Advanced Process Safety
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
2
Course Outline
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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Terminology & Definitions
Occupational Health and safety : Conditions
and factors that affect the well being of the
employees , temporary workers , contractors,
personnel , visitors and any other person in
the work place
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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What is Health & Safety
The dictionary defines the words health and safety as follows:
Health - the condition of body or mind
Safety - not being exposed to danger or risks
In industry, Health and Safety means preventing accidents and work related ill health.
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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Work related Ill Health
 Work related ill health is:
 "Any illness, disability or other
physical problem which affects a
person and is caused by their
working conditions”
 Work related ill health may be
temporary or permanent
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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Incident
Incident is an event which has
happened having a potential for harm
or could have resulted in some form of
harm, damage or loss
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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Near Miss
Near Miss
Is an incident, which resulted in no injury,
harm, damage or product loss.
It can have any severity ratings
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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Terms & Definitions
Victim
The person(s) suffering injury as the results of
an incident.
Work injury
Is an injury or illness regardless of severity ,
which arising from a single event ( or number of
events close together in time ) in the course of
employment
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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Terms & Definitions
REPORTABLE INCIDENTS
Are incidents that are work/task related and /
or associated with the Organization's
activities.
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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What is PPE
Equipment worn by
an employee that is
designed to prevent
injury or illness from
a specific hazard.
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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MSDS
 It is a data sheet about the material to find out
the Identity of Material and Manufacturer
 Hazardous Ingredients
 Physical and Chemical Characteristics
 Fire and Explosion Hazard Data
 Reactivity Data
 Health Hazard Data (Limits, Symptoms, etc.)
 Precautions for Safe Handling
 Control Measures and First Aid
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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Lockout
 Lock device applied to energy control point
 A positive means to secure isolation point
 Individual responsible for own lock & key
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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Tagout
 Tag device applied to energy control point
 Used in conjunction with Lockout
 Name, date, time, purpose, etc.
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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Hazard
Is the source or situation with a
potential to cause harm, including ill
health and injury , damage to property,
plant
products
or
environment,
production losses or liabilities.
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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Risk
Combination of the likelihood and
consequences of a specified hazardous
event occuring or An expression of
possible Loss in terms of severity
and probability
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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Risk Assessment
Overall process of estimating the
magnitude of risk and deciding whether or
not the risk is tolerable.
Tolerable risk that has been reduced to a
level that can be endured by the
organization having regard to its
obligations and its own OH&S Policy.
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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Audit
A Systematic examination to determine
whether activities and related results conform
to planned arrangements and whether these
arrangements are implemented effectively
and suitable for achieving the organization’s
policy and objectives.
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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Need of Health & Safety Management System
Deming's and other management specialist have discovered about 15 % of the
company’s problem or more is controlled by employees while 85% or more is
controlled by the management.
Management system help to maintain the consistency.
Management system provides structured paths for improved communication ,
accomplishment of goals, objectives, targets , development of personnel,
improvement of business process, and continual improvement.
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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Need of Health & Safety Management System
Loss control management system can be described as brining together issues like
quality, environment, security health and safety.
Occupational health and safety address a specific part of loss control.
The important reason is Cost.
Pro active approach of OH&S.
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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Background to Health & Safety Management System
Most industrial countries have legislation on their statute book covering issues
related to Health, Safety and the Environment.
In UAE, Federal and Ministerial Orders cover the requirements and provisions of
Health, Safety & Environmental.
In general terms, the legislation applies to:EMPLOYER
EMPLOYEE
VISITORS to SITES
and is enforced by Inspectors from the Municipalities, Local Authorities etc.
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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Need of Health & Safety Management System
The power of inspectors, depending upon their findings, may include the issue
of :
Improvement Notice
A formal legal document which indicates the requirement for change of conditions or
actions. The “Notice” is bound for completion within a certain time frame.
Prohibition Notice
A Formal document which ceases the operation of the concerned organization until
legal HSE requirements are met.
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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What Does Poor Health and Safety Cost
Ignoring Health and Safety has two types of cost:
 Human Cost
 Financial Cost
-to the organisation
- to the individual
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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Individual Human Costs
Accidents affect the individual:
 Physical - loss of limbs or mobility
 Mental - stress and depression
 General Health - loss of libido
Generally, they reduce quality of life
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Advanced Process Safety for GASCO
Date:22.03.2010
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Individual Financial Costs
After an accident, the individual involved looses through:
 Cost of treatment
 Loss of wages
 Higher cost of living
-adapting homes
-special transport
 Compensation does not fully compensate these losses
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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Direct Financial Costs to the Organisation
Each accident has direct costs:
 Prosecution and damages
 Repairs to damaged equipment
 Wages for sick or injured staff
 Capital costs - Eg. Replacement equipment
 Lost profits and depressed share price
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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Indirect Financial Costs to the Organisation
Most costs are hidden. Losses include:

Staff skills

Lost time (recruitment, training, idle equipment)

Lost production and opportunity

Uninsured losses and higher future insurance

Credibility and customer confidence

Staff morale
Indirect costs are between 8 and 36 times greater than direct costs
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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Trends in Health and Safety
Increasing realisation that health and safety cannot be managed through
 Prescriptive rules
 Individuals
 Common senses
History has shown this does not work
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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Trends in Health and Safety
It is now accepted that H&S needs to be managed through pro-active management
tools which:
 Identify risks
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Establish controls
Establish a management structure and responsibilities
Include training and awareness
Monitor performance and audit
Include management reviews
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Advanced Process Safety for GASCO
Date:22.03.2010
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Improving Health and Safety
Improvements in Health and Safety are the result of several factors:
 Greater knowledge of the causes and effects of accidents and work related ill
health
 Introduction of risk based approach
 Increases in the numbers of successful claims for compensation against
organisations
 (Continued next slide)
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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Improving Health and Safety
 Ever stricter legislation and bigger fines
 Recognition that good reputation is important
 Recognition of the moral imperative
There is a move from ‘compulsion’ to ‘expectation’ and to management through
systems
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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Trends in Health and Safety
Increasingly, Health and Safety performance is seen as:
 A direct benefit to the organisation
 Something that interests customers and public
 Even as a condition in a contract
 A reflection of cultural changes in management enabling employees to
improve their working conditions
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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Safety Culture
 A safety culture cannot exist in isolation
 A safety culture depends on a holistic approach to business where all aspects of
Health and Safety are integrated into everyday operations
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Advanced Process Safety for GASCO
Date:22.03.2010
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O&H Management System
This will enable organization to;
Adopt to changes
Facilitate planning, control … etc
Establish structure & programme
Set objectives & targets
Identify legislative & regulatory req.
Identify OH&S Risks
Establish OH&S Policy
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Advanced Process Safety for GASCO
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GASCO HSE Management System
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
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Process Safety Management
A series of catastrophic releases of chemicals
leading to fires, explosions and fatalities have
occurred in chemical processing plants around
the world over the years.
These incidents lead to the passage of the
Process Safety Management Rule in 1992.
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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Purpose of PSM
 This standard contains requirements for preventing or minimizing the consequences
of catastrophic releases of chemicals that are:
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


Toxic
Reactive,
Flammable,
Explosive
 These releases may result in toxic, fire or explosion hazards
 A number of catastrophic accidents have occurred resulting in loss of life and great
property damage.
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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Elements of PSM Standards
The PSM standard contains 14 Elements that must be addressed in the PSM
Program prepared by the employer, as follows:
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Process Safety Information (PSI)
Process Hazard Analysis (PHA)
Operating Procedures
Employee Participation
Training
Contractor Safety
Pre-Startup Safety Review
Mechanical Integrity
Hot Work Program
Management of Change (MOC)
Incident Investigation
Emergency Planning and Response
Compliance Audits
Trade Secrets
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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1. Process Safety Information
 Employers must complete a compilation of written process safety information before
conducting any process hazard analysis required by the standard.
 Process safety information must include information on the hazards of the highly
chemicals used or produced by the process, information on the technology of the
process and information on the equipment in the process.
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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A- Hazards of the Highly Hazardous Chemicals in the
Process
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Information Shall Consist of at least the following:
Toxicity
Permissible Exposure Limits (PEL)
Physical Data
Reactivity Data
Corrosivity Data, and
Thermal and chemical stability data, and hazardous effects of
inadvertent mixing of different materials.
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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A- Hazards of the Highly Hazardous Chemicals in the
Process
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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B- Information on the Technology

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Information Shall Consist of at least the following:
A block flow diagram or simplified process flow diagram,
Process chemistry,
Maximum intended inventory,
Safe upper and lower limits for such items as temperatures, pressures, flows, or
compositions, and
 An evaluation of the consequences of deviations, including those affecting the safety
and health of employees.
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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C- Equipment in the Process
 Information Shall Consist of at least the following:
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Materials of construction,
Piping and Instrument diagrams (P&IDs),
Electrical Classification
Relief system design,
Ventilation system design,
Design codes and standards employed,
Material and energy balances, and
Safety systems (e.g., interlocks, detection, or suppression systems)
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Advanced Process Safety for GASCO
Date:22.03.2010
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2- Process Hazard Analysis (PHA)
 The process hazard analysis (PHA) is the key provision of the Process Safety Management
Standard.
 The process hazard analysis is a thorough, orderly, systematic approach for identifying,
evaluating, and controlling the hazards of processes involving highly hazardous
chemicals.
 The employer must perform an initial process hazard analysis (hazard evaluation) on
all processes covered by this standard.
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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Process Hazard Analysis (PHA)
The employer must use one or more of the following methods, as appropriate, to
determine and evaluate the hazards of the process being analyzed:
 What-if,
 Checklist,
 What-if / checklist,
 Hazard and operability study (HAZOP),
 Failure mode and effects analysis (FMEA),
 Fault tree analysis, or
 An appropriate equivalent methodology.
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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3- Operating Procedures
 The employer must develop and implement written operating procedures, consistent
with the process safety information, that provide clear instructions for safely conducting
activities involved in each covered process .
 The procedures must address at least the following elements:
 Steps for each operating phase:
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Initial startup;
Normal operations;
Temporary operations;
Emergency shutdown, including the conditions under which emergency shutdown is
required, and the assignment of shut down responsibility to qualified operators to ensure
that emergency shutdown is executed in a safe and timely manner;
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Operating Procedures
 Normal shutdown; and Startup following a turnaround, or after an emergency
shutdown.
 Emergency operations;
 Operating Limits:
 Consequences of deviation, and
 Steps required to correct or avoid deviation.
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Advanced Process Safety for GASCO
Date:22.03.2010
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Safety and Health Considerations

Properties of, and hazards presented by, the chemicals used in the process;

Precautions necessary to prevent exposure, including engineering controls,
administrative controls, and personal protective equipment;

Control measures to be taken if physical contact or airborne exposure occurs;

Quality control for raw materials and control of hazardous chemical inventory levels;
and any special or unique hazards.

