N cann haz aus 2013 mo c final
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Lessons from a Management of Change incident utilizing AcciMap to identify causes to address including: Management of change system, Utilitiy connections to process, regulatory oversight and training
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N cann haz aus 2013 mo c final
- 1. Lessons from a Management of Change Incident Nigel Cann, Arup FIChemE, CEng, CEnv, RPEQ Nigel.cann@arup.com
- 2. 2 What we will cover… • Timing of incident • Plant process • Plant Layout • Incident Event • AcciMap of Incident • Actions that followed • What questions do you have? Agenda
- 3. 33 Incident Timing Timing 5 Oct 98 – I started
- 4. 4 Production Process STRIPPING COLUMN DEGASSER AUTOCLAVES STEAM ADDITIVES VCM TANKER CHARGE WATER VCM GAS HOLDER LIQUID VCM STORAGE VCM RECOVERY PLANT BAGGING AND PALLETIZING BULK SUPPLY SLURRY TANK STORAGE SILO FLUID BED DRYER CENTRIFUGE PACKAGED SUPPLY Production Process
- 6. 6 Layout
- 7. 7
- 9. 9 AcciMap – Modification Control Incident AcciMap of Modification Control Incident Accident Sequence Governance / Organisational Regulatory Outcomes 3500kg VCM LoC via steam trapsVCM is in Utility Steam System Operator missed H2O/VCM interface Disperses in atmosphere or absorbed in water spray Human and Environmental Factors Was Operator present? Liquid VCM in Receiver Reliance on NRV Cold weather – autumn night 1. Poor Mod Control paper based system Lower SEPP VCM boundary limits 1. HAZOP boundary not including existing plant when additional capacity added 3. Poor Regulatory Oversight Back pressure in Receiver Orifice Plate inserted when additional production stream added Equipment and Design Steam used to scrub Receiver Water Orifice Plate blocked by ice Block in VCM vapour line to Recovery Water mostly in other Recovery Tank Operator observation of difficult venting not addressed 4. Loss of Plant learning culture 2. Utilities connected to Process Organisation focus on Environmental Improvements
- 10. 10 AcciMap of Modification Control Incident Accident Sequence Governance / Organisational Regulatory Outcomes 3500kg VCM LoC via steam trapsVCM is in Utility Steam System Operator missed H2O/VCM interface Disperses in atmosphere or absorbed in water spray Human and Environmental Factors Was Operator present? Liquid VCM in Receiver Reliance on NRV Cold weather – autumn night 1. Poor Mod Control paper based system Lower SEPP VCM boundary limits 1. HAZOP boundary not including existing plant when additional capacity added 3. Poor Regulatory Oversight Back pressure in Receiver Orifice Plate inserted when additional production stream added Equipment and Design Steam used to scrub Receiver Water Orifice Plate blocked by ice Block in VCM vapour line to Recovery Water mostly in other Recovery Tank Operator observation of difficult venting not addressed 4. Loss of Plant learning culture 2. Utilities connected to Process Organisation focus on Environmental Improvements
- 11. 1. Modification Control System • Development of Electronic system • Checksheet and reviewer inputs requiring comments • Authoriser provided details of comments, usually assigned conditions • Details of HAZOP and Review actions assigned and followed up via Actions Review • Notifications via email • Pre-commissioning and Post commissioning checks. • OH&S signoff 1. Poor Mod Control paper based system 1. HAZOP boundary not including existing plant when additional capacity added 11 Modification Control System
- 12. 12 AcciMap of Modification Control Incident Accident Sequence Governance / Organisational Regulatory Outcomes 3500kg VCM LoC via steam trapsVCM is in Utility Steam System Operator missed H2O/VCM interface Disperses in atmosphere or absorbed in water spray Human and Environmental Factors Was Operator present? Liquid VCM in Receiver Reliance on NRV Cold weather – autumn night 1. Poor Mod Control paper based system Lower SEPP VCM boundary limits 1. HAZOP boundary not including existing plant when additional capacity added 3. Poor Regulatory Oversight Back pressure in Receiver Orifice Plate inserted when additional production stream added Equipment and Design Steam used to scrub Receiver Water Orifice Plate blocked by ice Block in VCM vapour line to Recovery Water mostly in other Recovery Tank Operator observation of difficult venting not addressed 4. Loss of Plant learning culture 2. Utilities connected to Process Organisation focus on Environmental Improvements
