Serious Incident Prevention. How to Achieve and Sustain Accident-Free Operations in Your Plant or Company

200 Pages·2002·2.82 MB·English

by  Thomas E. Burns

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Riding a wave is easy; starting a wave is a much more ambitious
task. My objective for the first edition of Serious Incident Prevention,
published in 1999, was to start such a wave. The book communicated a
vision for breakthrough levels of improvement in the prevention of seri-
ous incidents through safety management processes that incorporate the
critical elements required for success. The old approach tends to focus on
compliance with OSHA, DOT, EPA, or other regulatory requirements as
the primary basis for an effective process. The new wave recognizes the
critical need for increasing employee involvement and ownership, devel-
oping improved measures and feedback systems, improving the quantity
and quality of recognition, and incorporating other proven performance
management principles into the safety management process.
It is satisfying to see that the ripples have started to grow in number
and strength. Line managers, safety professionals, and others are show-
ing increased understanding and appreciation for the need to take a more
effective, systematic approach in preventing serious incidents. Programs
previously focused on regulatory compliance are being adjusted to in-
clude other critical actions required for success. Feedback from industry
and other organizations continues to reinforce that the same performance
management principles that have proven effective in improving quality
ix
and other key organizational performance indicators are the key to achiev-
ing and sustaining improved safety results.
My 28-year career with Eastman Chemical Company involved manag-
ing safety-related risks from the perspective of both operations management
positions and as Eastman's Texas Division Safety Director. During my ca-
reer with Eastman, company honors included winning the Malcolm
Baldrige National Quality award, STAR recognition through OSHA's
Voluntary Protection Program (VPP), and receipt of the Texas Chemical
Council's prestigious "Best in Texas" award. The serious incident preven-
tion process model, as presented in this publication, was developed through
the merging of proven performance management principles with sound risk
management practices that include the lessons learned during my nearly
three decades of experience. The eight-element safety management model
has proven effective for all organizational levels~top management through
first-level operating teams. It is a model for operational excellence~a
proactive, team-based approach for sustaining serious incident free opera-
tions.
Managers tend to be energized by a limited number of events~typi-
cally, either by a crisis or by proactive recognition of a significant opportu-
nity. While a crisis emits alarm signals that cannot be ignored, opportunities
are not as easy to detect. The objective of this publication is to clearly com-
municate the significant opportunity for improvement and to provide a sys-
tematic, straightforward approach for development and implementation of
more effective safety management processes. With the catastrophic conse-
quences of serious incidents, initiation of management action si clearly
preferable in the opportunity stage rather than in the crisis stage that ac-
companies the occurrence of an incident. For organizations ready to recog-
nize and act upon opportunity, the chapters that follow provide a vision and
road map for a safer, more prosperous future.
Thomas Burns, PE, CSP
SIP Management Systems, Inc./Quality Safety Edge
PO Box 3743
Longview, Texas 75606
(903) 238-9360
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Our individual perspectives are shaped by past experiences. Two seri-
ous incidents involving fatalities and major property damage occurred
during the early years of my career. These tragedies left me with a clear
understanding of the need for more effective serious incident prevention
processes. I've also come to understand that much of the work necessary
to sustain incident-free operations is of low visibility often performed in
the trenches of the organization. It is a paradox that this low-visibility
work has profound implications for the organization's highest-priority per-
formance indicators, including profitability, customer satisfaction, safety,
environmental performance, and public image.
My career with Eastman Chemical Company began in 1969 with an
assignment as a process improvement engineer in Eastman's Texas
Division polyethylene manufacturing facility in Longview. Eastman had
operated high-pressure polyethylene reactor lines since the mid-1950s.
However, as with many chemical plants of that era, the polyethylene plant
did not always run smoothly. Full understanding and control of the manu-
facturing process was still evolving at the time I joined the company.
Employees new to the polyethylene facility were often on the listening
end of stories repeated by plant operators. Many stories were of past inci-
dents that had potential to be major events, but through a phenomenon
2 II Serious Incident Prevention
known as "Eastman luck" were mitigated without significant consequences.
