Serious Incident Prevention: How to Sustain Accident-Free Operations in Your Plant or Company

213 Pages·2002·5.68 MB·English

by  Thomas Burns

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Serious
Incident
Prevention
How to Achieve and Sustain
Accident-Free Operations in
Your Plant or Company
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Serious
Incident
Prevention
How to Achieve and Sustain
Accident-Free Operations in
Your Plant or Company
SECOND EDITION
THOMAS E. BURNS
an imprint of Elsevier Science
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Gulf Professional Publishing is an imprint of Elsevier Science.
Copyright © 2002, Elsevier Science (USA). All rights reserved.
No part of this publication may be reproduced, stored in a retrieval system, or
transmitted in any form or by any means, electronic, mechanical, photocopying,
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Recognizing the importance of preserving what has been written, Elsevier
Science prints its books on acid-free paper whenever possible.
Library of Congress Cataloging-in-Publication Data
Burns, Thomas, 1946-
Serious incident prevention : how to achieve and sustain accident-free
operations in your plant or company / Thomas E. Burns.—2nd ed.
p.cm.
Includes bibliographical references and index.
ISBN 0-7506-7521-7 (alk. paper)
1. Industrial safety. 2. Accidents—Prevention. I. Title.
T55 .B83 2002
658.3’82—dc21 2001058497
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Printed in the United States of America
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Dedicated to America’s unsung heroes:
Men and women who help prevent tragic
events before they occur through their daily
commitment to the prevention of serious,
high-consequence incidents.
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DISCLAIMER
The information contained in this publication consists of facts, con-
cepts, principles, and other information for developing and implementing
a strategy for preventing serious incidents. This information is intended to
provide general guidance in the development of effective safety-manage-
ment processes. The information presented is not specific to the opera-
tions of any company, facility, unit, process, system, or equipment, and
neither the author nor publisher assumes any liability for its use.
The information provided in this publication is not a substitute for
company, facility, or unit-specific operating and maintenance procedures,
checklists, equipment descriptions, safety practices, etc. DO NOT attempt
to operate any facility, unit, process, system, or equipment based solely
upon the information provided in this publication.
............................................D...I.S..C...L.AIMER
Preface................................................................ ix
1 The Improvement Challenge ......................... 1
Serious Incidents of the Past........................................ 3
References................................................................... 18
2 The Barriers to Improvement ........................ 21
A Focus on Today’s Problems ..................................... 22
Limited Employee Involvement .................................... 22
Inadequate Measurement and Feedback..................... 23
Inadequate Recognition ............................................... 24
Limited Line Organization Ownership .......................... 25
Limited Personal Experience........................................ 25
Misguided Optimism..................................................... 26
Overcoming the Barriers .............................................. 27
References................................................................... 28
3 A Proven Process Improvement Model........ 29
Process Model For Serious Incident Prevention .......... 32
References................................................................... 36
4 Management Commitment and
Leadership ......................................................... 37
Achieving and Sustaining Effective Leadership ........... 40
Achieving a Common Focus ........................................ 42
Allocation of Resources................................................ 43
Knowledge of Results................................................... 43
Reinforcement of Performance .................................... 44
Decisions Consistent with Objectives........................... 44
Commitment and Leadership - Closing Thoughts........ 46
References................................................................... 47
5 Employee Involvement................................... 48
Synergy ........................................................................ 50
Prison Break Exercise.................................................. 52
Teamwork..................................................................... 53
An OSHA Perspective on Employee Participation ....... 54
Leveraging the Power of Employee Involvement......... 55
References................................................................... 59
Employee Involvement on Teams ................................ 60
6 Employee Involvement - Developing
Teamwork........................................................... 60
Effective Teamwork Techniques .................................. 61
References................................................................... 67
7 Understanding the Risks ............................... 68
Do Managers Understand the Risks? .......................... 69
Small Boat Operation: An Illustration of Risks.............. 71
Understanding More Complex Risks............................ 72
A Systematic Process of Risk Identification ................. 74
Understanding the Role of Human Error...................... 76
Classifying and Prioritizing Risks.................................. 78
Understanding the Risks - A Prerequisite for
Success........................................................................ 81
References................................................................... 82
Managing Similar Risks with Varying Levels of
Success........................................................................ 83
8 Identifying the Critical Work.......................... 83
Beyond Regulatory Compliance................................... 86
Identifying Critical Work................................................ 87
Causal Factors for Serious Incidents ........................... 88
Critical Work for a Tank Car Loading Operation........... 89
Sustaining Performance ............................................... 91
A Systematic, Knowledge-Based Approach................. 93
Process Safety Management Standard........................ 94
References................................................................... 95
9 Identifying the Critical Work -
Management of Change.................................... 96
Unplanned Changes..................................................... 97
Planned Changes......................................................... 99
Management of Change in the Serious Incident
Prevention Process ...................................................... 101
References................................................................... 102
10 Establishing Performance Standards......... 103
Corporate/Company Standards.................................... 105
Facility/Operating Level Standards .............................. 106
Explicit and Implicit Standards ..................................... 108
Standards - A Prerequisite for Measurement,
Feedback, and Accountability ...................................... 109
References................................................................... 110
11 Measurement and Feedback ....................... 111
Performance Accountability.......................................... 113
Performance Measurement for Critical Work ............... 113
Feedback and Its Linkage to Reinforcement................ 120
Elevating the Visibility of Critical Work ......................... 121
Characteristics of Effective Measurement and
Feedback Systems....................................................... 122
Measurement Systems................................................. 122
Feedback Systems....................................................... 123
Types of Measurement and Feedback Systems .......... 124
Safety Performance Indexing ....................................... 124
Essential to the Process............................................... 125
References................................................................... 125
12 Measurement and Feedback - Safety
Performance Indexing....................................... 126
Establishing a Safety Performance Index for
Prevention of Serious Incidents.................................... 127
References................................................................... 140
Reinforcement.............................................................. 141
13 Reinforcement and Corrective Action ........ 141
Corrective Action.......................................................... 148
Addressing Causal Factors .......................................... 148
Responding to Red Flags............................................. 149
References................................................................... 152
14 Improving and Updating the Process......... 153
Shared Vision............................................................... 155
Organizational Learning ............................................... 156
Employee Involvement................................................. 156
Transforming Concepts to Actions ............................... 157
References................................................................... 158
Management Commitment and Leadership ................. 159
15 Applying the Process Model - A Case
Study................................................................... 159
Implementing Other Process Elements........................ 161
Chemical Handling Department Team ......................... 162
Chemical Handling Department Pipeline Operations ... 167
Chemical Handling Department: Tank Storage
Operations.................................................................... 178
Chemical Handling Department: Warehouse
Operations Team.......................................................... 179
Manufacturing Department - Serious Incident
Prevention Processes .................................................. 182
HSE - Serious Incident Prevention Processes............. 183
QMI Site Management Team: Serious Incident
Prevention .................................................................... 187
Benefits Achieved from the Serious Incident
Prevention Process ...................................................... 189
References................................................................... 189
16 Responding to the Challenge...................... 190
Keys for Successful Implementation ............................ 192