- 13. 13 2. Remove Utilities from Process • Utility steam and air not intended for connection to process streams • Generally lower pressure than process units can get • Process streams need proper pressure and or flow control – NRV’s fail • (This was another indicator of loss of integrity originally designed in). 2. Utilities connected to Process Utilities
- 14. 14 AcciMap of Modification Control Incident Accident Sequence Governance / Organisational Regulatory Outcomes 3500kg VCM LoC via steam trapsVCM is in Utility Steam System Operator missed H2O/VCM interface Disperses in atmosphere or absorbed in water spray Human and Environmental Factors Was Operator present? Liquid VCM in Receiver Reliance on NRV Cold weather – autumn night 1. Poor Mod Control paper based system Lower SEPP VCM boundary limits 1. HAZOP boundary not including existing plant when additional capacity added 3. Poor Regulatory Oversight Back pressure in Receiver Orifice Plate inserted when additional production stream added Equipment and Design Steam used to scrub Receiver Water Orifice Plate blocked by ice Block in VCM vapour line to Recovery Water mostly in other Recovery Tank Operator observation of difficult venting not addressed 4. Loss of Plant learning culture 2. Utilities connected to Process Organisation focus on Environmental Improvements
- 15. 15 3. Exemplar Safety Case Program • Recognition needed to do something different • Would need to do it twice • Capture corporate knowledge • Wanted to be a leader • It was an unknown quantity • Opportunity to learn and share lessons Exemplar Safety Case 3. Poor Regulatory Oversight
- 16. 16 AcciMap – Modification Control Incident AcciMap of Modification Control Incident Accident Sequence Governance / Organisational Regulatory Outcomes 3500kg VCM LoC via steam trapsVCM is in Utility Steam System Operator missed H2O/VCM interface Disperses in atmosphere or absorbed in water spray Human and Environmental Factors Was Operator present? Liquid VCM in Receiver Reliance on NRV Cold weather – autumn night 1. Poor Mod Control paper based system Lower SEPP VCM boundary limits 1. HAZOP boundary not including existing plant when additional capacity added 3. Poor Regulatory Oversight Back pressure in Receiver Orifice Plate inserted when additional production stream added Equipment and Design Steam used to scrub Receiver Water Orifice Plate blocked by ice Block in VCM vapour line to Recovery Water mostly in other Recovery Tank Operator observation of difficult venting not addressed 4. Loss of Plant learning culture 2. Utilities connected to Process Organisation focus on Environmental Improvements
- 17. 17 4. Training and Development • First Aid • Emergency • Chemical Awareness • Fire Fighting • Working at Heights • Permit to Work • Critical Systems Training 4. Loss of Plant learning culture • OH&S Legislation • Natural Gas, Boilers and Water Quality • Project Management
- 18. 18 Internal Audit - 2007 • 1 months MoCs 6 months previous • Automated system functioning well and well accepted. • Mods allocated appropriate process • Mods allocated to correct personnel for review • Implementers frustrated at time to close out: • Procedures, drawings, training materials • Less concerned at safety checks and hit sheets • Changes to personnel were going through formal review processes • Small number of personnel had not completed training Internal Audit
- 19. 19 Summary – Process Safety Control Process Safety Fundamentals Process Safety Control Inherent Design Safety
- 20. 20 What QUESTIONS do you have? Questions
Editor's Notes
- 12 May 1999 2nd Paper – 14:15 – Grand Ballroom Nth – Trish Kerin – Session starts 12:30 pm – 4th paper
- Layout of plant benefitted from: Designed early 70’s Flixborough Discovery of link between VCM and angiocarcinoma of liver The late Trevor Kletz left his footprint