Safety systems (e.g., interlocks, detection or suppression systems) and their functions.
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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Safety work practices
 The employer must develop and implement safe work practices to provide for the control
of hazards during work activities such as:
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
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Lock-out/tag-out
Confined Space Entry
Opening Process Equipment or piping
Control over entrance into a facility by maintenance, contractor, laboratory, or
other support personnel.
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Advanced Process Safety for GASCO
Date:22.03.2010
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4- Employee Participation
 The standard requires employers to:
 Develop a plan of action for implementation of Employee Involvement.
 Consult with employees on the conduct of the development of PSM elements.
 Provide access to PSM information.
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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5- Training
 PSM requires that each employee presently involved in operating a process or a
newly assigned process must be trained in an overview of the process and in its
operating procedures.
 The training must include emphasis on the specific safety and health hazards of
the process, emergency operations including shutdown, and other safe work
practices that apply to the employee's job tasks.
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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Refresher Training
 Refresher training shall be provided at least every three years, and more often if
necessary, to each employee involved in operating a process to assure that the
employee understands and adheres to the current operating procedures of the
process.
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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6- Contractors
 PSM includes special provisions for contractors and their employees to
emphasize the importance of everyone taking care that they do nothing to endanger
those working nearby who may work for another employer.
 PSM applies to contractors performing maintenance or repair, turnaround, major
renovation, or specialty work on or adjacent to a covered process.
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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Contractors
 When selecting a contractor, the employer must obtain and evaluate information regarding
the contract employer's safety performance and programs.
 The employer also must inform contract employers of the known potential fire, explosion,
or toxic release hazards related to the contractor's work and the process.
 Explain to contract employers the applicable provisions of the emergency action plan.
 Develop and implement safe work practices to control the presence, entrance, and exit
of contract employers and contract employees in covered process areas.
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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7- Pre-Startup Safety Review
 PSM requires the employer to perform a pre-startup safety review for new facilities
and for modified facilities when the modification is significant enough to require a
change in the process safety information.
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
Date:22.03.2010
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Pre-Startup Safety Review
Prior to the introduction of a highly hazardous chemical to a process, the pre-startup safety
review must confirm that the following:
 Construction and equipment are in accordance with design specifications;
 Safety, operating, maintenance, and emergency procedures are in place and
are adequate;
 A process hazard analysis has been performed for new facilities and recommendations
have been resolved or implemented before startup, and modified facilities meet the
management of change requirements; and
 Training of each employee involved in operating a process has been completed.
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Advanced Process Safety for GASCO
Date:22.03.2010
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8 Mechanical Integrity
PSM mechanical integrity requirements apply to the following equipment:
 Pressure vessels and storage tanks;
 Piping systems (including piping components such as valves);
 Relief and vent systems and devices;
 Emergency shutdown systems;
 Controls (including monitoring devices and sensors, alarms, and
interlocks);
 Pumps.
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Advanced Process Safety for GASCO
Date:22.03.2010
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Mechanical Integrity
 The employer must establish and implement written procedures to maintain the ongoing
integrity of process equipment.
 Inspection and testing must be performed on process equipment, using procedures that
follow recognized and generally accepted good engineering practices.
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9- Hot Work Permit
 A permit must be issued for hot work operations.
 The permit must document that the fire prevention and protection
requirements have been implemented prior to beginning the hot work
operations;
 It must indicate the date(s) authorized for hot work; and identify the object
on which hot work is to be performed.
 The permit must be kept on file until completion of the hot work.
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10- Management of Change
 OSHA believes that contemplated changes to a process must be thoroughly
evaluated to fully assess their impact on employee safety and health and to
determine needed changes to operating procedures.
 The employer shall establish and implement written procedures to manage changes
to process chemicals, technology, equipment, and procedures; and changes to
facilities that affect a process.
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Management of Change
These written procedures must ensure that the following considerations are
addressed prior to any change:





The technical basis for the proposed change, (Flixborough Disaster)
Impact of the change on employee safety and health,
Modifications to operating procedures,
Necessary time period for the change, and
Authorization requirements for the proposed change.
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Management of Change
Employees who operate a process and maintenance and contract employees whose
job tasks will be affected by a change in the process must be informed of, and
trained in, the change prior to startup of the process or startup of the affected part
of the process.
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11- Incident Investigation
 A crucial part of the process safety management program is a thorough investigation
of incidents to identify the chain of events and causes so that corrective measures can
be developed and implemented.
 PSM requires the investigation of each incident that resulted in, or could reasonably
have resulted in, a catastrophic release of highly hazardous chemical in the workplace.

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An investigation report must be prepared including at least:
Date of incident,
Date investigation began,
Description of the incident,
Factors that contributed to the incident, and
Recommendations resulting from the investigation.
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11- Incident Investigation
 A system must be established to promptly address and resolve the incident report
findings and recommendations.
 Resolutions and corrective actions must be documented and the report reviewed by
all affected personnel whose job tasks are relevant to the incident findings (including
contract employees when applicable).
 The employer must keep these incident investigation reports for 5 years.
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12- Emergency Planning and Response
 If, despite the best planning, an incident occurs, it is essential that emergency preplanning and training make employees aware of, and able to execute, proper
actions.
 For this reason, an emergency action plan for the entire plant must be developed
and implemented.
 In addition, the emergency action plan must include procedures for handling small
releases of hazardous chemicals.
 Employers covered under PSM also may be subject to the OSHA hazardous waste
operation and emergency response regulations.
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13- Compliance Audits
 To be certain process safety management is effective, employers must certify that they
have evaluated compliance with the provisions of PSM at least every three years
 This will verify that the procedures and practices developed under the standard
are adequate and are being followed.
 The compliance audit must be conducted by at least one person knowledgeable
in the process and a report of the findings of the audit must be developed and
documented noting deficiencies that have been corrected.
 The two most recent compliance audit reports must be kept on file.
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14- Trade Secrets
 Employers must make available all information necessary to comply with PSM to
those persons responsible for compiling the process safety information, those
developing process hazard analysis, those responsible for developing the
operating procedures, and those performing incident investigations, emergency
planning and response, and compliance audits, without regards to the possible
trade secret status of such information.
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Hazard & Risk
Types of Hazard
Physical
Chemical
Biological
Psychological
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Identification of Hazards by Category
 Mechanical
 Electrical
 Substances
 Fire
 Explosion
 Temperature
 Radiation
 Biological
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Machinery Hazards
Typical Hazards
Mechanical
Non-Mechanical
Entanglement
Trapping
Abrasion/Friction
Cutting
Shearing
Puncturing/Stabbing
Crushing
Impact
Electrical - shock/burn
Chemical - toxic, corrosive
Noise
Vibration
Mist, fumes and dusts
Radiation
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Machinery Hazards
 The Hazards arising from the operation of large, powered machinery may be
divided into two groups.
 Mechanical Hazards – Arising from the direct interaction of people with machine
itself.
 Non – Mechanical hazards- associated with the use of machine , often in respect to
the environment within which the machines are located, the materials used and
other aspects of machine’s operations
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Machinery Hazards
Shearing
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Machinery Hazards
Cutting or Severing
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Machinery Hazards
Entanglement
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Machinery Hazards
Drawing in or Trapping
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Machinery Hazards
Impact
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Machinery Hazards
Stabbing or Puncture
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Machinery Hazards
Friction or Abrasion
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Machinery Hazard ( Non – Mechanical)
Noise
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Machinery Hazard ( Non – Mechanical)
Vibration
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Machinery Hazard ( Non – Mechanical)
Electricity
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Machinery Hazard ( Non – Mechanical)
Temperature
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Machinery Hazard ( Non – Mechanical)
Radiation
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Machinery Hazard ( Non – Mechanical)
Ergonomics
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Machinery Hazard Exercise
 What Hazards might arise from the use of the
following machines?
 Bench top grinder
 Pneumatic Drill
 Bench – mounted saw.
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Biological Hazard
Biological Hazards relate mainly to illness
contracted from exposure to harmful micro
organisms. The biological agents which are
directly connected with work undertaken or which
are incidental to it. Example in respect of farming,
sewage treatment or health care
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Biological Hazard




Forms of Biological Agents
Fungi
Bacteria
Viruses.
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Chemical Hazards
 There are 3 general classifications of hazards.
 Physico – Chemical hazards- those are caused by the intrinsic physical or
chemical properties.
 Toxicological Hazards- Harmful effects to living organisms- May cause Acute or
Chronic effects.
 Environmental Hazards – Potential damage to Environment (Soil, water, air).
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Chemical Hazards
 Physico – Chemical hazards- Explosive, Oxidizing, Flammable.
 Toxicological Hazards- Toxic, Corrosive, Irritant, Sensitizing, Carcinogenic,
Toxic for reproduction.
 Environmental Hazards – Dangerous to ozone layers
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Hazard Classification and Placards/ Labels
 The color coding and distinctive graphics of a placard or label are based on
the hazard classification
 The hazard classifications are established to group materials based on their
characteristics.
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Diamond Labels
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Respiratory Hazards
 Toxic
 Dusts, fumes, and mists (particulate)
 Gases and vapors
 Oxygen deficiency or enrichment
 Immediately Dangerous to Life and Health (IDLH)
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Hazard Identification & Risk Assessment
Addresses the identification, evaluation and management of HSE hazards and
evaluation of HSE risks for all activities, products and services, and the development
of measures to reduce risks within GASCO’s operations.
a. What could go wrong?
b. What can cause it to go wrong?
c. What could be the effects?
d. What can I do to prevent it?
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Why Risk Assessment
 Increases Awareness of Workplace Hazards
 Provides opportunity to identify and control workplace hazards
 Can lead to increased productivity
 May prevent an Occupational Injury or Illness
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Hazard Identification & Risk Assessment
The organization shall establish:
 Through experience and judgement.
 Using checklists.
 By undertaking more structured review techniques
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Hazard Potential
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Hazard
Hazard - Source, situation or act with a potential for
harm, in terms of human injury or ill health combination
of these.
.
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Risk
Risk - COMBINATION of the PROBABILITY of an
occurrence of a hazardous event or exposure and
SEVERITY of injury or ill health that can be caused by
the event or exposure.
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Risk Assessment
Risk assessment – Process of evaluating risk arising
from a hazard(s), taking into account the adequacy of
any existing controls and deciding whether or not the
risk(s) is acceptable.
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Hazard & Effects Management
Hazard & Effects Management is the heart of HSEMS
Leadership and Commitment
IDENTIFY
Policy and Strategic Objectives
Organisation, Responsibilities
Resources, Standards & Doc.
ASSESS
HEMP
Hazard and Effects Management
Planning & Procedures
Corrective
Action
CONTROL
Implementation
RECOVER
Audit
Management Review
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Monitoring
Corrective Action &
Improvement
Corrective Action &
Improvement
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Hazards & Effects Management Process
There are four steps in the Hazards & Effects Management (HEMP) Process:

Identify,

Assess,

Control and

Recover.
These steps cover identification of the major hazards to people, assets and reputation,
assessment of the related risks, as well as implementing measures to control these risks
and to recover in case these measures fail.
Use of the Risk Assessment Matrix will enhance appreciation of HSE risk and achieving
ALARP ( As Low As Reasonably Practicable ) at all levels in GASCO.
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Step 1: Hazards Identification
The first step in Risk Assessment is to systematically identify the potential HSE hazards
and effects of the activities and operations.
Hazards and effects need to be identified as early as possible and tracked through the life
cycle of each activity.
Hazards can be identified and assessed in a number of ways:
 Through experience and judgement.
 Using checklists.
 By undertaking more structured review techniques
(Examples include HAZID, HAZOP study, Job Hazard Analysis etc.)
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Hazard Identification
Acceleration: When we speed up or slow down too quickly
Toxic: Toxic to skin and internal organs.
Radiation: Non-ionizing - burns, Ionizing - destroys tissue.
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Hazard Identification
Ergonomics: Eight risk factors
1. High Frequency;
2. High Duration;
3. High Force;
4. Posture;
5. Point of Operation;
6. Mechanical Pressure;
7. Vibration;
8. Environmental Exposure.
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Hazard Identification
Pressure: Increased pressure in hydraulic and pneumatic systems.
Mechanical: Pinch points, sharp points and edges, weight, rotating parts, stability,
rejected parts and materials, impact.
Flammability/Fire: In order for combustion to take place, the fuel and oxidizer must
be present in gaseous form.
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Standard Scope
Hazard Identification
Explosives: Explosions result in large amounts of gas, heat, noise, light and overpressure.
Electrical Contact: Inadequate insulation, broken electrical lines or equipment,
lightning strike etc.
Chemical Reactions: Chemical reactions can be violent, can cause explosions,
dispersion of materials and emission of heat.
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Hazards Identification
For each process step hazards must be identified.
Lifting
Electricity
Skin abrasion
Dust
Falling
etc.
Falling
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Equipment Miss-use
Equipment Malfunction
Accident
etc.
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Hazards Identification
Identify all the HSE hazards arising during the entire lifecycle of an asset or activity.
In doing this consider the following:
 Planning, construction and commissioning.
 Normal operating conditions.
 Abnormal operating conditions (including, shutdown, maintenance, start up
and upset condition).
 Reasonably foreseeable accidents, incidents and/or emergency situations.
 Decommissioning, abandonment, dismantling and disposal.
 Past activities.
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Exercise : Identify the hazards from the picture
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Exercise
Sl. No.
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Activity
Significant HSE Hazards
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Hazards Analysis
Hazard analysis techniques can be quite complex.
While this is necessary in some cases, frequently a basic, step-by-step review of the
operation is sufficient.
The methodologies include:
 What-if checklist
 Hazard and operability study (HAZOP)
 Failure mode and effect analysis (FMEA)
 Fault tree analysis
 Job hazard analysis (JHA) or Job safety analysis (JSA)
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Step 2: Assessing the Risk
Risk = Probability X Severity
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Step 2: Assessing the Risk
GASCO Risk Assessment Matrix standardises qualitative risk assessment within all
Operating areas.
The assessment of Probability is shown on the horizontal axis with assessment of
Severity shown on the vertical axis.
Plotting the intersection of both Probability and Severity provides a qualitative
assessment of the risk.
Quantify the Risk arising from the hazards and estimate the risk rating.
Decide whether existing precautions are adequate or more should be done.
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Qualitative Risk Assessment Matrix
Probability
Severity
People
Assets
4. Severe
3. Critical
2. Marginal
Massive
effect
Has Occurred
in World wide
Industry but not
in ADNOC
Has Occurred
in other
ADNOC Group
Company
Has Occurred
in Specific
ADNOC Group
Company
D
Happens
several times
each year
in ADNOC
E
Happens
several times
each year
same loc/act
HIGH RISK
damage
effect
impact
effects
damage
effect
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C
impact
National
Localised
Slight injury
or health
effects
B
International
Major
Local
Minor injury
or health
tation
Major
Major injury
or health
effects
1. Negligible
- Repu -
ment
Multiple fatalities Extensive
5. Catastrophic
or permanent
damage
total disabilities
Single fatality
or permanent
total disability
Environ
A
Minor
damage
Minor
effect
Considerable
impact
MEDIUM RISK
(ALARP)
Minor
impact
Slight
Slight
Slight
damage
effect
impact
LOW RISK
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Semi Quantitative Risk Assessment
The semi-quantitative approach depends on a
select team of experienced personnel who have
access to accident, historical and failure data to
make “professional” probability decisions. Semiquantitative assessments might determine
consequences based upon in-house modelling
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Semi Quantitative Risk Assessment
Semi Quantitative Risk Assessment Matrix
Probability
Severity
People
Assets Environ- Repument
tation
Multiple fatalities Extensive
5. Catastrophic or permanent damage
total disabilities
Massive
effect
International
impact
Major
effect
National
impact
Localised
effect
Considerable
impact
B
Remote
1 in 10,000
C
Occasional
1 in 1000
D
Probable
1 in 100
E
Frequent
1 in 10
years
years
years
years
years
HIGH RISK
4. Severe
Single fatality
or permanent
total disability
3. Critical
Major injury
or health
effects
Local
damage
2. Marginal
Minor injury
or health
effects
Minor
damage
Minor
effect
Minor
impact
1. Negligible
Slight injury
or health
effects
Slight
damage
Slight
effect
Slight
impact
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A
Improbable
1 in 100,000
Major
damage
MEDIUM RISK
(ALARP)
LOW RISK
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Risk Acceptability
Intolerable region
Risk cannot be justified on any grounds, until and alternative method has been developed,
or additional controls have been implemented, to reduce the risk to tolerable/acceptable
levels.
ALARP region
Activities/Operations should only commence, or proceed, when risk-reducing measures
have been implemented, or with specific sanction by management.
Acceptable region
No need for detailed HEMP exercises to demonstrate ALARP
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Step 3: Control Measures
The third step in Risk Assessment process is to control hazards and risks by preventative
measures (reducing the probability of hazards), mitigation measures (reducing the
severity of hazards) and recovery measures (reducing the chain of consequences
arising from the first hazardous event).
In all cases, risk reduction should be undertaken tovachieve a level that is “As Low As
Reasonably Practicable” (ALARP).
Controls should include preventative and mitigation measures involving active, passive
and/or operational systems. Examples of operational systems to be considered include:
 Training programmes.
 Monitoring programmes.
 Operational procedures.
 Emergency response plans.
 Audit and inspection programmes.
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Step 3: Control Measures
Development of controls should also consider the “Hierarchy of Control.”
Risks can be reduced by using the following hierarchy:
 Eliminate
 Substitute
 Engineering
 Administration
 PPE
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Hierarchy of Control
ELIMINATION
The Best method of dealing with a hazard is to eliminate it.
Once the hazard has been eliminated the potential for harm
has gone.
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Hierarchy of Control
SUBSTITUTION
This involves substituting a dangerous process or substance with one that is
not as dangerous.
This may not be as satisfactory as elimination as there may still be a risk
(even if it is reduced).
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Hierarchy of Control
ISOLATION
Separate or isolate the hazard from people. This method has its
problems in that the hazard has not been removed.
The guard or separation device is always at risk of being removed or
circumvented.
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Hierarchy of Control
ADMINISTRATION
Administrative solutions usually involve modification of the likelihood of an
accident happening.
This can be done by reducing the number of people exposed to the danger
reducing the amount of time exposed and providing training to those people
who are exposed to the hazard.
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Hierarchy of Control
PERSONAL PROTECTIVE EQUIPMENT
Provision of personal protective equipment should only be considered when
all other control methods are impractical, or to increase control when used
with another method higher up in the Hierarchy of Control.
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Step 4: Recovery Measures
If the controls fail to prevent or avoid the release of a hazard then some kind of counter
measures are required to limit the consequences of the hazardous event or effect. These
counter measures are aimed at mitigating the consequences of the hazard and aid in
reinstatement of the operation or activity.
Recovery measures shall be developed and implemented to mitigate the consequences
arising from a hazard and aid in reinstatement of the operation or activity.
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Step 4: Recovery Measures
Effective recovery procedures also require testing and review. For instance, all procedures
for recovery from high risk and emergency scenarios shall be in place and subject to
testing and review.
To assist with a recovery, it is important that all personnel are fully briefed and drilled as to
the response measures planned, including evacuation and restoration procedures.
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Factors to be Considered
The hazards frequency and duration of activities likelihood
and severity injury.
 Legal requirements
 No of employees
 What control is already in place
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Monitoring and Review
KEY POINT
A review follow-up is always essential.
Review is an important aspect of any risk management process.
It is essential to review what has been done to ensure that the controls put in
place are effective.
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Exercise
Identify the different activities in your department and carry out risk assessment
based on GASCO’s Risk Assessment matrix
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Exercise Risk Assessment Format
Activity
Significant
HSE Hazard
Severity
Probability
Risk
Ranking
Risk
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Control
Measures
Proposed
Recovery
Residual Risk
Rating
(After controls
in place)
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Hazard Identification
HAZID (HAZard IDentification) is a team-based brainstorming technique, normally
guided by a Hazard Checklist/Guidewords and taking benefit from the collective
knowledge and experience of the workshop team to identify potential health safety and
environmental (HSE) hazards.
The aim of the HAZID is to identify all relevant potential causes of harm to people,
damage to the environment and damage to property. Once hazards are identified
they can be assessed and if necessary avoided, prevented or controlled.
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Objectives of HAZID
Primary Objectives
Completeness
Knowledge-based
Multi-disciplinary
Full list of potential hazards
Be aware of past accidents and other work
Allow lateral thinking from diverse experiences
Secondary Objectives
Auditable
Structured
Efficient
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Possible to track the process, well documented
To ensure completeness and quality of documents
Focus on immediate problem, useful purposes
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Techniques of HAZID
There are a number of techniques for hazard Identification.
Their purpose is to identify the hazards themselves or the failure cases that might initiate
them.
Some of these techniques are:







Past Experience
Hazard Checklist
What-If (What-If Checklist Technique)
Hazard and Operability Study (HAZOP)
Failure Modes, Effects and Analysis (FMEA)
Fault Tree Analysis (FTA)
Event Tree Analysis (ETA)
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HAZID Actions
Typically, a hazard identification type study will result in a series of actions such as
the requirement to:





Modify the design of plant;
Modify operational procedures;
Modify maintenance procedures;
Evaluate the need for modifications to plant, procedures or maintenance
activities; or
Carry out more detailed assessments.
An appropriate action tracking system should be used to ensure that all actions
Are carried out and closed out in a timely fashion, including further actions and
recommendations that may result from detailed studies.
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What – If Analysis
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What – If Analysis
What –If Analysis is a structured brainstorming method of determining what things
can go wrong and judging the likelihood and consequences of those situations
occurring.
The answers to these questions form the basis for making judgments regarding
the acceptability of those risks and determining a recommended course of
action for those risks judged to be unacceptable.
Lead by an energetic and focused facilitator, each member of the review team
participates in assessing what can go wrong based on their past experiences and
knowledge of similar situations.
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What – If Analysis
“WHAT-IF” questions often may often begin with the words "What-If" but they don't
have to. "How could", "Is it possible," or any other form of question is perfectly
acceptable.
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What – If Analysis
Comparison with HAZOP
When compared with HAZOP, it lacks the structure provided by the
guideword approach and least systematic unless the leader imposes a
pattern.
The What-If methodology lacks the structure of a HAZOP or a checklist,
and is therefore highly dependent upon the study leader to ensure
that the right questions are asked and answered.
It is a team based approach which asks many of the same questions
which might be raised during a HAZOP.
It is simple to use than a HAZOP and generally requires commitment of
fewer resources study.
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Steps for What – If Hazard Analysis
The first steps in performing an effective analysis include:
1.
Picking the boundaries of the review
The boundaries of the review may be a single piece of equipment, a collection of
related equipment or an entire facility.
2.
Involving the right individuals
Individuals experienced in the design, operation, and servicing of similar
equipment or facilities is essential. Their knowledge of design standards,
regulatory codes, past and potential operational errors as well as
maintenance difficulties brings a practical reality to the review.
3.
To have the right information
One important way to gather information on an existing process or piece of
equipment is for each review team member to visit and walk through the
operation. Videotapes of the operation or maintenance procedures or still
photographs are important. Additionally, design documents, operational
procedures, or maintenance procedures are essential information for the
review team.
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Steps for What – If Hazard Analysis
4.
Developing the “What-If” Questions – Using the documents available and
knowledge of the review team, “What-If” questions can be formulated around
human errors, process upsets, and equipment failures. These errors and failures
can be considered during normal production operations, during construction,
during maintenance activities etc. The questions could address any of the
following situations:

Failure to follow procedures or procedures followed incorrectly

Procedures incorrect or latest procedures not used

Operator inattentive or operator not trained

Procedures modified due to upset

Process conditions upsets
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Steps for What – If Hazard Analysis