Having heard the stories of past near misses, I immediately thought of the
polyethylene unit when my apartment shook in the early morning of
February 25, 1971. It was the day "Eastman luck" ended. To researchers the
event is now simply a line item on a long list of worldwide vapor cloud ex-
plosions in the past half-century:
25 Feb. 1971 ... Longview, Texas... Polyethylene facility.., ethylene
(450 kg) ... 0.5 tonnes TNT. . . 10% Yield... $17.5M Property Damage
(1991 Value)... 3 Dead
Leak from 12mm pipe connection to large pipe at 572 Mpa. Three
explosions occurred. Second saw .esrow
Some confinement by barricades and building around .yawyella
Explosion felt 6.9 km .yawa ~
oT those directly involved, the magnitude of this 1971 incident was
sobering, and its occurrence, despite the vigilance of a committed manage-
ment team, made a lifelong impression. Such events raise doubts about
human capabilities to successfully control technology. With improved man-
agement processes, however, Eastman's polyethylene manufacturing units
have now completed more than a quarter century without a major incident.
Rather than "war stories," new employees now hear success stories of im-
provements in product quality, equipment reliability, customer satisfaction,
and safety.
After completing three years as a process improvement engineer, I
began a supervisory assignment with responsibilities for the polyethylene
warehousing and shipping functions. The assignment served as an intro-
duction to the challenges of sustaining manual handling operations in an in-
jury-free manner. The experience continually reinforced the inadequacy of
simply exhorting workers to "be more careful." I quickly developed and
have continued to maintain a favorable bias towards minimizing hazards
through improving the process.
I was later transferred to Eastman's polypropylene manufacturing facil-
ity as manager of the polypropylene processing unit. During this assign-
ment, another major incident occurred at the Texas Division site~further
reinforcing the need for more effective incident prevention processes. This
time, the incident involved an ethylene release from the ethyl alcohol man-
ufacturing unit:
The Improvement Challenge n
15 Oct. 1976... Longview, Texas... Ethyl alcohol facility.., ethylene
... $26.1MProperty Damage (1991 Value)... 1 Dead
Failure of mixing nozzle led to jet of ethylene directed into courtyard
between control room, process structure and pipe rack. Ignition by heaters
45 m away. Control room destroyed. Pipe breakage led to ensuing fire
damage. 2
During my years as safety director, major changes occurred in the chemi-
cal industry. The Bhopal, India, incident in 1984 triggered numerous initia-
tives, including OSHA special emphasis programs targeted for chemical
facilities (ultimately leading to the OSHA Process Safety Management stan-
dard), the establishment of Chemical Manufacturers Association Responsible
Care initiatives, and more active EPA involvement in process safety issues.
Despite the many opportunities to learn from past incidents and additional reg-
ulatory actions, serious injuries continue to occur on a much-too-frequent
basis.
Serious Incidents of the Past
News reports of failures to sustain safe operations have a special impact
on individuals with responsibilities for preventing serious incidents.
Reactions to the initial reports can vary from disdain to empathy, depend-
ing upon the initial details provided.
(cid:12)9 After experiencing a major incident resulting in multiple fatalities
and property damage in excess of $200 million, a facility spokesper-
son made the following statement: "It's been a relatively safe plant.
We've had numerous safety awards over the years. This is just dev-
astating. 3''
(cid:12)9 A press release following the occurrence of an explosion at another
company emphasized that OSHA had conducted seven facility in-
spections, all with zero violations, in the months preceding the inci-
dent. 4
A report from the National Transportation Safety Board indicated
that the crash of a commercial plane departing from a Houston air-
port was caused by failure to reinstall 47 screws in the plane's tail
section following maintenance. 5 One year later, another flight by the
airline required an emergency landing due to excessive vibration.
4 II Serious Incident Prevention
Investigators found the cause to be another failure to reinstall wing
6.swercs
(cid:12)9 In Hamlet, North Carolina, 25 people died in a chicken processing
plant fire because designated emergency exit doors were locked. 7
(cid:12)9 In Houston, Texas, an inadequately trained night clerk silenced the
switchboard buzzer indicating the need to activate the hotel's fire
alarm system because "the noise annoyed him." Ten people were
killed and 30 injured in the blaze. 8
(cid:12)9 In Dallas, Texas, three construction workers died when a crane col-
lapsed. At the time of collapse, the workers were positioned along the
crane boom approximately 21 stories above the ground. After re-
moving an 80-foot section from the front of the boom, the workers
apparently failed to remove the proper number of concrete counter-
weights to keep the structure in balance prior to swinging the boom, 9
(cid:12)9 In a Florida hospital, doctors mistakenly amputated the left leg of a
diabetic instead of the right leg as scheduled. With corrective sur-
gery, the patient became a double amputee. Eleven days later in the
same hospital, a patient died when a respiratory technician unhooked
the wrong patient. ~~
(cid:12)9 At a major university, 21 students died and dozens of others were in-
jured when a massive bonfire of traditional but suspect design col-
lapsed during construction. ~
Since the mid-1980s, industry and many service organizations have
made great strides in improving performance in key areas including prod-
uct quality, customer service, productivity and cost control. Progress has
often been driven out of necessity to recapture market share and improve
profitability in the face of fierce competition. Performance management
principles including teamwork, empowerment, employee participation,
measurement, feedback, and positive reinforcement of individuals and
teams have been a cornerstone of the improvement process.
