Guidelines for Managing Abnormal Situations

The book discusses why management of abnormal situations is important to process safety. The book provides guidance on practical steps to avoid or mitigate an accident or incident before it escalates into a more dangerous and costly issues which can include downtime, lost production, equipment damage, injuries, and external/ environmental damage. Through the use of case studies the book illustrates the impact these deviant occurrences can have on operating facilities. Management principles that can be established before an issue occurs are presented while case studies are used to illustrate the impact that an abnormal situation can have on an operating facility. The impact of plant design are detailed, with separate focus points on new plant design and retrofits to existing plants. A section on writing plant procedures and plant policies so that they incorporate the principles of managing abnormal situations is also included. Training content is provided on how to manage deviant situations, with guidance on presenting the information to specific target populations, such as front-line operators, operations managers, plant engineers, and process safety engineers. Readers are also shown tools that are currently available for recognizing and responding to abnormal situations, and actions that process safety engineers can use during Hazard Identification and Risk Analysis (HIRA). Cover 1 Title Page 5 Copyright 6 TABLE OF CONTENTS 7 LIST OF FIGURES 13 LIST OF TABLES 15 LIST OF EXAMPLE INCIDENTS 17 ACRONYMS AND ABBREVIATIONS 19 GLOSSARY 23 ACKNOWLEDGMENTS 33 PREFACE 37 DEDICATION 38 1 INTRODUCTION 39 1.1 Purpose and Scope of the Book 39 1.2 What Are Abnormal Situations? 40 1.3 The Business Case for Managing Abnormal Situations 42 1.4 Content and Organization of the Book 43 2 PROCESS SAFETY AND MANAGEMENT OF ABNORMAL SITUATIONS 47 2.1 Impact on Process Safety 47 2.2 The Case for Positive Management of Abnormal Situations 49 2.3 Adverse Outcomes of Abnormal Situations 51 2.4 Importance of Training for Abnormal Situations 60 2.5 Safety Culture and the Management of Abnormal Situations 61 3 ABNORMAL SITUATIONS AND KEY RELEVANCE TO PROCESS PLANT OPERATIONS 65 3.1 Focus Areas for Abnormal Situation Management 65 3.1.1 ASM Research Areas 65 3.1.2 Additional Focus Areas 68 3.2 Abnormal Situations Affecting Process Plant Operations 70 3.2.1 Process Control Systems –the First Line of Defense 78 3.2.2 Frontline Operators 82 3.3 Management of Abnormal Situations and Links to Risk Based Process Safety 86 3.3.1 Commitment to Process Safety 88 3.3.2 Understand Hazards and Risk 88 3.3.3 Manage Risk 88 3.3.4 Learn from Experience 89 3.3.5 Additional RBPS Elements Related to Management of Abnormal Situations 90 3.4 Procedures and Operating Modes for Managing Abnormal Situations 91 3.4.1 General Principles for Procedure Development 91 3.4.2 Operating Modes 96 3.4.3 Types of Material Being Processed 116 4 EDUCATION FOR MANAGING ABNORMAL SITUATIONS 123 4.1 Educating the Trainer 123 4.2 Primary Target Populations for Training 124 4.2.1 Front-line Operators 125 4.2.2 Operations Management 127 4.2.3 Plant Engineers/Technicians 128 4.2.4 Process Safety Engineers 129 4.2.5 Design Engineers 129 4.2.6 Environmental Health, Safety and Security (EHSS) Personnel 138 4.2.7 Technical Experts 138 4.2.8 Other Parties 140 4.3 Guidance for Organizing and Structuring Training 140 4.3.1 Organization of Training 140 4.3.2 Structure of Training Topics 141 4.3.3 Skills and Competencies of Trainers 144 4.4 Summary 144 5 TOOLS AND METHODS FOR MANAGING ABNORMAL SITUATIONS 145 5.1 Tools and Methods for Control of Abnormal Situations 