Cultural Causal Factors Present – Summary
of Study Results
Cultural Causal Factor – Decreasing Frequency
1. Normalization of deviance
2. Non-responsiveness to safety concerns
3. Lack of a questioning/learning environment
4. No performance monitoring/pursuit of
improvement
5. Lack of sense of vulnerability
6. Lack of trust – unsafe reporting environment
42
21

22. How to Change PS/HSE Culture
Embracing the idea that YOU affect culture
Understanding potential root causes
Determining ways to improve culture weaknesses
Follow-thru throughout an organization
43
How Leaders Influence Beliefs/Values
What leaders pay attention to, measure, or
control
Reactions to critical incidents or crisis
Criteria used to allocate scarce resources
Deliberate attempts at role modeling, teaching,
and coaching
Criteria for reinforcement and discipline
Criteria used to select, promote, or terminate
employees
44
22

23. Small Group/Individual Mentoring and Coaching
Workshops and role play
Examples of accidents that occurred due to safety culture problems
CCPS 12 essential features of a good safety culture
Taking personal responsibility for evolving your Process Safety and
Occupational Safety (Total Safety) behavior and culture
Understanding potential historical root causes for culture problems
Soliciting ideas for improving culture
Decide which culture elements you are going to address
Decide who in management is needed to support your efforts
Develop a plan for the next month, the next six months, the next
year, and the next three years
Determine what metrics will be used to monitor progress
45
Some Culture Improvement Lessons
If you have poor culture, marked by mistrust or
needs large improvement, the worst thing y can
g p , g you
do is too just start “talking” about it at the top
The “top” needs to first start “behaving” better to
address culture weaknesses
Then, the talk will build up from the bottom
If you survey, do it anonymous and voluntary; you
survey
should commit to sharing the results – quickly
Any education/training, etc. should extend to ALL of
the workforce, including contractors
BUILD OWNERSHIP
46
23

24. Sense, Learn, and Fix at Every Level
Put sensors, not censors, at every level
Develop learnings at every level
Take corrective action at every level
47
Strategy for Process Safety
Performance Management
Monitor PSM health
For ALL PS learning opportunities:
Evaluate PSM failure modes
Determine PSM failure culture causal factors
Ensure sustainable PSM/HSE performance
improvement
Avoid organizational warning signs
Embrace critical success factors for PSM
48
24

25. Evaluating PSM Element Failure Modes
Determine basic element steps
Review element written program
Identify life-cycle activities completed and current
status
• Design and development
• Implementation and rollout
• Operation
• Monitoring and improvement
Develop workflow diagram of element work process
Review relevant incident root causes for element
Review relevant element metrics - leading and
lagging indicators
49
Evaluating PSM Element Failure Modes
Review previous two audit cycle results for element
Assign 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 greatest
Highlight work process point where most
element performance issues have occurred
50
25

26. Evaluating PSM Element Failure Modes
Determine corrective and preventive actions to
reduce chance of element performance failure
p
occurring again
Implement/redo life-cycle phase in a more reliable fashion
Improve element work process design
Create better leading indicators to monitor element
performance area
Improve use of existing relevant metrics to monitor
element performance
Increase management review scrutiny on element
performance area
All of this may not be enough
51
Evaluating PSM Element Failure
Culture Causal Factors
Map element performance issues to cultural
features
Compare performance to known culture
weaknesses
Identify which culture features appear to be
contributing to element performance lapses
52
26

27. Ensuring Sustainable PSM/HSE
Performance Improvement
Make technical corrections to PSM element
performance
Implement culture improvement activities to
address culture weaknesses
Monitor culture change and improvement
53
Guidelines for
Management of Change for Process Safety
Recognize
Classify
Evaluate hazards and risks
Approve (or not) or modify
Get ready for the change
Communicate/train
Update documentation
200 pages. April 2008, US $95
ISBN: 978-0-470-04309-7
http://www.wiley.com/WileyCDA/WileyTitle/productCd-0470043091.html
54
27

28. MOC Program Life-Cycle Phases
Design and development
Implementation and rollout
Operation
Monitoring and improvement
55
MOC System Design/Development Failure Modes
Inadequate workforce involvement
Inadequate design basis - wrong change types
types,
inadequate review/authorization protocols
MOC use rate not considered when establishing MOC
resources
Inadequate MOC resources designated
MOC protocol complexity inappropriate for change types,
resources, or workforce culture
MOC system roles and responsibilities inadequate
Scope of application of MOC program inadequate
56
28

