Major Hazard Facilities
Introduction to Safety Report
Some Abbreviations and Terms
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AFAP - As far as practicable
BPCS – Basic process control system
Employer - Employer who has management control of the
facility
FTA – Fault tree analysis
HAZOP – Hazard and operability study
HSR - Health and safety representative
LOPA – Layer of protection analysis
MHF - Major hazard facility – as defined in the regulations
MA - Major accident
OHS -Occupational health & safety
QRA – Quantitative Risk Assessment
SMS - Safety management system
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Topics Covered in This Presentation
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Introduction
Key principles and objectives of the MHF regulations
Why is a Safety Report needed?
What is the Safety Report?
What must the Safety Report do?
Main components of the Safety Report
Hazard identification
Safety assessment
Risk controls
Emergency response plans
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Topics Covered in This Presentation
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Demonstration (of adequacy)
What else is in the safety report?
MHF regulations versus process
Sources of additional information
Review and revise
Conclusion
Examples of major accidents
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Introduction
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This seminar is a basic introduction to the Safety Report that
is required under the MHF Regulations.
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It has been developed for the following purposes:
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To provide a simple overview
To be suitable for new MHF Employers
Outline the reason for a safety report
Overview of all parts of a safety report
Show examples of major accidents
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Key Principles of MHF Regulations
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Focus on major hazards (catastrophic events i.e. typically
high consequence and low frequency)
Requires a proactive risk based approach
Places the responsibility on the Employer
Employer has to actively demonstrate safe operation
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Key Principles of MHF Regulations
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Consultation with different parties required at all critical
stages
Facilitate culture change at major hazard facilities
Regulator ‘peer review’, tied to a licence
Addresses both on-site and off-site safety
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Focus of MHF Regulations
Increasing risk
Relative Frequency of Occurrence
Minor
risks
OHS risks
already
regulated
Very high risks
should already
be eliminated
after risk
assessment
Focus of MHF
Regulations is
high consequence
(catastrophic)
but low frequency
incidents
Consequence Severity
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Objective of the MHF Regulations
• The objective of the MHF Regulations is to provide for the safe
operation of major hazard facilities to:
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Reduce the likelihood of an MA occurring
Reduce the consequences to health and safety and damage to
property in the event of an MA occurring
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MHF Regulations
Specific parts of the MHF Regulations relevant for this seminar are:
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Hazard identification (9.43)
Risk assessment (9.44)
Risk control measures (9.45)
Safety management system (9.46)
Emergency planning (9.53)
Provision of information to the community (9.50)
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Why is a Safety Report Needed?
There is a need for specific control of major hazards due to:
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Changing scale and complexity of specific facilities
Advances/changes in technology - unforeseen hazards
Changing community perceptions
Range of major accidents that have occurred
Prescriptive approach has proven inappropriate
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Why is a Safety Report Needed?
Some major accidents that have occurred
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Coode Island, Australia – storage terminal fire, August 1991,
0 dead, 0 injured
Longford, Australia – explosion and fire, September 1998, 2
dead, led to the development of Victorian MHF legislation
Entschede, Holland – fireworks factory explosion, May 2000,
21 dead, 1,000 injured
Texas City, USA – fire and explosion, March 2005, 15 dead,
over 170 injured
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Why is a Safety Report Needed?
Port Kembla Ethanol Tank Fire, NSW, Australia, 28th
January 2004
Quote from the Coroner…“not a lack of adequate safety procedures but rather
the failure to adhere to them”.
(Welding was carried out in an unsuitable area without a ‘hot work’ permit)
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Why is a Safety Report Needed?
This has led to Regulations where:
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The Employer knows what technical and human activities
occur
The Employer decides on the appropriate means of major
hazard control for the facility, and prepares a Safety Report
explaining this
The Regulator assesses and audits performance adequacy
against the safety report
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Why is a Safety Report Needed?
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The introduction of
regulations were ‘fast
tracked’ in Victoria primarily
as a result of the Royal
Commission into the
incident at Longford in
1998.
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The Victorian MHF regime is
now mature and is working
well.
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What is the Safety Report?