146 5.2 Predictive Hazard Identification 150 5.2.1 Hazard Recognition for Abnormal Situations 151 5.2.2 HIRA Approach to Hazard Prediction 151 5.3 Process Control Systems 153 5.3.1 Process Trend Monitoring 155 5.3.2 Alarm Management 157 5.3.3 Big Data 160 5.3.4 Advanced Diagnostics and Artificial Intelligence 161 5.4 Policies and Administrative Procedures 162 5.4.1 Expectations of Policies and Administrative Procedures 164 5.4.2 The Relationship of Policies to Abnormal Situation Management 164 5.4.3 Process Metrics 167 5.5 Operating Procedures 168 5.5.1 Standard Operating Procedures 169 5.5.2 Emergency Procedures 170 5.5.3 Transient Operation Procedures 171 5.5.4 Preparing Written Procedures 172 5.6 Training and Drills 173 5.7 Ergonomics and Other Human Factors 177 5.7.1 HMI (Human Machine Interface) System 178 5.7.2 Control Room Ergonomics/ Human Factor Assessment 180 5.7.3 Crew Resource Management 181 5.8 Learning from Abnormal Situation Incidents 185 5.9 Change Management 187 5.9.1 Management of Change Guideline Tools 188 5.9.2 Management of Organizational Change 191 5.9.3 Pre-Startup Safety Review 192 6 CONTINUOUS IMPROVEMENT FOR MANAGING ABNORMAL SITUATIONS 193 6.1 General 193 6.2 Landscape of Available Metrics for Improvement 194 6.3 Abnormal Situations and Incident Investigations 196 6.4 Auditing 197 6.5 Management Review and Continuous Improvement 200 6.6 Summary 201 7 CASE STUDIES/LESSONS LEARNED 203 7.1 Case Study 7.1 – Air France, 2009 204 7.1.1 Background 204 7.1.2 Incident Overview – Air France AF 447 207 7.1.3 Speed Measurement on A330 Aircraft 207 7.1.4 A330 Flight Control Systems 209 7.1.5 Airbus Pitot Tube History 211 7.1.6 The Incident - Air France AF 447 211 7.1.7 Lessons Learned Relevant to Abnormal Situation Management 216 7.1.8 Epilogue 220 7.2 Case Study 7.2 – Texaco Refinery, Milford Haven, Wales, July 1994 222 7.2.1 Background 222 7.2.2 Incident Overview – Texaco Milford Haven 223 7.2.3 Outline Process Description of Milford Haven Refinery 224 7.2.4 Controls and Instrumentation 226 7.2.5 Some Relevant History at the Refinery 227 7.2.6 The Incident 228 7.2.7 Immediate Cause 231 7.2.8 Lessons Learned Relevant to Abnormal Situation Management 231 7.2.9 Epilogue 236 7.3 Case Study 7.3 – The Hickson And Welch Fire, 1992, Castleford, UK 237 7.3.1 Background 237 7.3.2 Incident Overview – Hickson and Welch fire 238 7.3.3 Outline Process Description of Meissner Plant 239 7.3.4 History of Meissner Plant Prior to Incident 241 7.3.5 The Incident 243 7.3.6 Immediate Causes 244 7.3.7 Lessons Learned Relevant to Abnormal Situation Management 245 7.3.8 Epilogue 248 APPENDIX A Managing Abnormal Situations – Training Materials 249 APPENDIX B ASM Joint Research and Development Consortium: Background 251 REFERENCES 253 INDEX 263 EULA 266 "Abnormal situations within the process industry occur when there is a disturbance in a process where basic process control system cannot cope. In the context of hazard evaluation procedures this can be viewed as a deviation. Abnormal situations that developed or occurred have resulted in adverse events that could have been prevented. Process plants often rely on complex control systems along with various tools and techniques including intelligent system to help manage such issue. However, such automated solutions are not always effective and can worsen the occurrence, particularly when it leads to confusion on the part of the operators. Some of the events are associated with non-typical conditions can be identified and managed through careful consideration as to how they may occur and by developing methods to prevent or mitigate the consequences of an event"-- Provided by publisher