29. MOC System Rollout Failure Modes
Inadequate workforce involvement
Inadequate awareness training of workforce
workforce,
including contractors
Inadequate detailed training of MOC system
participants
Insufficient MOC system tools/forms/resources
provided
Insufficient pilot-testing
57
MOC System Operation Failure Modes
Failure to identify a proposed change - system circumvented
Change classified as an emergency change when it did not
meet established criteria
Mistakenly included a RIK in the MOC review process
Proposed change improperly classified - type or review path
MOC origination information inadequate
MOC initial review not completed or inadequate
Inadequate MOC reviewers
Wrong MOC review method used
MOC hazard review path step missed, out of order, incomplete
MOC hazard evaluation inadequate - hazards missed or risks
improperly evaluated
58
29

30. MOC System Operation Failure Modes
Emergency MOC review procedure not finished
MOC authorization inadequate - wrong, missing or risks
accepted are inappropriate
PSI not updated based upon change
Personnel not informed of change
Personnel not trained on change
Wrong communication or training provided to personnel
Temporary change left in place too long without further review
Failure to restore system to original condition after a
temporary change
MOC review records inadequate or missing
MOC delayed or lost in the system
59
MOC System Monitoring Failure Modes
MOC metrics not properly developed or used
Inadequate management review/oversight of
MOC system
MOC not addressed sufficiently in PSM audit
60
30

31. Top MOC Operating Phase Failure Modes % of MOC
Issues
Failure to identify a proposed change
61 %
- system circumvented
Temporary change left in place too 43 %
long without further review or failure
to restore system to original
Personnel not informed of change g 35 %
MOC delayed or lost in the system 23 %
MOC hazard evaluation inadequate -
hazards missed or risks improperly 18 %
evaluated
61
MOC Failure Example –
Offshore Gas Compressor Module
62
31

32. Unrecognized Change Led to Release
Original position Modified position
63
Gas Release Resulted in a “Lucky Explosion”
64
32

33. Company PS Metrics Related to Incident
Number of open MOCs
MOC action item aging
Process piping inspection aging
None of these metrics addressed monitoring
the technical performance aspects of MOC
that
th t contributed to the incident
t ib t d t th i id t
65
Top MOC Cultural Causal Factors
1. Establish process safety as a 7. Defer to expertise
core value
l 8. Ensure open and effective
2. Provide strong leadership communications
3. Establish and enforce high 9. Establish a
standards of performance questioning/learning
environment
4. Formalize the process safety
culture emphasis/approach 10. Foster mutual trust
5. Maintain a sense of 11. Provide timely response to
vulnerability safety issues and concerns
6. Empower individuals to 12. Provide continuous
successfully fulfill their safety monitoring of performance
responsibilities
66
33

34. MOC Failure Was a Root Cause
Several MOC failures occurred
Development – failure to account for change type
Rollout – precursors occurred during period
Operation – failure to recognize, failure to evaluate
Several safety culture issues were uncovered
that contributed to the MOC system failures
Lack of a sense of vulnerability
Failure to empower individuals
Lack of a questioning/learning environment
Normalization of deviance
67
Conclusions from Example
MOC is a critical PSM element
MOC performance management (audits) often
don't provide sufficient improvement information
We must examine MOC failure modes to support
continuous improvement
MOC failure prevention must consider "life-cycle
improvements
Culture and behavior issues MUST be addressed
for sustainable improvement
Leading indicators supported by frequent
management review are needed
68
34

35. Strategy for Process Safety
Performance Management
Evaluating PSM failure modes
Determining PSM failure culture causal factors
Ensuring sustainable PSM/HSE performance
improvement
Avoiding organizational warning signs
Critical success factors for PSM
69
How Does a Company Tell If It Is:
In a process safety ditch
On th d
O the edge of a ditch
f dit h
Getting closer to a ditch
Moving away from a ditch
Maintaining proper distance from a ditch
AVOID loss of visibility or fidelity in
performance evidence sources – maintain
a well-shaped and complete pyramid
70
35

36. Example of a Faulty Pyramid
Accidents
Incidents
Precursors
Management System Failures
Unsafe Behaviors and Attitudes
Culture – Individual and Organizational Tendencies
71
Recognizing Catastrophic
Incident Warning Signs in
the Process Industries
ISBN: 978-0-470-76774-0
264 pp
December 2011
US $125.00
$125 00
http://www.wiley.com/WileyCDA/WileyTitle/pro
ductCd-047076774X.html
72
36