Equipment failure

Instrumentation miscalibrated

Utility failures such as power, steam, gas

External influences such as weather, vandalism, fire

Combination of events such as multiple equipment failures
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Steps for What – If Hazard Analysis
5.
Determining the Answers – After being assured that the review team has
exhausted the most credible “What-If” scenarios, the facilitator then has the team
answer the question, What would be the result of that situation occurring?
6.
Assessing the Risk & Making Recommendations - the next task is to make
judgments regarding the likelihood and severity of that situation. In other
words what is the risk. The review team needs to make judgments regarding the
level of risk and it’s acceptability.
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Steps for What – If Hazard Analysis
What-If Analysis Form
Division:
What
If?
Desc. of Operation:
Answer
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Likelihood
By:
Consequences
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Example of completed What – If Hazard Form
Division: Chemical Ops
Desc. of Operation: Manufacturing B Mix/Drum
Charging Operations – Page 2 of 4
Answer
Likelihood
Consequences
Recommendations
1. Back injury potential when
breaking up clumps
2. Quality issue only
3. If wet, could cause
exotherm
4. Back injury potential
5. Quality issue only
6. Quality issue only
7. Leg, foot, back, arm injury
Quite
Possible
Remote
Unlikely
Serious
Design delumping equipment
Serious
Minor
Contact vendor
Include inspection in procedure
Possible
Remote
Possible
Remote
Serious
Minor
Serious
Serious
Serious
Train personnel & ensure use
None
Require 2nd check on weight
Ensure hoist on PM program
8. Iron contamination as well
as drum failure & injury
9. Dusting & potential
operator exposure
10.Same as above
11.Possible burn
Remote
Unlikely
Minor
Unlikely
Minor
Quite
Possible
Serious
What If?
1. Granular powder is not freely
flowing?
2. Drum is mislabeled?
3. Wrong powder in the drum?
4. Drum hoist is not used?
5. Two drums are added?
6. Drum is misweighed?
7.
Drum hoist fails?
8. Drum is corroded?
9. Ventilation at mixing tank is not
operating?
10.Granular powder becomes
dusty?
11.Powder gets on operator’s
skin?
12.Tank liquid level too high?
12.Possible caustic splash as
well as quality issue
None
Include vent check in SOP
Remote
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Very
Serious
None beyond existing procedure
Use dust suit & gloves
Use goggles and apron
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Steps for What – If Hazard Analysis
7.
Reporting of the results – The make up of the organization generally
determines to whom and how the results get reported. Usually, the department
or plant manager is the customer of the review. The leader of the review team
will generate a cover memo that details the scope of the review as well as the
major findings and recommendations.
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What – If Advantages and Disadvantages
Advantages
Disadvantages
Easy to use
Unstructured format
Rapid focus on major plant hazards
Complete coverage not guaranteed
Group technique
Recording of results is inherently sparse
No specialized tools or techniques are
needed
Hard to achieve quality control
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HAZOP : Hazard and Operability
Study
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What is HAZOP?
A Hazard and Operability (HAZOP) study is a structured and systematic
examination of a planned or existing process or operation in order to identify
and evaluate problems that may represent risks to personnel or equipment, or
prevent efficient
operation.
A HAZOP is a qualitative technique based on guide-words and is carried out by a
multi-disciplinary team (HAZOP team) during a set of meetings.
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When to perform a HAZOP?
The HAZOP study should preferably be carried out as early in the design phase
as possible - to have influence on the design.
A HAZOP study may also be conducted on an existing facility to identify
modifications that should be implemented to reduce risk and operability problems.
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HAZOP Case Study
PEOPLE
•Operators
•Engineers
•Maintainers
•Others
INFORMATION
•Process Design
•Operating Procedures
•Codes
•Standards
•etc.
FINDINGS
and
RECOMMENDATIONS
MODIFY
Design
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HAZOP Team and Meetings
HAZOP team leader
Responsibilities:
 Define the scope for the analysis
 Select HAZOP team members
 Plan and prepare the study
 Chair the HAZOP meetings
• Trigger the discussion using guide-words and parameters
• Follow up progress according to schedule/agenda
• Ensure completeness of the analysis
The team leader should be independent.
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Team Members
HAZOP team members
The basic team for a process plant will be:
 Project engineer
 Commissioning manager
 Process engineer
 Instrument/electrical engineer
 Safety engineer
Depending on the actual process the team may be enhanced by:
 Operating team leader
 Maintenance engineer
 Suppliers representative
 Other specialists as appropriate
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How to be a good HAZOP participant
• Be active! Everybody’s contribution is important
• Be to the point. Avoid endless discussion of details
• Be critical in a positive way - not negative, but constructive
• Be responsible. He who knows should let the others know
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Worksheet Entries - 1
 Node
A node is a specific location in the process in which (the deviations of) the
design/process intent are evaluated.
Examples might be: separators, heat exchangers, scrubbers, pumps,
compressors, and interconnecting pipes with Equipment
 Design Intent
The design intent is a description of how the process is expected to behave at
the node; this is qualitatively described as an activity (e.g., feed, reaction,
sedimentation)
 Deviation
A deviation is a way in which the process conditions may depart from their
design/process intent.
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Worksheet Entries - 2
 Parameter
The relevant parameter for the condition(s) of the process
(e.g. pressure, temperature, composition).
 Guideword
A short word to create the imagination of a deviation of the design/process
intent. The most commonly used set of guide-words is: no, more, less, as well
as, part of, other than, and reverse. The guidewords are applied, in turn, to all
the parameters, in order to identify unexpected and yet credible deviations from
the design/process intent.
Guide-word + Parameter ⇢ Deviation
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Worksheet Entries - 3
Cause
The reason(s) why the deviation could occur. Several causes
may be identified for one deviation. It is often recommended
to start with the causes that may result in the worst possible
consequence.
Consequence
The results of the deviation, in case it occurs.
Consequences may both comprise process hazards and operability
problems, like plant shut-down or reduced quality of the product.
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Worksheet Entries - 4

Safeguard
Facilities that help to reduce the occurrence frequency of the deviation or to
mitigate its consequences.
1. Identify the deviation (e.g., detectors and alarms, and human operator
detection)
2. Compensate for the deviation (e.g., an automatic control system that reduces
the feed to a vessel in case of overfilling it. These are usually an integrated
part of the process control)
3. Prevent the deviation from occurring (e.g., an inert gas blanket in storages of
flammable substances)
4. Prevent further escalation of the deviation (e.g., by (total) trip of the activity.
These facilities are often interlocked with several units in the process, often
controlled by computers)
5. Relieve the process from the hazardous deviation (e.g., pressure safety
valves (PSV) and vent systems)
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HAZOP Procedure
1. Divide the system into sections (i.e., reactor, storage)
2. Choose a study node (i.e., line, vessel, pump)
3. Describe the design intent
4. Select a process parameter
5. Apply a guide-word
6. Determine cause(s)
7. Evaluate consequences/problems
8. Recommend action: What? When? Who?
9. Record information
10. Repeat procedure
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Modes of Operation
The following modes of plant operation should be considered for each node:
 Normal operation
 Routine start-up
 Routine shutdown
 Emergency shutdown
 Commissioning
 Special operating modes
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Process HAZOP Worksheet
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Examples of Process Parameters
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HAZOP Guide Words and Meanings
Guide Words
Meaning
No
Negation of the design intend
Less
Quantitative Decrease
More
Quantitative Increase
Part of
Qualitative Decrease
As Well As
Qualitative Increase
Reverse
Logical opposite of the intend
Other Than
Complete Substitution
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Guidewords
The basic HAZOP guide-words are:
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Additional guidewords
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Guideword + Parameter
Some examples of combinations of guide-words and parameters:
 NO FLOW
Wrong flow path - blockage - incorrect slip plate – incorrectly fitted return valve burst pipe - large leak - equipment failure incorrect pressure differential isolation in error
 MORE FLOW
Increase pumping capacity - increased suction pressure - reduced delivery head
- greater fluid density - exchanger tube leaks - cross connection of systems control faults
 MORE TEMPERATURE
Ambient conditions - failed exchanger tubes - fire situation - cooling water failure
- defective control - internal fires
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HAZOP
Guide Word
Parameter
Deviation
NO
FLOW
NO FLOW
MORE
PRESSURE
HIGH PRESSURE
AS WELL AS
ONE PHASE
TWO PHASE
OTHER THAN
OPERATION
MAINTENANCE
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HAZOP Case Study
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Reporting and review
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Report Contents
Summary
1. Introduction
2. System definition and delimitation
3. Documents (on which the analysis is based)
4. Methodology
5. Team members
6. HAZOP results
 Reporting principles
 Classification of recordings
 Main results
Appendix 1: HAZOP work-sheets
Appendix 2: P&IDs (marked)
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Review Meetings
Review meetings should be arranged to monitor completion of agreed actions that
have been recorded.
The review meeting should involve the whole HAZOP team. A summary of actions
should be noted and classified as:
 Action is complete
 Action is in progress
 Action is incomplete, awaiting further information
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HAZOP Case Study
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HAZOP Case Study
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HAZOP Case Study
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Event Tree and Fault Tree Analysis
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Event Tree Analysis
An event tree begins with an initiating event, such as a component failure, increase in
temperature/pressure or a release of a hazardous substance.
The consequences of the event are followed through a series of possible paths.
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Definitions: Event Tree Analysis
An accidental event:
The first significant deviation from a normal situation that may lead to unwanted
consequences
Examples: gas leak, falling object, start of a fire, ...
Barriers:
Most well designed systems have barriers implemented to stop or reduce the
consequences of potential accidental events.
Also called as safety functions or protection Layers and may be technical and/or
organizational.
Examples: Alarms warning personnel/operators.
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Main Steps in ETA
1. Identify (and define) a relevant accidental (initial) event that may give rise to
unwanted consequences
2. Identify the barriers that are designed to deal with the accidental event
3. Construct the event tree
4. Describe the (potential) resulting accident sequences
5. Determine the frequency of the accidental event and the (conditional)
probabilities of the branches in the event tree
6. Calculate the probabilities/frequencies for the identified consequences (outcomes)
7. Compile and present the results from the analysis
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ETA Example
Event
Failure
Success
No
Accident
Accident
Safety System 1
Safety System 2
Accident
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No
Accident
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Identifying an Accidental Event
• An essential first step is to identify an accident event:
• What type of an event? (leak, fire, explosion, etc.?)
• Where is it? (control room, laboratory, etc.?)
• When does it occur? (normal operation, maintenance, etc.?)
• May be caused by:
• System or equipment failure
• Human error
• Process error
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Identifying Barriers
Note: Accidental event is normally anticipated! System designers will put barriers to
respond to the event by terminating the accident sequence or mitigating its
Consequences
• List all relevant barriers for the specific accidental events, in the sequence they will
be activated
Examples:
•
•
•
•
Automatic detection systems (fire detection)
Automatic safety systems (fire extinguishing)
Alarms warning personnel/operators
Procedures and operator actions
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ETA Generic Event Tree
Generic Event Tree:
Accidental
event
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B1
B2
B3
B4
Additional
Event 1
occurs
Barrier 1
does not
function
Barrier 2
does not
function
Additional
Event 2
occurs
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Outcome/
Consequence
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Example
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Example
In the above example fire protection is provided by a sprinkler system.
A detector will either detect the rise in temperature or it will not. If the detector succeeds
the control box will either work correctly or it will not - and so on.
There is only one branch in the tree that indicates that all the subsystems have
succeeded:
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ETA
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ETA Example: Fire Scenario Example
Initiating
event
Start of fire
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Sprinkler
System does
not function
Fire alarm is
not activated
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Outcomes
Frequency
(per year)
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Fault Tree Analysis
What is fault tree analysis?
Fault tree analysis (FTA) is a top-down approach to failure analysis, starting with a
potential undesirable event (accident) called a TOP event, and then determining all the
ways it can happen.
The analysis proceeds by determining how the TOP event can be caused by individual or
combined lower level failures or events.
The causes of the TOP event are “connected” through logic gates AND-gates and ORgates.
FTA is the most commonly used technique for causal analysis in risk and reliability studies.
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History
FTA was first used by Bell Telephone Laboratories
in connection with the safety analysis of
the Minuteman missile launch control system in
1962.
Technique later improved by Boeing Company.
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FTA Main Steps
 Definition of the system, the TOP event (the potential accident), and the boundary
conditions.
 Construction of the fault tree.
Qualitative analysis of the fault tree.
 Quantitative analysis of the fault tree.
 Reporting of results.
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Fault Tree Construction
Define the TOP event in a clear and unambiguous way.
What are the immediate, necessary, and sufficient events and conditions causing the TOP
event?


