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Implementation Issues of PSM in a Fertil (1)

Implementation Issues of PSM in a Fertilizer Plant:
An Operations Engineer’s Point of View
M. Imran Rashid,a Naveed Ramzan,b Tanveer Iqbal,b Saima Yasin,b and Sana Yousafb
Operation Engineer, Dawood Herculeus fertilizer Complex, Pakistan
Department of Chemical Engineering, University of Engineering and Technology, Lahore, Pakistan;
ramzan50@hotmail.com (for correspondence)
Published online 30 January 2013 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/prs.11553
In this article, guidelines are provided for implementation
of the elements of process safety management (PSM) such as
management of change (MOC), process hazard analysis
(PHA), incident investigation, emergency planning, and
response. The role of mechanical integrity, operating procedures, compliance audits, pre-start-up safety review, contractors, training, work permits, and process safety information
for implementation of the PSM in a fertilizer plant are discussed. Implementation of MOC is an important step for the
adoption of PSM standards and a necessary condition for internal and external audits of the plant. There are many
issues linked with implementation of PHA like plant modifications, shut downs, and production losses as well as the
behaviour of the design engineer whenever modifications are
required. Consequence analysis, an evaluation of an incident in terms of its effects on environment, equipment, and
people is of great help. Incident reporting for a company can
be improved by ensuring confidentiality and not exposing
the reporting person. Improvement in the operating procedures and preserving mechanical integrity of the process
plant are necessary conditions for the implementation of the
standards. Internal and external audits of the company are
the most important part of the PSM implementation. In general, the PSM implementation requires much effort and time
C 2013 American Institute
but pays off well if implemented fully. V
of Chemical Engineers Process Saf Prog 32: 59–65, 2013
Keywords: process safety management; process safety
information; process hazard analysis; management of
The compliance period established by the occupational
safety and health administration (OSHA) for implementation
of the process safety management (PSM) standard [29 CFR
1910.119(e)(1)(i)-(iv)] was between May 26, 1992 and May
26, 1997. It was assumed that the number of plant accidents
would be reduced significantly after implementation of the
standard. But 46 full investigation reports (1998–2008) of
plant facility accidents published by U.S. Chemical Safety
and Hazard Investigation Board (CSB) indicate that accidents
have not decreased as expected [1]. Accidents are continuously damaging the people, plant facilities, and environment.
Half of the reported accidents occurred in the PSM imple-
C 2013 American Institute of Chemical Engineers
Process Safety Progress (Vol.32, No.1)
mented plants while other half in smaller plants that are not
covered by PSM [2]. A process reactor vessel was destroyed
in December 2007 by a runaway reaction at the T2 plant in
Jacksonville, Florida, similar to the previous accidents [3].
The Canadian Chemical Producers Association 2004 processrelated incidents measure analysis report of 89 incidents has
shown that six PSM elements contributed to 85% of occurred
incidents. Namely, these elements were, “Process and equipment Integrity,” “Process knowledge and documentation,”
“Process risk management,” “Human factors,” “Management
of change,” “Capital project review and design procedures”
[4]. A similar study was conducted by Blair (2004) on 21
chemical accident investigations of CSB to identify repeatedly
occurring causes. His top five ranked categories include:
“maintenance procedures,” “process hazard analysis (PHA),”
“engineering design and review,” “management of change,”
and “operation procedures” [5]. Detailed analysis of incident
data has identified operational discipline as a key factor in
nearly half of the PSM incidents and was a key factor in over
50% of process incidents in 2000 [6]. Contribution of operational discipline to incidents at one site has increased from
61% in 2003 to 86% in 2006 [7]. These reports clearly demonstrate that there are potential issues in implementation of
regulations from OSHA. PSM regulation has excellent
requirements that could and should prevent accidents if process plants follow the regulation as intended [2]. Now the
need is to address the practical difficulties faced in implementing PSM elements and provide guidance for industries
to overcome the issues. Many authors have provided
recommendations for continuous improvements in PSM
systems [2–4,8–11].
Actual implementation costs for the PSM regulation have
been orders of magnitude higher than originally estimated
[12]. PSM auditing costs are high, and people are doubtful
about its effectiveness [8]. PSM documentation is very difficult and requires great effort. Also, good documentation is
just beginning and proper utilization is again difficult [2].