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The safety report must address all hazardous events that
could result in MAs that pose serious danger or harm to:
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Persons
The community
Property
The environment
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What is the Safety Report?
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A safety report is a detailed document that outlines:
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The
and
The
The
The
identification and control mechanisms in place to prevent
mitigate all MAs for the facility
types of safety studies undertaken
results obtained for such studies
management arrangements in place
to ensure the continued safety of the facility and its people
and the surrounding community.
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The safety report must be prepared in consultation with
employees and be a true reflection of the state of the safety
arrangements for the facility.
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What is the Safety Report?
The Role of the Safety Report
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Regulatory role: The primary document used by an approved
assessor to verify that the facility is operated safely to
support the Employer’s licence application.
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Information Repository: Contains all information about the
safe operation of the facility which contributes to continuous
improvement of safety at the facility.
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What Must the Safety Report Do?
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Document the state of safety arrangements for the facility
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Demonstrate to the satisfaction of the Commission, through
content and supporting material, that:
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The employer knows what technical and human activities occur
How activities are managed
How safety will be managed in the event of an emergency
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What Must the Safety Report Do?
Identify methods to be used
for monitoring and
reviewing all activities for
continual improvement of
the safety arrangements of
the facility over its lifetime.
Review
Monitor
Safer
Facility
Improve
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The Safety Report Should…
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Reflect the facility safety culture
Contain information about the facility and interaction with its
surroundings
Describe the systems used to achieve safety
Identify, assess and show controls for potential major
accidents
Demonstrate ongoing consultation between the employer and
workforce
Be integrated into the Employers management systems rather
than a collection of separate individual safety studies
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Safety Report Timeline
Time Scale
Time taken
for Activity
Activity
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0
Regulations in force
3 months
3 months
Employer notifies the Commission of MHF or potential MHF
9 months
6 months
The Commission notifies employer of classification
15 months
6 months
Employer submits a safety report outline
24 months
9 months
Employer completes safety report, contracts an approved assessor
30 months
6 months
Approved assessor completes the safety report assessment and
employer applies to the Commission for an MHF licence
36 months
6 months
The Commission issues the employer with a licence and conditions
for licence up to 5 years
Refer Guidance Booklet 4
for this timeline
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Main Components of a Safety Report
The main components of the safety report are:
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Facility description
Risk assessment
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Hazard and MA identification
Risk control measures
Safety management system description
Emergency response plan
Demonstration of adequacy
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Control measures
Safety Management System
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Facility Description
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History
Daily operations
Schedule 9 materials and their characteristics
Demographic description
Facility topography & meteorological data
Simplified process flow diagrams
Site layout drawings
Location plans, surrounding facilities and sensitive neighbours
Proposed changes
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Risk Assessment Requirements
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Hazard identification – for determining MAs
Risk assessment studies – for determining controls
Risk evaluation - for determining risk acceptability
Recommendations and review – for continuous improvement
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Hazard and MA Identification
Hazards that can
lead to major
accidents are
identified. From
these, MA
scenarios can be
developed for
further analysis.
Process
Hazard
Studies
(HAZOP/What
If)
Past Risk
Assessments
Unit
Technical
Review Input
(Specialist
Review)
Incident
History
(internal /
external)
Dangerous
Goods
Present and
Material
Properties
Major
Accident
Event
Grouping
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Risk Assessment
The information for assessment can be presented as a bowtie diagram
Causes
Outcomes
Mitigative Controls
Preventative Controls
M
A
Hazards
Controls
Controls
Consequences
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Risk Assessment
Example: Layer of Protection Analysis
Analysing the safety
measures and controls
that are between an
uncontrolled event and
the worst potential
consequence - risk
reduction study
COMMUNITY EMERGENCY RESPONSE
PLANT EMERGENCY RESPONSE
PHYSICAL PROTECTION &
MITIGATION SYSTEMS
AUTOMATIC SIS
CRITICAL ALARMS AND
OPERATING PROCEDURES
BPCS
PROCESS
DESIGN
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Risk Assessment
Example Risk Matrix
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Description of the Safety Management System
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A comprehensive and integrated management system for all
aspects of control measures adopted
Documented and describes how compliance is to be achieved
Site safety philosophy and how it is reflected in the SMS
Safety policy and safety objectives
Organisation and personnel responsible for the
implementation and compliance with the SMS
Major features/elements of the SMS
SMS performance monitoring processes
Consultative processes used to develop and implement the
SMS
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OH&S Management System Model – AS 4801
Overall
vision, goals
and
commitment
to improve
Continual
Improvement
 Suitable, adequate,
effective
 Changes needed?