Connect via AND- or OR-gate
Proceed in this way to an appropriate level (= basic events).
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Logic Symbols
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Steps in FTA
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FTA Example: 1
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FTA Example: 2
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Case Study FTA
Figure 1 shows a protective system consisting of a circuit breaker, a ct, a relay, a battery,
and associated control wiring.
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Case Study FTA
The fault tree in the figure helps us analyze the failure chances of the protective system.
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Case Study FTA
The Top Event is a box containing a description of the failure event of interest. The
selected top event is usually described in terms of what event occurred, and the maximum
tolerable delay for successful operation.
For example, our top event here is “Protection Fails to Clear Fault in the Prescribed Time.”
We assume the power system is faulted and we assume the protection system is intended
to detect and isolate the fault in question in a very short time, usually a few cycles. We wish
to know the probability that the protection system will fail to clear the fault in the prescribed
time limitation.
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Case Study FTA
The fault tree breaks down the Top Event into lower-level events.
Logic gates show the relationship between lower-level events and the Top Event. The OR
gate in Figure 1 expresses the idea that any of several failures can cause the protection
system to fail.
If either the DC system, the current transformer, the protective relay, the circuit breaker, or
the control wiring fail, then the Top Event “Protection Fails to Clear Fault in the Prescribed
Time” occurs.
Assume the following chances of failure of the individual devices: 0.01 for the breaker,
0.0001 for the ct, 0.001 for the relay, 0.01 for the battery, and 0.0001 for the control
wiring.
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Case Study FTA
The chance the system will fail to clear a fault is the sum: 0.0212 failures to clear per fault.
We can improve the system by finding better components, which lowers the individual
failure rates, by designing simpler systems, or by adding redundancy.
Let us improve the system by adding a redundant relay. The fault tree of Figure 2 contains
an AND gate. This AND gate expresses the idea that both protective relays must fail for the
Event “Relays Fail to Trip” to occur. Our failure rate for the relays taken together is
0.00150.001 = 0.000001.
The sum implied by the OR gate is 0.0202. The reliability improvement in this case is small,
because failures other than that of the relay dominate the system.
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Case Study FTA
Figure 2: Fault Tree for Radial Line Protection With Redundant Relays
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Case Study FTA
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Example Fault Tree Analysis
FINGERS
AMPUTATED
&
PERSONNEL
CONTACTS
STEM ROLLER
CUTTER
WAS ROTATING
&
&
PERSONNEL
OPENS GUARD
WITHOUT ISOLATION
PERSONNEL
DOES NOT WAIT
FOR CUTTER TO STOP
GUARD
INTERLOCKING
DEVICE LTA
1
INTERLOCKING
DEVICE CONTACTS
LOOSE
2
&
&
UNAWARE OF
ISOLATION
PROCEDURES
UNAWARE
OF CUTTER
HAZARDS
MAINTENANCE
LTA
INSPECTION
LTA
&
SUPERVISION
LTA
PROCEDURES
LTA
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LTA
Risk Assessment
LTA
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Risk Managmt
LTA
LTA = Less Than Adequate
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FMEA : Failure Mode & Effect
Analysis
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What is FMEA?
Failure Mode and Effects Analysis (FMEA) is a technique
which is used to identify hazards or ways in which
components or systems can fail to perform their design
intention.
It will also identify the effects of those functional failures on
the system of which those components or sub-systems are
a part. It is largely a qualitative technique.
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History of FMEA
 Created by the aerospace industry in the 1960s.
 Ford began using FMEA in 1972.
 Automotive Industry Action Group and American Society for Quality Control
copyright standards in 1993.
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Application of FMEA
 It is an analysis which is usually carried out during the design phase of a system.
 An FMEA can however be applied to systems already in operation to determine
possible failures and associated losses.
 The results of an FMEA are often used to assist in maintenance planning.
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When to use
 FMEA is most effective when it occurs before a design is released rather than “after
the fact”.

focus should be on failure prevention not detection.
 As such, FMEA is often a standard process used in the development of new products.
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Two Types of FMEA
 Design FMEA - examines the functions of a component, subsystem or main system.

Potential Failures: incorrect material choice, inappropriate specifications.

Example: Air Bag (excessive air bag inflator force).
 Process FMEA - examines the processes used to make a component, subsystem, or
main system.

Potential Failures: operator assembling part incorrectly, excess variation in
process resulting in out-spec products.

Example: Air Bag Assembly Process (operator may not install air bag properly
on assembly line such that it may not engage during impact).
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FMEA Terminology (Car Door Example of a Design FMEA)
Basic and Secondary Functions - descriptions of what product (process) does.


Basic Function: ingress to and egress from vehicle
Secondary functions - protect occupant from noise
Failure Mode - physical description of a failure.

noise enters at door-to-roof interface
Failure Effects - impact of failure on people, equipment

driver dissatisfaction.
Failure Cause - refers to cause of the failure.
 Insufficient door seal.
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Risk Priority Number (RPN)
The RPN identifies the greatest areas of concern. It comprises the assessment of
the:
(1) Severity rating,
(2) Occurrence rating, and
(3) detection rating for a potential failure mode.
RPN = Severity Rating x Occurrence Rating x Detection Rating
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FMEA Variables
Severity is a rating corresponding to the seriousness of an effect of a potential
failure mode.
Scale: 1-10
1: No effect on output,
5: Moderate effect,
8: Serious effect,
10: Hazardous effect
Occurrence is a rating corresponding to the rate at which a first level cause and its
resultant failure mode will occur over the design life of the system, over the
design life of the product, or before any additional process controls are applied.
Scale: 1-10
1: Failure unlikely,
5: Occasional failure,
8: Highely likely,
10: Failures certain
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FMEA Variables
Detection is a rating corresponding to the likelihood that the detection methods
or current controls will detect the potential failure mode before the product is
released for production for design, or for process before it leaves the
production facility.
Scale: 1-10
1: Will detect failure,
5: Might detect failure,
10: Almost certain not to detect failures
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Corrective actions should be taken if:
 The severity is 9 or 10 (potentially hazardous failures), OR.
 Severity rating x Occurrence rating is high, OR.
 High RPN (severity x occurrence x detection).
 No absolutes rules for what is a high RPN number. Rather, FMEA often are
viewed on relative scale (i.e., highest RPN addressed first).
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Conducting FMEA
Prior to conducting an FMEA, it is often useful to:
1.
Perform a functional analysis, and
2.
Generate FMEA cause-and-effect diagrams.
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1. Functional Analysis
 Identify the basic and secondary function(s) of products or processes.
 Basic functions: specific functions which a product or process is designed to do.
 Secondary functions: all other functions which are subordinate to the basic function
 Example: Seat Belt
Identify Basic and Secondary Functions:
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Identifying Failure Modes
 After functional analysis, failure modes are typically just the inability to perform a
function.
 Describe failure modes for car door:
 Basic function: ingress / egress vehicle
 Failure mode: door does not open, door sticks, door does not open wide
enough
 Secondary Function: protect occupant from noise
 Failure Mode: door does not seal, door header leaks
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FMEA Worksheet
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Example: Worksheet for Air Bag
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Continuous Improvement
Last Columns of FMEA worksheet are used to identify improvement plan.
 Recommend action
 Identify responsibility to complete action.
 Identify target dates to complete action.
 List action taken and reassess RPN.
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Bow Tie Analysis
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Major Accident Hazard Analysis (Bowtie Analysis)
Bowtie diagrams provide a graphical representation of the relationships between
1.
The causes of hazardous events,
2.
Escalation of such events to a range of possible outcomes,
3.
Controls preventing the event from occurring, and
4.
Measures that limit the consequences and enable recovery from the event.
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Major Accident Hazard Analysis (Bowtie Analysis)
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Major Accident Hazard Analysis (Bowtie Analysis)
In the Bowtie diagram (above Figure), the Hazard (e.g. crude oil under pressure) is
Located at the centre of the diagram together with the Top Event. The top event is the
release of the hazard i.e. the loss of control of the hazard. For the hazard of crude oil
under pressure, the top event would be loss of containment.
On the left-hand side of the Bowtie are the identified potential causes or Threats
which may release the hazard or bring about the loss of control of the hazard
E.g. Internal corrosion, external corrosion, overpressure, impact damage, etc.
On the right side of the bowtie are the potential Consequences which could develop
from the top event.
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Major Accident Hazard Analysis (Bowtie Analysis)
On the right side of the bowtie are the potential Consequences which could develop
from the top event.
Consequences shall be described in sufficient detail to allow specific barriers to be
identified and recorded. For example, the Top Event “loss of containment of crude
oil under pressure” may have the following Consequences:






Fire (pool fire, jet fire, flash fire)
Explosion
Fatality or injury
Oil spill/environmental impact
Asset damage
Reputation impact
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Major Accident Hazard Analysis (Bowtie Analysis)
.
In between the threats and the top event are the Barriers that prevent the top
event occurring.
Barriers may be:
Design features (e.g. separation distances, pressure and temperature
rating, materials of construction)
Hardware (e.g. pressure relief valve, fire and gas diction system)
Processes (e.g. lock out/tag out, PTW)
Operational intervention (e.g. plant monitoring/shutdown)
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Major Accident Hazard Analysis (Bowtie Analysis)
On the right-hand side of the Bowtie are the barriers that serve to minimise, or recover
from, the consequences, in the event that the top event occurs. For example, for a
loss of containment of crude oil under pressure, a typical recovery measure would
Be an ESD system.
Also illustrated on the Bowtie are Escalation Factors, these are factors that defeat, or
reduce the effectiveness of a Barrier. Escalation Factor Controls are the measures
put in place that prevent or mitigate the effects of these factors, thereby ensuring
integrity of the Barrier.
For a loss of containment of crude oil under pressure, an escalation factor on a
preventive barrier of ‘pressure relief valve installed’ may be ‘pressure relief valve
removed for maintenance and testing’, which defeats the barrier.
For the same example, an Escalation Factor Control may be ‘dual redundant
pressure relief valves installed’.
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Bowtie Analysis
Hazard
Threat1
Consequence 1
Threat2
Barrier
(Escalation Factor
Control)



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Barrier
(Recovery
Measure)
Barrier
(Control)
Threat3
Escalation
Factor
Consequence 2
TopEvent
Consequence 3
Barrier
(Escalation Factor
Control)
Escalation
Factor
HSE Critical Activities
Engineering
Maintenance
Operations
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How does each “threat Line” looks like?
Bowtie Analysis
Recovery
Measure Barierss
Control Barriers
THREAT
H
A
Z
A
R
D
Design and
Verification System Other
Barriers Barriers
Barriers
•Dsg. Specs
Design and
System
Verification
Barriers
Barriers
TOP
EVENT
•PTW
•Procedures
•Op Window •MOC
•Sampling
•Safeguarding •PM
•Operator
Intervention
•PHA
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Other
Barriers
•JSA
•Dsg. Specs
(diking,
Detector,
ESD)
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•PM
•PPE
•Proc
C
O
N
S
E
Q
U
E
N
C
E
S
•Emergency
Response
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COMAH
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COMAH
What is the main aim of the COMAH Regulations?
Their main aim is to prevent and mitigate the effects of those major accidents involving
dangerous substances, such as chlorine, liquefied petroleum gas, explosives and
arsenic pentoxide which can cause serious damage/harm to people and/or the
environment. The COMAH Regulations treat risks to the environment as seriously as
those to people.
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COMAH
Take all measures necessary to prevent major accidents and limit their
consequences to people and the environment.
Where hazards are high, then high standards will be required to ensure risks are
acceptably low, in line with the HSE's and Agencies' policy that enforcement should
be proportionate.
Prevention should be based on the principle of reducing risk to a level as low as is
reasonably practicable (ALARP) for human risks and using the best available
technology not entailing excessive cost (BATNEEC) for environmental risks. The
ideal should always be, wherever possible, to avoid a hazard altogether
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MAPP
Prepare a Major Accident Prevention Policy
The MAPP also has to address issues relating to the safety management system.
The key areas are:
Organisation and personnel
Identification and evaluation of major hazards
Operational control
Planning for emergencies
Monitoring, audit and review.
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Control of Major Accident Hazards (COMAH)
The aim of a COMAH Report is to demonstrate, in relation to the project, facility or
operation:

That all Major Accident Hazards (MAHs) have been identified in the Hazards &
Effects Register, inclusive of relevant risk classification (e.g.High, Medium and
Low).