One major pitfall in implementation of effective PSM is that
many companies believe that the “Risk Assessment” is sole
responsibility of HSE and risk specialists, instead of being
carried out in a more pragmatic way [13].
This article provides the guidelines for implementation of
the elements of PSM such as management of change (MOC),
PHA, incident investigation, emergency planning, and
response. The role of mechanical integrity, operating procedures, compliance audits, pre-start-up safety review (PSSR),
March 2013
contractors, training, work permits, and process safety information for implementation of the PSM in a fertilizer plant are
also discussed.
MOC is not only one of the basic elements of OSHA’S
PSM System but also is required by U.S. EPA’s Risk Management Program Regulation [14]. With any idea or problem,
first you are required to initiate an MOC, that is, provide the
problem/purpose of change, a proposed solution, and/or
justifications for the said change. Then MOC approval from
different departments such as operations, technical, project,
safety, and authorizations from the higher management is
required. After approval of the MOC proposal, you need to
complete a job safety analysis. After the job, updates to the
P&IDs, operating procedures, maintenance procedures, risk
assessments and its accommodation in PHAs, PSSRs, employees trainings (or involved contractor workers training) along
with communication to all shifts or other staff in factory are
required. Employees involved in operation and maintenance
of the process affected by said change need to be trained as
well. How difficult it is to implement all above requirements
when several hundred MOCs are raised annually in big
organizations as reported by Nir Keren after gathering data
from 26 facilities [15]. Follow-up with MOC in emergency situations is also difficult. Sometimes conflict arises when two
departments disagree whether the job will be covered under
the MOC or work permit system. Hence, proper training for
MOC originators, processors, approvers, record keepers, and
auditors are required after scheduled intervals. Figure 1
shows the MOC cycle for all steps in MOC. Detailed check
lists are important but every change does not have to use every check list and the MOC process may become so uncertain that potential hazards may be overlooked in assessments
[16]. Inadequate MOC has resulted in accidents such as Flixborough [17], fire and explosion at Giant Industries’ Ciniza
oil refinery [18], and hydrogen reformer furnace failure at
Syncrude Canada Ltd [19].
As PSM regulations require a PSM audit at least every 3
years, proper records of MOCs and whether jobs have been
done under MOCs are required. However, different internal
audit schemes by plant personnel or by corporate audits
may be established inside the company [20] but on the other
hand these also require much effort and cost. One other suggestion is to develop a software system, on which every
MOC description is present along with its status in technical
study phase, management review phase or approved. But
again you need people to update and maintain such a system and manpower requirements will increase. One other
suggestion is a monthly MOC meeting in which people from
different departments should involve to discuss progress of
all generated MOCs. Further guidance is provided by Nir
Keren in a questionnaire for bench marking MOC [15].
Figure 1. MOC cycle/hierarchy
Processes installed before 1980s, when technology was
not so advanced, have undergone a lot of modifications and
P&IDs were not always updated. The first main problem
faced during PHAs is P&IDs that do not match site installations. P&IDs do not show all flanges of process plant, so
more and more field visits are required. If leaking flanges
due to reduced life, wrong gasket materials, or insufficient
tightening (control valve upstream flange, downstream
flange, bonnet flange, by pass line flange, isolating valves
flanges) is considered to develop scenarios then 100 and
1000 different scenarios are possible, which confuses the
PHAs team and turn PHAs into boring exercises.
Operation engineers work in shifts and are well aware of
incidents/accidents occurred in their shifts but not about all
previous accidents. Usually, incident investigation reports are
not available. This makes it difficult to consider all accidents
in PHAs. Also, guidance from OSHA is not clear about consideration of previous incidents. Should previous incidents
be limited to only those that occurred in a particular process
that is undergoing a PHA? Or should other incidents be
included, such as ones that occurred in other processes in
the same plant; similar processes operated by the company
at different plants; or all known published incidents involving a similar process or a particular piece of equipment? [1].