 Opportunities to
improve?
• Monitoring and
measurement
• Incident investigation
• Records management
• Audits
Safety Policy
Management
Manageme
Review
Revie
nt
Measurement
Checking
& Evaluation
Correctiv
&
Actio
• Legal compliance
• Objectives and targets
• Implementation plans
Planning
g
Implementation
Implementation
& Operation
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Resources
Leadership responsibility
Training and competency
Consultation and communication
Documentation
Hazard identification, risk assessment
and controls
• Emergency response
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Emergency Response Plans
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Promote preparation
Ensure necessary equipment is available
Ensure personnel are trained and prepared to respond
Identify communication methods
Identify community resources
Consultation with emergency services, local council &
community
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Emergency Incident Scenario Plans
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Analysis of the consequences of specific MA’s to determine fire
fighting access and to identify affected areas
Determination of firewater and foam requirements for
extinguishing the fire and/or protecting affected equipment
Available as a resource for training
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Demonstration of Adequacy
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The safety report must demonstrate that the Employer is
achieving safe operation of the facility by :
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Use of adequate control measures
Satisfactory management systems
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Demonstration of Adequacy of Control Measures
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Controls linked to hazards and proportionate to risk
Depth and breadth of control measures
Performance indicators defined and performance monitored
Risk has been reduced AFAP
Standards, industry practices
Decisions are documented and justifiable
Improvement programs – past and future
 More information is available in the Comcare guidance Booklet 3
(control measures).
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Demonstration of Adequacy of SMS
Comprehensive and Integrated
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Performance standards for the control measures are defined
Control measures are monitored and failures are addressed
Adequate education and training is provided for employees
Processes are provided for review and revision of control
measures
Sufficient resources are provided, responsibilities,
accountabilities defined
Planning, implementation and monitoring processes are provided
for control measures and the system as a whole
 More information is available in Booklet 3 (SMS)
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What Else is in a Safety Report?
Detailed Risk Assessment Records
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Risk analysis of the hazards on site. E.g.
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LOPA
FTA
Risk matrix
QRA
Provides a more detailed analysis of
causes/frequency/consequences/controls for each identified
MA
Assessment of off-site risk
Comparison of risk reduction options
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What Else is in a Safety Report?
Occupied Buildings Risk Assessment
• Analysis of the impact of MAs on occupied buildings
• Mainly risks (due to flame impingement, explosions, toxic
gas) from other buildings/operations
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What Else is in a Safety Report?
Risk Assessment Procedures
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Details of all the hazard and risk assessment work
documented in procedures and referenced
Procedures provide step by step guidance on how the
assessments were undertaken – enables corporate memory
retention
Consistency of approach for all assessments
Justification for selection of risk assessment processes
Resources/guidance for the conduct of future assessments
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What Else is in a Safety Report?
Community Consultation
• Community consultation philosophy
• Summary of Safety Report information for community
• Community bulletins
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What Else is in a Safety Report?
Recommendations and Improvements
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Identification of opportunities to reduce risk via risk
assessments
Recommendations are assessed and prioritised
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MHF Regulation vs. Suggested Process
Reg No.
Regulation
Process
9.43
Identify, in consultation with
employees, all:
a) Hazards that could cause or
contribute to causing a potential
Major Accident
b) Potential Major Accidents
Hazard identification
workshop using What If
/ HAZOP, checklists or
other suitable methods
9.44
The Employer, in consultation with
employees, must ensure that any
risks associated with the hazards or
potential major accidents are
assessed
Risk assessment
workshop using
structured risk
assessment process
(for example fault tree
analysis or LOPA)
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MHF Regulation vs. Suggested Process
Reg No.