That all MAHs have suitable control, mitigation and recovery measures
proposed (for projects) or implemented.

That there is an implementation plan that shows how the control,
mitigation and recovery measures for MAHs will be implemented and
managed throughout the facility lifecycle;
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Control of Major Accident Hazards (COMAH)

How all MAHs will be managed and controlled via the GASCO or main
Contractor’s HSE Management System

That Emergency Response Plans (on-site and off-site where necessary)
in relation to MAHs have or will be prepared based on credible
emergency scenarios, with the necessary stakeholder consultation.
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Control of Major Accident Hazards (COMAH)
A COMAH Report shall be required in GASCO for all projects, facilities or Operations
with Major Accident potential, and shall include, but not be limited to, the following
activities:










Seismic surveys
Exploration drilling
Field development
Well testing
Oil & Gas production operations
Pipeline construction
Terminal and tanker loading operations
Construction operations, including construction of artificial islands
Power Generation and other utilities
Other projects with potential to cause significant harm or impact to the
environment or health and safety of GASCO employees, contractors or
external 3rd parties
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COMAH Reports
Facility Description
The COMAH Report shall provide a detailed description of the main features of the
project, facility or operation and in particular those features relevant to Major Accidents
such as:







Main storage facilities
Process installations
Inventory of hazardous substances including quantities, location and
pressure/temperature conditions
Key equipment (including vessels, pipes, loading/unloading facilities)
Utilities and services
Means of access and egress from the site for both normal and emergency
purposes
Areas where people may congregate such as control rooms, offices,
workshops, canteens, contractor facilities and other occupied buildings.
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COMAH Reports – Management Measures to Prevent MAH’s
HSE Management System
The COMAH Report shall demonstrate how all HSE hazards are managed (or will be
managed for new projects), inclusive of low and medium-risk HSE hazards via the
GASCO, HSE Management System.
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COMAH Reports – Management Measures to Prevent MAH’s
Hazard Identification and Screening
The HAZID technique selected shall be appropriate to the project, facility or operation
being assessed and the relevant COMAH Report phase.
All HSE hazards identified shall be ‘screened’ using the ADNOC Risk Assessment
Matrix (RAM) in accordance with GASCO Technical Guidance Document ‘Qualitative
Risk Assessment’ and all HSE hazards shall be screened as High/Medium/Low risk.
In addition, all HSE hazards listed in the Hazard and Effects Register shall be screened
for Major Accident potential and all MAHs shall be identified and documented in the
COMAH Report.
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COMAH Reports – Management Measures to Prevent MAH’s
Major Accident Hazard Analysis
The COMAH Report shall provide an overview of the methodology for identifying and
assessing Major Accident Hazards.
All High-Risk and MAHs shall be subjected to Quantitative Risk Assessment.
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COMAH Reports – Management Measures to Prevent MAH’s
Prevention, Detection, Control, Mitigation and Recovery Systems
The COMAH Report shall identify all systems (procedural and equipment) that are in
place, or will be in place to prevent, detect, control or mitigate High-Risk and Major
Accident Hazards.
The COMAH Report shall include the prevention, detection, control, mitigation and
recovery measure that are in place, or will be in place, for all High-Risk and Major
Accident Hazards.
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COMAH Reports – Management Measures to Prevent MAH’s
ALARP Demonstration
The COMAH Report shall provide a detailed demonstration that the HSE risk is both
tolerable and reduced to ALARP.
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COMAH Reports – Management Measures to Prevent MAH’s
Emergency Response Plans
The COMAH Report shall also provide a demonstration that:

Emergency plans have been communicated to all stakeholders;

Emergency plans have been tested and will continue to be tested periodically;
and

Necessary training / exercising has and will continue to be provided.
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COMAH Reports – Management Measures to Prevent MAH’s
Improvement Action Plans
The COMAH Report shall provide a summary of the improvement actions (remedial
actions) that have been identified in the COMAH development process to ensure that all
HSE risks are managed to tolerable and ALARP levels, inclusive of any significant
issues requiring immediate attention.
Improvement actions should be SMART.
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HSE Impact Assessment
Abu Dhabi National Oil Company (ADNOC), as the regulator for Health, Safety and
Environment for the Abu Dhabi onshore and offshore oil and gas industry, requires all
Group Companies to prepare an integrated Health, Safety and Environmental Impact
Assessment (HSEIA) for all new and substantial modification projects, existing
facilities, sites and operations.
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HSE Impact Assessment
A HSEIA shall be required in GASCO for, as a minimum, the following activities:










Seismic surveys
Exploration drilling
Field development
Well testing
Oil & Gas production operations
Pipeline construction
Terminal and tanker loading operations
Construction operations, including construction of artificial islands
Power Generation and other utilities
Other projects with potential to cause significant harm or impact to the
environment or health and safety of GASCO employees, contractors or external
3rd parties
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Environmental Fundamentals
What is environment
What is environmental aspects and impacts
Understanding of aspects and impacts register
Understanding of environmental limits
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Environmental Fundamentals
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Environmental Fundamentals
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Environmental Fundamentals
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Matrix
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Quantitative Risk Assessment
Quantitative Risk Assessment (QRA) is a technique for the evaluation and integration
of hazard frequency and consequence to derive a numerical estimate of risk.
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QRA Methodology
The QRA involves the following steps:
1. Identify potentially hazardous events;
2. Develop incident scenarios;
3. Estimate likelihood of events;
4. Assess consequences; and
5. Evaluate risk.
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QRA Methodology
1. Identification of Potentially Hazardous Events
The potential hazardous event is usually called the 'top event'. Examples of such top
events in EP operations are:




Hydrocarbon leaks from process equipment, risers or pipelines;
Blowouts during drilling, production and work-over;
Collisions with visiting or passing vessels; and
Extreme environmental loads.
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QRA Methodology
2. Development of Incident Scenarios (Event Tree Analysis)
QRA studies use event trees to model the chronological series of events.
Event trees provide a systematic method to ensure all potential outcomes as a result of a
specified top event are identified. Where two possibilities exist, for example ignition or
non-ignition or failure / success of a mitigating factor, the tree is branched to form a 'no'
or a 'yes' branch. The probabilities at each branch point must sum to one.
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QRA Methodology
Example - Event Tree
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QRA Methodology
3. Estimation of Likelihood of Events
a. Top Event Frequency
The frequency of potentially hazardous events should be estimated from historical
databases combined with project / facility-specific information (e.g. length of
pipelines, number of valves/flanges, etc.).
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QRA Methodology
b. Event Tree Node Probabilities
Where event trees have been used, probabilities shall be entered on each event
tree node.
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QRA Methodology
c. Fault tree analysis
Fault trees are constructed by tracing back from the top event to the possible causes,
which can be component failures, environmental conditions, etc.
They describe the logical interconnection between various components in a system by
using a combination of 'or' and 'and' gate symbols.
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QRA Methodology
Example Fault tree
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QRA Methodology
4. Assessment of Consequences
a. Physical Effects Modelling
The term 'effect' refers to the possible consequences from releases of hydrocarbons
and toxic gases.
For example, this may be the extent of a gas cloud's flammability or toxicity or it may
be a measure of thermal radiation or explosion overpressure.
Physical effects shall be calculated to identify which parts of the facility, community,
company personnel and the public may be exposed for each potential event and the
extent of that exposure.
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QRA Methodology
Physical Effects Following a Release of Hazardous Material
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QRA Methodology
b. Weather Conditions
Consequence analysis shall be conducted for representative weather conditions specific
to the location. Weather conditions should be defined in terms of wind speed, wind
direction and stability category. The stability describes the amount of turbulence in the
atmosphere and depends on the wind speed, time of day and other conditions
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QRA Methodology
c. Escalation Analysis for Domino Effects
The results obtained from the physical effects modelling will identify which
equipment would be most likely to fail causing further escalation.
The QRA shall consider the following escalation scenarios:



BLEVE;
Boilover;
Secondary fires and explosions.
The potential for escalation shall be reduced as far is reasonably practicable through:




Equipment spacing/layout;
Detection, isolation and blowdown systems;
Passive fire protection;
Active fire protection systems.
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QRA Methodology
Effects on People
Estimates of the consequences to people shall be made. Usually, mathematical
algorithms are developed to relate physical effects model results to consequences.
If a person is caught in a cloud / flash fire or fireball, it is assumed they will be seriously
injured / will die. For persons outside the fire, heat radiation can cause serious burns or
Death.
Explosion overpressure itself can cause injury (e.g. eardrum rupture, lung damage) or
death although, in practice, most fatalities arise from persons being thrown by the
explosion, or thrown off ladders, platforms, etc. resulting in impact injury, or from flying
debris and glass, or by collapse of buildings.
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QRA Methodology
5. Risk Evaluation
a. Potential Loss of Life (PLL)
Having assessed the frequency and consequence for each of the incident scenarios
of the event tree, the statistically expected loss for each scenario may be calculated by
multiplying frequency and consequence.
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QRA Methodology
b. Fatal Accident Rate (FAR)
FAR is defined as the potential number of fatalities in a group of people exposed for a
specific time to the activity in question.
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Task Risk Assessment
Task Risk Assessment (TRA) is the GASCO specified technique for identifying hazards,
assessing risks and determining prevention and control measures for a wide range of
occupational and operational activities.
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Simplified TRA Process
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INTRODUCTION TO OHSAS 18001: 2007
Steps in Task Risk Assessment
TRA Step 1
Define the work to be carried out and watch the work being done
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Steps in Task Risk Assessment
List Basic Job Steps




Define the job task to be studied
Observe task and break into major steps
Record results
Ensure that information is complete and accurate
Gathering Information




