Lessons Learned from the US Chemical Safety and Hazard Investigations Board presented at The IAEA International Conference on Human and Organizational Aspects of Assuring Nuclear Safety Exploring 30 Years of Safety Culture Presented by Mark Griffon Mark Griffon Consulting LLC February 24, 2016
WHAT IS THE CSB? An independent U.S. federal agency investigating chemical accidents promoting prevention public knowledge Authorized by Congress in 1990 Five Board Members; approximately 45 staff Modeled after NTSB Intent of CSB investigations are to get to root cause(s) and make recommendations toward prevention Not regulatory; no enforcement authority
CSB Investigation Approach Formal analysis to identify underlying technical, human factor, management system, organizational and regulatory causes of the incident. Beyond immediate technical events and individual actions Focus is on improving safety NOT assigning blame Addressing the immediate cause ONLY prevents that exact accident from occurring again.
PHYSICAL EVENTS AND CONDITIONS INDUSTRY CODES AND STANDARDS No requirement for ALARP LEGEND Refer to Chevron Interim Investigation Report Essential process safety analyses not required by regulator Regulatory regime reactive and activity-based rather than goal-based Regulators had little input into safety precautions in the refinery. Refer to Chevron Regulatory Report Refer to Chevron Final Investigation Report Regulator does not require or oversee safety culture assessment follow-up action items API does not require 100% component inspection Inconsistent API standards Minimal industry emergency leak response protocol requirements No formal method to communicate, implement, oversee and track to Thorough inherently safer Thorough No Damage completion ETC findings and systems analysis not safeguard Mechanism recommendations conducted in PHA evaluation not Hazard Review conducted in PHA performed Chevron reliability programs not effective to implement ETC Sulfidation Failure Assumption that Prevention Initiative non-inspected components were of sufficient Important safety projects not thickness brought to management rather 100% component inspection not in than IMPACT team for Richmond Inspection Plan No guiding emergency leak approval if outside framing response protocol in place document requirements OUTCOME CHEVRON Turnaround team relied Requests for on replacement or inspection 100% inspection data outside of framing document requirements Chevron Chevron No MOC did not allowed performed use API inspector to 574 to lower evaluate default alert risk of new values thickness T-Min Recommendations to replace or 100% inpect T-Min lowered so 4-sidecut 4-Sidecut line not could stay in operation implemented Increased sulfidation Line constructed of variable corrosion rates in lowsilicon carbon steel steel corrosion rate-prone carbon 4-Sidecut piping component was extremely thin Leak in 4-Sidecut line Flammable material released Low-silicon component not inspected Unit Consequences of potential metallurgists damage mechanisms were not were not evaluated Inspection data did consulted not indicate pipe was thin Stop Work uncommon Trust in for shutting management Risk of catastrophic down plant failure not perceived by decision makers Past practice is to keep running with Stop Work a small leak not called Decision to remove insulation to identify leak location rather than shut down unit Hot Zone not of sufficient size to protect Released personnel process fluid autoignited Oxygen People Ignition source present source 19 potential worker fatalities, 6 injuries, 15,000 people sought medical treatment CSB, Chevron Report, 2012
BP Texas City March 23, 2005 15 deaths and 180 injuries During startup, tower and blowdown drum overfilled Liquid hydrocarbon released, vapor cloud formed and ignited Explosion and fire
CSB Investigation Most extensive investigation in CSB history Conducted 370 interviews Reviewed over 30,000 documents Assessment of 5-years of electronic data from the computerized control board system Based on human factors framework (Reason, 1997) and methodologies used in investigations of other catastrophic incidents, such as Bhopal and Chernobyl
Baker panel findings BP had not provided effective process safety leadership BP had not established an open trusting relationship between management and the workplace Lack of a unifying process safety culture Personal Safety emphasis; not process safety Reliance on low LTIR gave misleading risk indicator Cost cutting pressures seriously degraded infrastructure Mgmt failed to assess impact of cost and staff reductions on safety
Safety Culture Attributes the degree to which the workforce feels empowered as to process safety the extent to which the workforce feels free to report safety-related incidents the process safety awareness, knowledge, and competency of the workforce; relationships and trust between different workforce / management and contractors whether deviations from policies and procedures are tolerated; the extent of information flow at all levels whether the workforce has a shared belief that safety comes first, regardless of financial, scheduling, or cost objectives; and the extent to which the workforce is vigilant about process safety risks, continuously tries to reduce them, and seeks to learn from incidents and near misses.
5+ Years Later.. Lessons Learned??
Macondo April 20 th, 2010 11 deaths > 60 injured ~5 million barrels of oil spilled in Gulf over 80+ days Tremendous Economic Impact
CSB Investigation Examine specifics of organizational factors Staffing and organizational structure (changes) Safety Metrics Awards and Bonuses Cost and Performance Pressures (cost and production goals) Human factors analysis of how mistakes occurred Reliance on human intervention Evidence / Explanations for inexplicable decisions leading up to the incident Control / display panels Decision making process
Macondo Safety Culture Government oversight must be accompanied by sweeping reforms that accomplish no less than a fundamental transformation of its safety culture (POSC) The lack of a strong safety culture resulting from deficient overall systems approach is evident in the multiple flawed decisions that led to the blowout. (NAE)
Chevron Refinery, Richmond, CA August 6, 2012 Flammable Vapor release and Fire 6 Injured ~ 15,000 sought medical treatment
California PSM Reform Employee Participation Process Safety Culture Assessment Human Factors Management of Organizational Change
10+ years after BP Texas City How are things going?
Maintaining Safe Production Cut exploration Reduce manning Reduce training <$50 Reduce maintenance Focus on today, not tomorrow? UK HSE, S. Mackenzie, 2015
Safety Performance Personal Process UK HSE, 2015
Cautions / Challenges the popularity of the concept has been counterproductive and there is a danger of it becoming meaningless (M. Fleming, Regulator s Guide to Safety Culture and Leadership ) Overemphasis on the sharp end (front line worker) rather than the blunt end (organizational / management) Risk Tolerance How is it defined and who defines it Safety culture study / change must consider inequalities of power and authority
Cautions / Challenges Unified safety culture vs. understanding different subcultures within an organization and optimizing how they work together Focus on Organizational Culture(s) influence on safety rather then Safety Culture Trusting and Reporting culture Look at the real effect of resource limitations on safety
Will Off-Shore Drilling and Refinery Safety be transformed like the Nuclear Industry? Nuclear Industry, post TMI, developed a real belief that if one of us fails, we all fail Nuclear Industry agreed to collect and share accident, near miss and indicator data (thru INPO) Unclear whether same climate exists in Oil and Gas Industry Deepwater was just a rogue operator Sharing of lessons learned, accident data, and near miss data is limited Reaction to the price of oil Public Reaction
Thank You