37. Monitor Warning Signs – Company
Organizational change/stress without sufficient HSE
impact evaluation and mitigation
p g
External-induced
• Regulations, enforcement, economics, disasters, M&A
target, etc.
Internal-induced
• Competency, memory, resources, focus loss, initiative
overload, M&A,
overload M&A leadership instability demographics
instability,
shift, turnover, absenteeism
Loss of visibility/fidelity in performance evidence
sources – maintain a good pyramid
Poor reporting, trending, sharing, monitoring
73
Metrics Layered within the Pyramid
# of PS incidents Accidents
# of first aids
f fi t id
Severity rate Incidents
Number of Near Misses Reported
Precursors
HSE/PSM audit score
Number of Overdue Action Items
Corrective Actions Generated Management System
Safety Meeting Attendance, %
Training Completed, %
Failures
RC Contacts
Safety Inspections Completed, % Unsafe Behaviors and Attitudes
BBS at-risk observations
Trend incident and Culture – Individual and
management system Organizational Tendencies
technical and cultural
root causes as learning Conceive of cultural
opportunities occur weakness metrics to
collect across
© ABSG Consulting, Inc. company 74
37

38. Process Safety Metrics – Arendt Suggestions
1. Process Safety incidents – ANSI/API RP 754 Tiers 1 and 2
2.
2 Process Safety incident precursors – RP 754 Tier 3
3. Failure to follow procedures/SWPs – BBS at-risk
observation rate
4. Failure to fix identified process safety problems – action
item backlogs or aging, equipment deficiencies backlogs
5. Failure to identify process safety deficiencies– inspection
(all sources) backlog, failure to identify/report incidents or
do adequate RCA
6. Failure to assess risk– MOC circumvention or low quality,
PHA schedule backlog, PHA quality review
7. Safety culture weaknesses – Map RCs of incidents to
cultural causal factors
75
Emerging Challenges with PS Metrics
Don’t pick too many
Make sure they roll up properly
Make sure they add value
Don’t just pick things you can measure; make
certain they affect accident risk
Think through how you will use them; anticipate
unintended behaviors
Make them visible – positive culture influence
76
38

39. Characteristics of Good Process
Safety Companies
Not blind or arrogant – willing to look into the mirror
Safe questioning/learning environment
Proper safety ownership and leadership
Effective, fit-for-purpose management systems
Disciplined in execution - low/decreasing backlogs
Effective action - prevention not just correction
prevention,
Action at multiple levels of the pyramid
Builds better ownership and fosters a better culture
77
Characteristics of Good Process
Safety Companies (cont’d)
Learns lessons cheaply taught from all sources -
py g
avoids repeat teaching
Pursues effective continuous improvement – seeks
out better practices
High quality incident investigations
Proper process safety metrics and discerning
audits
Effective management review
78
39

40. Keys to Future Process Safety Success
To 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 at
Fit-for-purpose PSM/HSE system that is well-executed
Nurture culture and operating discipline
Create an effective learning organization
Apply root cause thinking to everything
Maintain an effective corrective action process
High quality incident investigations
Proper process safety metrics
Discerning audits
Effective management review
79
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 again
Do people remember it and the lessons
What have you done to embed it in your "lore"
What effective approaches still exist to prevent it
What do you have to protect against PS Alzheimers
Pick a notable event from another company or
industry - and do the same
Go up your chain-of-command and see how far
the “remembering” goes
80
40

41. “Perfect Process Safety”
Is a worthy and valuable goal
Can only be pursued by highly reliable
organizations that embody effective learning
patterns
Sustainable process safety does not allow
learning to evaporate or “retire”
Should be the stretch goal for all companies and
organizations
81
Swiss Cheese Model for Accident Causation
82
41

42. Time for Questions
sponsored by
In Search of “Perfect Process Safety”
How to Ensure Sustainable Continuous Improvement
Learning from the M
L i f th Macondo D
d Deepwater H i
t Horizon Bl
Blow O t
Out
August 21, 2012 Runcorn, UK
Steve Arendt, Vice President, P.E.
North America Process Industries
Organizational Performance Assurance Center
sarendt@absconsulting.com
42