Direct observation
Videotape
Employee participation
Other supervisors
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INTRODUCTION TO OHSAS 18001
Steps in Task Risk Assessment
TRA Step 2
Job Hazard Analysis Worksheet
JHA Number: _______________
Page ____ of ____
Job Description: ____________________________________________________________________
Step 1._____________________________________________________________________________
Hazard(s)
_____________________________________
Control Measure(s) Required
______________________________________
_____________________________________
______________________________________
_____________________________________
______________________________________
_____________________________________
______________________________________
Step 2._____________________________________________________________________________
Hazard(s)
_____________________________________
Control Measure(s) Required
______________________________________
_____________________________________
______________________________________
_____________________________________
______________________________________
_____________________________________
______________________________________
Step 3._____________________________________________________________________________
Hazard(s)
_____________________________________
Control Measure(s) Required
______________________________________
_____________________________________
______________________________________
_____________________________________
______________________________________
_____________________________________
______________________________________
Step 4._____________________________________________________________________________
Hazard(s)
_____________________________________
Control Measure(s) Required
______________________________________
_____________________________________
______________________________________
_____________________________________
______________________________________
_____________________________________
______________________________________
Step 5._____________________________________________________________________________
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Hazard(s)
_____________________________________
Control Measure(s) Required
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Steps in Task Risk Assessment
TRA Step 3
Select a task and describe the hazards in each step of the task.
One of the primary purposes of the TRA is to make the job safer.
The information gathered in this step will be valuable in helping to eliminate and/or reduce
hazards associated with the job, and improve the system weaknesses that produced them.
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Steps in Task Risk Assessment
There are many techniques which can be used to identify hazards and some of these are
already well established and used in the industry, one such example is the “ WHAT IF ”
technique.
This originates from the question; what could go wrong ? or what if ...... should occur ?
This involves assuming that each part of the equipment or step of the procedure fails, in
turn.
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Steps in Task Risk Assessment
Brainstorming is another way to identify hazards, using a small group of people.
The team is given a description of the work activity and they contribute ideas for
hazards that could be present in the task.
These hazard identification processes can also be supported by checklists with
relevant questions or topics.
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Sample Hazard Checklist
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Risk Assessment
Steps in Task Risk Assessment
TRA Step 4
Assess the risks.
The level of the risk should be estimated by considering the potential for harmful
severity and the likelihood that these will occur.
To help focus the team on the more important concerns, a general appreciation for
the level of severity and likelihood should be established.
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GASCO Qualitative Risk Assessment Matrix
Probability
Severity
People
Assets
4. Severe
3. Critical
2. Marginal
Massive
effect
Has Occurred
in World wide
Industry but not
in ADNOC
Has Occurred
in other
ADNOC Group
Company
Has Occurred
in Specific
ADNOC Group
Company
D
Happens
several times
each year
in ADNOC
E
Happens
several times
each year
same loc/act
HIGH RISK
damage
effect
impact
effects
damage
effect
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impact
National
Localised
Slight injury
or health
effects
B
International
Major
Local
Minor injury
or health
tation
Major
Major injury
or health
effects
1. Negligible
- Repu -
ment
Multiple fatalities Extensive
5. Catastrophic
or permanent
damage
total disabilities
Single fatality
or permanent
total disability
Environ
A
Minor
damage
Minor
effect
Considerable
impact
MEDIUM RISK
(ALARP)
Minor
impact
Slight
Slight
Slight
damage
effect
impact
LOW RISK
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Steps in Task Risk Assessment
TRA Step 5
Control Measures
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Incident Investigation
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Incident
Immediate Causes
As with Heinrich’s theory, the immediate causes of the Incident are the unsafe acts of
persons and the existence of unsafe conditions
Unsafe Acts -- examples
Unsafe Conditions -- examples
Working without authority
Removing safeguards
Ignoring instructions and procedures
Using defective equipment
Unauthorised servicing
Horseplay
Bad driving of fork truck
Missing guards
Excessive noise
Defective tools and equipment
Poor lighting or ventilation
Poor housekeeping
Fire hazards
Caused by poor Job factors
and Personal factors
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Incident
Basic or Underlying Causes
Basic or underlying causes of Incidents are generally held to be the result of poor job
factors or poor personal factors
Job Factors -- examples
Personal Factors -- examples
Poor supervision
Inadequate engineering
Inadequate tools and equipment
Inadequate work standards
Inadequate purchasing
Inadequate maintenance
Wear and tear
Lack of knowledge or skill
Improper motivation
Inadequate physical or physiological
capability
Physical stress
Mental stress
Caused by Lack of Management Control
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Incident
The Incident Process
Immediate Causes
Incident occurs
Lack of
Management
Control
Loss
Underlying Causes
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Injury, ill-health,
damage to plant
and equipment
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Incident Investigation
Most important
Incident Investigation is not intended to place blame.
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Purpose
The purpose of conducting an incident investigation is to:

Identify the immediate and underlying cause(s) of an incident;

Prescribe and implement suitable remedial measures to prevent recurrence of
a similar incidents;

Develop and communicate lessons learned to different level of GASCO
management and contractors;

Ensure that legal, ADNOC, GASCO and shareholder requirements incident
reporting are met, and

Protect GASCO against future unsubstantiated claims.
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Objective
The main objective of investigation is to determine the underlying cause (system failure) to
Initiate corrections, corrective actions and preventive actions that can remedy the
circumstances and thus bring the system back under control.
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Initial Incident Investigation
The objectives of the initial investigation and site (event scene) preservation are:

To ensure that the site is made safe and that action has been taken to
identify the most obvious cause(s) of the incident and protect against
recurrence.

To collect and preserve initial information prior to the site being disturbed. This will
normally include:
•
•
•
•
•
•
Identification of witnesses;
Documentation/ procedures in operation at the time of incident (e.g. PTW/
certificates);
Phase of operations, process condition, etc.;
Position of personnel and equipment;
Documentation of emergency response procedures immediately following
the incident;
Time of day and prevalent weather conditions.
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Investigation Timing
Investigations should take place as soon as possible
after the incident has occurred.
The quality of evidence can deteriorate rapidly with time,
and delayed investigations are never as conclusive as those
performed soon after the event.
Important evidence can be gained from observations
made at the location, particularly if equipment remains as it
was immediately after the incident.
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Background Information
Most of incidents require the following background information to be in place:

General procedures and standards for the type of activity/ operation being
carried out at the time; These may include departmental instructions, safety
regulations, method statement, permit to work, policies and contract scope
of work;

Site plans/ layouts, P&ID’s, etc.;

Organization charts showing local command structures and listing persons
involved;

Roles and responsibilities of the involved persons;
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Background Information

Contingency plans and emergency response procedures;

Hazard management controls according to the provisions of the contract; and

HSE Plan, Task Risk Assessment (TRA), Method Statement, other Risk
Assessments performed etc.
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Team Selection

Selection of Team

Roles of Team Leader & Investigating Team

Preparation of Team Members for Investigation ( Check List Interview)
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Selection of Team
Team should consists of










Team Leader
Manager or Supervisor of Process Owner
Safety and Environmental Representative
Experts ( External and Internal )
Manger or supervisor of Maintenance
Manger or supervisor of Production
Medical professionals
Security Officers
Personal involved in the incident
Others ( Consultants, Technicians, Contractors,
Purchase managers, Lab personnel etc. )
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Preparation of Check list
It is an “ aides – memoire“
Purpose:






To assist memory;
To ensure covering all aspects;
To ensure continuity of the investigation;
To manage time;
To organize note taking; and
Part of investigation report.
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Incident Management Process
 Step 1: Emergency actions in the event of an Incident
 Step 2: Incident notification
 Step 3: Incident Investigation
 Step 4: Incident Review
 Step 5: Action Close-out
.
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Incident Management Process
Step 1: Emergency actions in the event of an Incident
 Get treatment for individuals that may be injured.
 Assure the safety of others.
 Secure the site.
 Complete the Injury/Illness Reporting Form.
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Incident Management Process
Step 2: Incident notification
 The Responsible person shall prepare a first report of the incident.
 The Responsible person shall assign the actual and potential severity of the
incident by using the risk matrix.
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Incident Management Process
Step 3: Incident Investigation
 Once the actions described above have been completed the Incident Owner
shall initiate an investigation according to the potential of the incident.
 Incident Owner shall designate the investigation team
• The team will be responsible for investigating.
• Should have a good working knowledge of operating procedures.
 Be equipped with the right tools to do the job thoroughly.
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Information Gathering
Inspect the Incident site and note information such as:
 Positions of injured workers
 Equipment and materials being used
 Safety devices in use
 Position on appropriate guards
 Positions of controls of machinery
 Damage to equipment
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Information Gathering
 Housekeeping of the area
 Weather conditions
 Lighting levels
 Noise levels
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Fact Findings
The objective of fact finding is to collect as many facts as possible to help the investigators
understand the events surrounding the incident. Information on incidents can be obtained
from collecting documents, conducting interviews, taking photographs, making
sketches and reviewing safety programs.
The team leader should collect this information as soon as possible after the incident
for safe keeping and before anyone has a chance to remove any vital evidence.
Interviews with witnesses should be carried out as soon as practical after the
incident while the incident is fresh in their minds and before too much discussion
has taken place with their colleagues.
Have witnesses write down their statements of what they know. Interview
witnesses’ one person at a time, so they are not interrupted or questioned by others
involved. To ensure that one uncovers all the facts, one should ask the broad “who,
what, where, when, why and how” questions.
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Open-ended Questions

Where were you at the time of the accident?

What were you doing at the time of accident?

What did you see, hear?

What were the environmental conditions
(weather, light, noise, etc.) at the time?

What was (were) the injured worker(s) doing at
the time?

In your opinion, what caused the accident?

How might similar accidents be prevented in the
future?
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Interviewing
Don’t ask leading questions

Bad: “Why was the forklift operator driving
recklessly?”

Good: “How was the forklift operator driving?”
If the witness begins to offer reasons, excuses, or
explanations, politely decline that knowledge and remind
them to stick with the facts.
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Event Tree Analysis
An event tree begins with an initiating event, such as a component failure, increase in
temperature/pressure or a release of a hazardous substance.
The consequences of the event are followed through a series of possible paths.
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Fault Tree Analysis
Fault tree analysis (FTA) is a top-down approach to failure analysis, starting with a
potential undesirable event (accident) called a TOP event, and then determining all the
ways it can happen.
The analysis proceeds by determining how the TOP event can be caused by individual or
combined lower level failures or events.
The causes of the TOP event are “connected” through logic gates AND-gates and ORgates.
FTA is the most commonly used technique for causal analysis in risk and reliability studies.
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Incident Management Process
Step 4: Incident Review
Incident Review follows Investigation and is principally concerned with preventing the
recurrence of incidents via discussions on underlying causes and remedial actions.
The purpose of incident review is:
 To ensure all that the causes of failures are identified.
 To endorse recommended corrective and remedial action items .
 To confirm actions, action parties and deadline for close out.
 To determine appropriate lateral learning method to ensure that all key
personnel are adequately informed to prevent a reoccurrence.
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Incident Management Process
Step 5: Action Close out
 Incident Owner appoints follow-up Co-coordinator to expedite progress and
monitor close-out.
 The follow-up coordinator reports progress to the Incident Owner.
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Incident Investigation Report
Documenting the findings of an incident investigation is just as important as properly
performing the investigation.
Getting adequate and accurate report will help management, incident relevant
persons and planners to have a historical register for the case that can be
communicated to all employees as lessons learned.
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Lay Out of Incident Report
Structure/Format of Investigation Report
Cover Memo – Note from Management for distribution to
effected divisions/ contractors as appropriate.
Title Page –Executive Summary – A brief background
describing the purpose of the report, highlighting
significant findings and conclusions and referencing the
investigation team’s recommendations.
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Lay Out of Incident Report
Table of Contents – A listing of the report contents and page numbers.
Introduction
Summary – A brief outline of what happened, when the incident occurred, and who
initiated the investigation.
Terms of Reference – The ‘Terms of Reference’ given to the investigation team should be
stated here. This indicates the scope of work of the investigation in question.
Investigation Methodology – This section should describe the way in which the
investigation was carried out. It will indicate the method of investigation, time table
involved, places or sites visited and the names of the personnel who assisted with
investigation by discussion, interview, etc.
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Lay Out of Incident Report
Background
Various background information, for proper understanding of circumstances of the incident,
should be stated in this section. This could include descriptions of equipment,
organizations and management systems (policies/ standards/ procedures).
Sequence of Events
Status of Operation at Time of Incident – A brief description of the operation as a whole
illustrating the background of activity at the time of the incident. If relevant, the weather
conditions should be stated.
Sequence of Events Leading Up to and Following the Incident – This should include the
names of those involved and the time of significant events, if the incident was considered
to be time critical.
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Lay Out of Incident Report
Various – Various other discussion paragraphs should be included, as appropriate, to the
circumstances of the incident. For example, if a particular management system is found to
be deficient, a discussion concerning that system should be included.
Findings, Causes and Recommendations
Principal Findings, Causes and Recommendations – Principal or main findings, causes
and recommendations should be discussed at length to their importance. As a rule, the
main three to five findings should be discussed.

List immediate causes (with findings)

List Underlying Causes (with findings)
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Lay Out of Incident Report
Table of Findings, Causes and Recommendations
The Findings, Causes and Recommendations should be completed by the investigation
team. The Action Items, Responsible Party, Target Completion Date, and Priority will
be completed after discussion with Leadership Team of concerned action item. Each
finding should be tabulated as a separate item.
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Lay Out of Incident Report
The list of recommendations derived from these findings should be crossreferenced so that reasons supporting a particular recommendation can be readily found.
This table should contain the following:

The team’s conclusions as to the significant findings of the incident;

The team’s conclusion of the factual causes of the incident. Where the cause
of the incident cannot be definitively ascertained, the team’s opinion of probable
cause should be given;

The causes given should be clearly stated and where applicable include the
underlying cause(s); and

Please ensure that the action item has been discussed with action party or
their supervisor/manager prior to finalization of the report.
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Lay Out of Incident Report
Non-Contributory Factors
If factors were not responsible for the incident and outcome, it is often helpful to record that
fact. For example; concern may center on personnel competency issue and, if this not a
factor in the incident, it should be stated. Other non-contributory factors should be
recorded.
References
All documents that the investigation team has reviewed and/or used should be listed.
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Appendices

Supporting documentation of relevance to the overall report should be contained
in this section. This should include statements from witnesses, photographs or
drawings, copies of work permits/ certificates or other documents of
importance.