Is the progress in preventing serious safety-related incidents consistent
with the breakthrough levels of improvement achieved in other key per-
formance areas? Evidence indicates that progress has been less than stellar.
For example, a 30-year analysis of 100 large property damage losses oc-
curring in the hydrocarbon-chemical industry (Figures 1-1 and 1-2) indi-
cates that the frequency of incidents has remained high compared to
long-term historical levels. It is clear that breakthrough levels of improve-
ment have not been achieved. Serious incidents have continued to occur and
impact key company performance areas: safety, financial performance, em-
ployee relations, customer service, and company image.
The Improvement Challenge II 5
FIGURE 1-1. An analysis of 001 large hydrocarbon-chemical industry property
damage losses: 1967-1996. From J&H Marsh & McLennan, Inc. 21
FIGURE 1-2. An analysis of 001 large hydrocarbon-chemical industry property
damage losses: 1967-1996. From J&HMarsh & McLennan, Inc. 31
6 I Serious Incident Prevention
FIGURE 1-3. Annual number of fatal occupational injuries. Bureau of Labor
Statistics 61
The analysis, involving losses originating primarily from fires and ex-
plosions, indicates an average loss of $76 million per incident for property
damage alone--excluding the costs of business interruption, fines, penal-
ties, employee injuries, liability claims and other expenses. Many of the in-
cidents resulted in business interruption losses that far exceeded the total
for property damage, with one single incident resulting in a business inter-
ruption loss totaling $700 million.
MT
Although the analyses in Figures 1-1 and 1-2 are focused on the chem-
ical, oil refining, and gas processing industries, the opportunities for im-
provement in preventing serious incidents are not limited to any specific
industry or business. For example, as illustrated by Figure 1-3, the rate of
fatal occupational injures for all private businesses showed little improve-
ment during the decade of the 1990s. 5~ Although OSHA delights in empha-
FIGURE 1-4. Rail yard accident rate yard-switching per million 1 miles .0002-1991
From U.S. Department of Transportation, Federal Railroad Administration 71
The Improvement Challenge II 7
FIGURE 1-5. Large-loss fires that caused 5$ million or more in property dam-
age, 1991-1999 adjusted to 1990 dollars. 81
sizing that workplace fatalities are now about 60 percent lower than the
14,000 annual fatalities occurring when the agency was enacted in 1971, the
trend of the 1990s clearly indicates that the performance of businesses in
preventing fatalities is stuck on a plateau.
FIGURE 1-6. Causes of hydrocarbon-chemical industry property damage losses:
1967-1996. From J&H Marsh & McLennan, Inc. 91
8 I Serious Incident Prevention
FIGURE 1-7. Analysis of causes for large hydrocarbon/chemical property dam-
age losses 1967-1996.
The rail industry provides another example of where there has been no
improvement, and in fact an increasing rate of fatalities. As illustrated by
Figure 1-4, the rate of rail yard accidents, including serious injury and prop-
erty damage incidents, has increased from ! 4.4 accidents per million yard-
switching train miles in 1991 to 18.2 accidents in 2000~an increase of
about 26 percent.
The lack of significant improvements in the prevention of large-loss fires,
despite great strides in fire-fighting technology, is yet another example of the
need for improved management processes. Figure 5-1 illustrates that the num-
ber of fires causing $5 million or more in property damage has remained rel-
atively flat even when adjusted for inflation. Certainly, there is ample
evidence, based on fatality rates, property damage, and otherp erformance in-
dicators, that an improved, more effective approach is needed to reduce seri-
ous incidents.
Although the "all accidents are preventable" theme is often repeated by
managers, the degree to which management control can prevent serious in-
cidents is a valid question. Are such incidents truly uncontrollable, or do
their paths typically include opportunities for prevention through proactive
actions?
An evaluation of hydrocarbon-chemical property damage losses ~2 indi-
cates causes that are generally controllable account for about 80 percent of
past serious incidents (Figures 1-6 and 1-7). These generally controllable
causes include mechanical failure (43 percent), operational error (2i per-
cent), process upsets (11 percent), and design error (5 percent). The cate-
gories of natural hazards and sabotage, which might be considered