Regulation
Process
9.45
The Employer, in consultation with
employees, must adopt control
measures that eliminate or reduce as
far as practicable the risk to health
and safety. This relates to both the
likelihood of the potential Major
Accident and the severity of the
consequences.
Risk assessment
workshop using
suitable risk
assessment process
and risk register.
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Review & Revision
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Employers must review (and revise) the safety report for an
MHF to ensure risks remain reduced AFAP:
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Prior to modification
When new information becomes available regarding possible MA
hazards previously unknown
Upon licence renewal conditions or at least every 5 years
At the direction of the Commission
After a major accident
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Conclusion
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The safety report must demonstrate adequacy of all Safety
Duties required by the MHF regulations
Safety Duties are ongoing requirements
An Employer at a MHF who fails to comply with the MHF
regulations may be subject to civil proceedings or criminal
prosecution under the OHS Act.
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Sources of Additional Information
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Part 9 of the Occupational Health and Safety (Safety
Standards) Regulations 1994
Major Hazard Facility Guidance Material – Comcare website
www.comcare.gov.au
WorkSafe Victoria www.workcover.vic.gov.au
NSW Major Industry Hazard Advisory Papers 1 to 9
Centre for Chemical Process Safety
UK Health and Safety Executive, www.hse.gov/comah
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Questions?
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Publicly Available Data/Incidents
Several examples of incidents are available. These include:
1. Tosco Avon refinery fire incident, Martinez California, 23rd
February 1999 (source: U.S. Chemical Safety and Hazard
Investigation Board, Report No. 99-014-1-CA, issue date
March 200)
2. Buncefield fire, December 2005 (source: UK HSE)
3. Dubai Dry Dock Incident (source: Web site, US Naval Sea
Systems Command)
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Buncefield Incident (UK) – December 2005.
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In the early hours of
Sunday 11 December 2005,
a number of explosions
occurred at Buncefield Oil
Storage Depot, Hemel
Hempstead, Hertfordshire
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At least one of the initial
explosions was of massive
proportions and there was a
large fire, which engulfed a
high proportion of the site
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Over 40 people were
injured; fortunately there
were no fatalities
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Buncefield Incident
Off-Site Consequences
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“Significant damage” to commercial and residential
neighbours
2000 people evacuated
Sections of M1 Motorway closed
Very large smoke plume over Southern England → Air
pollution
Large quantities of foam and water → contaminated water
courses and ground water
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Buncefield Incident
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HSE/EA investigation determined the direct cause (initiating
event) as follows:
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“Tank 912 ……. overflowed at around 05.30 hours …….. while
being filled at a high rate”
Large vapour cloud formed and flowed off-site
First explosion at 06.01 hours
There were multiple root causes (failures) identified
Many related to management system failures
Still some unanswered questions
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Why was there so much explosive force?
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Buncefield Fuel Storage – before incident
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Buncefield – during the incident
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Buncefield – after the incident
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Dubai Dry Dock Incident
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On 27 March, 2002 in Dubai there was a breach and failure in
one of the dock gates that caused uncontrolled flooding in the
dry dock.
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Several vessels were set on blocks inside the dry dock at the
time of the failure. The vessels included the large vessel "Key
Burmuda," a cargo barge and the accommodation barge "SEP
350“.
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Dubai Dry Dock Incident
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The dry dock gates failed at 09.30 during a working day.
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The dock is 500 metres long by 100 metres wide and 11
metres deep.
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Dubai Dry Dock Incident
Everything looks normal!!
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Dubai Dry Dock Incident
Moments after the first breach at 09:30 on 27.3.02
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Dubai Dry Dock Incident
Larger vessels coming off the blocks
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Dubai Dry Dock Incident
Cargo barge getting ready to roll. Many trapped inside, a
few on deck getting ready to jump
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Dubai Dry Dock Incident
“KEY BERMUDA” coming off blocks. “INDRA-1”
swinging towards rig
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Dubai Dry Dock Incident
Accommodation barge “SEP 350” sinking
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Dubai Dry Dock Incident
“SEP 350” touching bottom
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Dubai Dry Dock Incident
The aftermath. Official reports account for 26
persons killed.
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