The sequence of events if lengthy may be included as an appendix rather
than the body of the report. If personnel were injured or equipment was damaged
the details could be recorded in this section.

The detailed interview notes may be appended to the report or archived as
considered appropriate.
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Example GASCO Incident Report
1. Example GASCO Incident report.
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Emergency Preparedness and
Response
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Emergency Preparedness
Emergency preparedness & response

Establish and maintain procedures to:
-
Identify potential accident & emergency situations.
-
Respond to such situations.
-
Preventing & mitigating risks associated with that.

Review and revise these as necessary.

Test these periodically.
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Emergency Preparedness
Emergency preparedness & response procedure should consists of

1. Preparation

2. Response/ Reporting

3. On scene control

4. All clear/ Reconstitution
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Emergency Preparedness
Emergency preparedness & response Checklist
1. Availability of documents approved by management
2. Availability of master plan for entire organization includes evacuation of people,
shutdown procedure, removal of materials
3. Appointing departmental/ sectional coordinators to the administer
4. Plan for training drill like mock shutdown, fire drills etc.
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Emergency Preparedness
5. Emergency lighting for all exits ,stairways, elevators etc.
6.Emergency power for the vital areas
7. Familiarity with the location and shutdown procedures
8. Adequate Fire fighting equipments
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Emergency Preparedness
11. Adequate detection system for proper reporting of emergency situations
12. Availability of adequate rescue equipments
13. Documentation show the adequate training and drills of the emergency to
maintain its potential effectiveness
14. Mutual aid agreement with other organization
15. Practical plan for emergency repair following an emergency occurrence
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Sample Emergency Preparedness
EMERGENCY PREPAREDNESS FLOW CHART
Accident / Incide nt
Fire
Spillage
Break the manual fire glass
to make siren in the security office
Communicate to
immediate supervisor
Check if fire
is Major
Secure the
accident site
Provide First Aid after
register in the First Aid Register
No
Extinguish Fire usinig
Available Resources
Refer A
Yes
If fire is under control
Proceed the victum
to hospital if necessary
Inform the Fire Brigadiar
Yes
Assemble at Fire Assembly Point
Contact Numbers
Inte rnal
Operation Manager- 9653700
Managing DirectorYard SupervisorIMS CoordinatorExte rnal
Ambulance -999
Environmental Directorate
BDF Hospital- 766666
Alba Clinic- 830000
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Chemical Spillage
Alert the Personnel
No
A
Use the extinguishers as follows
For wood, papper- Water type
For electrical - Co2 type or Halon
For Oil - Form type
Oil Spillage
Enclose the area
and take necessary actions
Remove the sand
Refill with fresh new sand
Inform the Environmental Directorate
Inform the Supervisor & Operation Manager
Check at assemply point that all the employees are assembled
to find out the missing persons if any.
Give first aid to the injured victum and
take them to the nearrest hospital if necessary
Fill up the Accident / Incident Report IMSF-007
by immediate Supervisor and analyse the root cause IMSF -010
Take Corretive and preventive action
Submit Yearly Annual Accident and Incident report to
Ministry of labour and social affairs
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IMSPR-007
Issue:A
Revision :1
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Exercise
Exercise – Identify the potential emergency situation and take control
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Training
Training needs to be identified
Induction Training for new staffs
Emergency preparedness training
Procedure or work instructions
Any introductions of new technology
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Safety Audit
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Safety Audit
Objectives :
 To determine the conformity of PSM;
 To determine the effectiveness of PSM;
 To verify that PSM continues to meet specified requirements and is being
implemented.
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Safety Audit
Audit Programme
Audit programme is the combination of activities to undertake all of the above audits
including the preparation of an audit plan, the management of audit procedures and
reporting tools.
Audit Plan
Audit Plan is the time-based schedule to conduct all of the above audit activities.
An Audit Plan typically covers a 3-5 year period and details:
 What is to be assessed and/or audited,
 When these activities are to take place,
 Who will conduct these activities ie. Internally or externally-led, team compositions,
etc.
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Approach to Audits
Auditee vs Auditor relation is very
critical to the success of an audit
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Safety Audit Process
Audit plan based on :
 Importance of activity

Previous audit results

Availability
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Safety Audit Process
Audit plan is influence by :
 Scope & Criteria of the audit

Activities being undertaken
 Anticipated Significant HSE Risks
 Time available
 Size of Team
 Complexity of site/operation
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COURSE OUTLINE
Sample Audit Plan
Sl
Department / Section /
Activity
J
F
M
A
M
J
J
A
S
O
N
D
1
2
3
4
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COURSE OUTLINE
Sample Audit Plan
Sl
Department / Section /
Activity
1
Drilling
2
Purchasing
3
Operations
4
QA / QC
5
Production
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J
F
M
*
A
M
J
*
J
A
S
O
N
D
*
*
*
*
*
*
*
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*
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Safety Audit
Responsibilities of Team Leader:
 Act on instructions of Team Leader
 Work as a co-ordinated team with other members
 Cover areas requiring specialist knowledge
 Never argue with other team members when auditee is present
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Safety Audit
Select Team
 Independence;
 Specialized skills;
 Availability;
 Language;
 Acceptance to auditee; and
 Team cohesion.
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On-Site Audit Schedule
Based on your review of HSE Risks & Activities
Allocate Tasks to Auditors
Match Criteria to Expertise
Required Time for Investigation?
Assess Time Required to Undertake
Specific Investigations
Create Timetable for Audit
Establish a Timetable for Interviews & Inspections
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Exercise No. 4
Prepare an HSE Audit Schedule for one of GASCO’s Department
Sample – Audit Schedule
Date/time
Day 1 09:00 – 10:00
Team 1
Team 2
Opening Meeting
Day 1 10:00 – 12:00
Day 1 12:00 – 13:00
Day 1 13:00 – 15:00
Day 1 15:00 – 17:00
Day 1 17:00 – 18:00
Auditors Meeting
Day 2 09:00 – 11:00
Day 2 11:00 – 13:00
Day 2 13:00 – 14:00
Auditors Meeting
Day 2 14:00 – 15:00
Closing Meeting
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Safety Audit
Planning/ Preparation
 Gather information;
 Determine amount of work;
 Prepare working documents; and
 Arrange audit timings.
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Safety Audit
Gather Information about
 Department / section;
 Activities;
 Organization; and
 Policies, objectives, plans, procedures & work instructions … etc.
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Safety Audit
Working documents:
 Checklists;
 Forms;
 Standard; and
 Schedule.
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Safety Audit
It is an “ aides – memoire”
Purpose:
 To assist memory;
 To ensure covering all aspects;
 To ensure continuity of the audit;
 To manage time;
 To organize note taking; and
 Part of audit report.
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Safety Audit
Undertaking the audit
 The opening meeting (depends on the audit type)
 The Site Audit
 The Closing Meeting
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Safety Audit
Opening Meeting:
 Introduce Team
 Confirmation of Audit Plan

Short summary audit activities

Confirm communications channels

Opportunity for Auditee Questions

Confirm Confidentiality Issues
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Safety Audit
Audit Reporting Structure
Auditor identifies Finding(s)
Based on outcome of Audit Activities
Discuss In Auditors Internal Meeting
Chaired by Team Leader
Allocate Level of Severity to NCR’s
ie, Major; Minor; Observation
Agree Feedback & Report Content
Agree which require discussion in Closeout Meeting;
Where more info required
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Safety Audit
Auditor’s Task
Interviews
Examination
Questions
Verify
Observation
Objective Evidence
Not Auditors Opinions
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Safety Audit
What Do We Examine ?
Plant Facilities.
Documentation
Equipments/ Instruments/ Tools
Operations & Conditions
People
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Safety Audit
Audit Conduct
Audit Sample
Non-conformity Investigation
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Safety Audit
Plan of Action
General Manager:
5 mins
Operations Manager:
20 mins
Sites Supervisor:
20 mins
Foreman
10 mins
Walking inspection of site:
30 mins
OH&SMS Coordinator
5 mins
General Manager
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10 mins
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Safety Audit
Audit Entry &
Exit Meetings
Auditor’s
Plan of Action
5+
10 mins
20
mins
30
mins
20
mins
15
mins
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Audit interface with
another audit area
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Safety Audit
Communication
A bad Auditor is one who cultivates
One-way Communication
By:
Asking Closed Questions
Answering Own Questions
Not giving Auditee time to respond
Talking continuously
Expressing opinions
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Safety Audit
Psychology of Audit
Auditors can appear threatening
Be Relaxed
Be Human
Be Courteous
Display Interest
Remain Cool, Calm & Collected
Act Professionally
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Safety Audit
Taking Notes
Record The Important Facts
For Future Reference
Where The Auditor Has Visited
Who Was Met & Spoken To
Record Of What Was Seen And Heard
Auditors Need To Learn The Art
Of Good Note Taking
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Safety Audit
Time Management
 Plan well;
 Do not allow audit to get side-tracked;
 Allocate time based on the criticality of the process
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Safety Audit
Non-Conformity
Management Need The Facts
WHAT WAS FOUND
WHERE WAS IT FOUND
WHY IS IT A NON-CONFORMITY
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Safety Audit
Non-Conformity
Factual Evidence of
a condition not in
accordance with a
Specified Requirement
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Safety Audit
Team Meeting
Chaired By Team Leader
Non-conformity Forms Completed
All Non-conformities Reviewed
Collective Review Of Non-conformities
To Identify Major Concerns
Summary Statement Prepared
Agenda For Closing Meeting Prepared
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Safety Audit
Evaluating Results
Major Concerns
All
Results
Minor Concerns
You will not earn respect for Reporting only Trivia
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Safety Audit
Major Non-conformity
A Significant Non-compliance with PSM Requirement;
A Failure of or Complete Omission of PSM Requirement
A Significant number of Minor Non-conformities regarding the same PSM Requirement
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Safety Audit
Minor Non-conformity
An isolated incident of a failure to comply with a procedure or a PSM Requirement
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Safety Audit
Observation
A statement of Fact made during an audit and substantiated by objective evidence
Allowing Auditors to make Observations can lead to Lazy Auditing
Observations can be very Subjective
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Safety Audit
Closing Meeting:
 Re-Introduce Team

Summary of Audit Findings

Confirm of Audit Reporting

Opportunity for Auditee Questions

Confirm Confidentiality Issues
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Exercise
Non Conformity Statement
Identify the Non conformity and prepare the NCR for the below case study.
An inspection of the fuel storage area revealed that the Chemical Storage Procedures
being used are referenced CHEM 27/02.
Central Document records show that Version CHEM 27/05 should be used
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Exercise
Non Conformity Statement
What
Where
Why
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Exercise
NON CONFORMANCE REPORT
Ref.:
Date:
NCR No.:
Section:
Department:
Type of NCR:
Major
/
Minor
/
Observation
Non conformance:
Cause of nonconformance:
Corrective action:
Preventive action:
Review:
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Exercise
Non Conformity Statement
What
Where
Why
Document No: TUV ME/ ADPS 001/ 01
Version CHEM 27/02 of Chemical Storage
Procedures Being Used
Fuel Storage Area
Current Version Of Chemical Storage
Procedures Is Referenced CHEM 27/05
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Safety Audit
Non-conformity
Raised
Corrective Action & Audit Close Out
Understand
Analyse
Root Cause
Determination
Audit Team Leader
Corrective
Action Proposal
Implement
Follow Up Audit
Verification
Ongoing Surveillance
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Safety Audit
Audit Report
Identification
Confidentiality
Audit Objective & Scope
Schedule / Dates / Auditors
Reference Documents
Summary Of Findings
Non-conformities
Recommendations
Follow Up
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Thank You
Document No: TUV ME/ ADPS 001/ 01
Advanced Process Safety for GASCO
08/02/2018
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