It is also difficult to consider all plant modes of operation
such as startup, shut down, emergency shut downs, reduced
load operation of plant, or partial plant shut down, and partial running conditions. Identification of all hazards associated with different forms of energy as given in Table 3.1 in
the DOE Handbook [21] also requires effort and time. It is
also difficult to address all hazard scenarios such as tube
leaks of all exchangers, leakage from all process lines, leakage from all process equipments, leakage from all flanges,
DOI 10.1002/prs
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Process Safety Progress (Vol.32, No.1)
leakage due to wrong gasket materials, leakage due to possible damaged gaskets, overflowing of process vessels, upsets
in all process vessel levels, falling materials, all pumps seal
or gland leakages, overpressures, high or low temperatures,
and variations in flows. Now consider the difficulty involved
for the PHA team if the team has to made qualitative consequence estimates for all such scenarios to determine type, severity, and number of injuries. Then, the PHA team should
also consider number of people who may be exposed, the
duration of exposure, evacuation routes and ventilation, and
the effects of released material on various people.
Sometimes workers are not free for PHAs. Sometimes process design engineers feel that their design is being questioned. For running plants, managers believe that a PHA will
cause plant modifications, shut downs, and production loss
[22]. Costly recommendations are not always welcomed or
sometimes these can only be implemented when plant is
down, so you may have to wait for a year. PHA teams sometimes use less rigorous PHA methodologies (What-If, Checklist) rather than hazard and operability study (HAZOP)/
failure mode and effect analysis (FMEA) because of time limitations from higher management and the estimated time for
each node [22] is ignored. Also many PHA teams have not a
single member knowledgeable in the specific PHA methodology being employed as per OSHA recommendations. Sparing
the staff for PHAs, scheduled training and generating incident databases is important. Integrating job safety analysis
(JSA) with PHAs [23] and suggestions about PHAs from Mark
Kaszniak [1] are helpful for improvement.
On April 5, 2012 when an operation engineer in a fertilizer plant started the Ammonium Carbamate pump 3 KV
motor during initial startup phase, it did not start; a minor
sound from the motor and a huge voltage dip in the control
room were observed. On checking the motor, it was found
to be burnt. Incident investigation was done using the WhyTree Analysis as shown in Figure 2 and it yielded the astonishing result that all 3 KV and 11 KV motors had not had any
inspection schedule since plant installation.
Usually, people are not well aware of the type of incidents
that have occurred so this causes difficulty in identifying the
root causes of the incident. Sometimes problems appear when
people do not report the minor incidents or near missess.
Major hindrances in incident reporting are the fear of punishment, disclosing one’s identity, and loss of personal relationships [24]. So incident report forms should not mention name
of the person but often management can determine the responsible person from the area in which work was carried out
or from time of incident. Authors have experience that sometimes such incidents have even affected the career of persons
involved. So development of confidence and trust among
workers is required to make these reports true and worthy for
preventing future incidents. Recurrence of incidents can also
be avoided by utilizing these incident investigation reports.
Crowl and Louvar have also reported on the significance of
incident investigation [25]. Learning from accident root causes
is worthless unless shared with all company employees. Again
during its communication, some specific people or specific
department staff may not feel good about it. This creates dissatisfaction or conflict among the employees. Some companies
even cannot understand the root causes of multiple incidents
because of unavailability of skilled employees who can use different models such as Domino Loss Causation Model and
Kletz’s Layered Investigation Model etc. Also, inherent safetybased incident investigation methodologies [26] are not
adopted by industries which lack in such expertise. One other
problem is that recommendations generated after the investigations of the accidents may not be closed in a timely manner
Process Safety Progress (Vol.32, No.1)
because some can only be implemented when the unit is down
and this sometime takes a year. Some experienced professionals feel bad that they are asked questions during incident
investigations and people feel that telling the truth will affect
their careers or others.
Many process plants have emergency response teams and
procedures. However, often only a general emergency plan
exists and for each separate case, a separate plan does not
exist. Similarly, a general assembly point exists where people
have to go in case of emergency siren. Emergency plans for
ammonia release, carbamate release, chlorine release, vapor
cloud explosion, heat radiation, and explosion blast wave
must be different from each other and accordingly assembly
points or evacuation procedures. Plants usually lack in training of the people regarding behavior in an emergency and
people get confused in emergencies. The use of consequence analysis in most industries is rare and without it,
emergency response planning is hard to do accurately.
Different software can be used for consequence analysis
such as: ALOHA [27], Computational Fluid Dynamics (FLACS,
Fluent, CFX, etc.), BP Cirrus, Shell FRED, Canary from Quest
Consultant, PHAST from DNV, Slab from EPA, LNGFire3,
Breeze LFG Fire/Risk, and DEGADIS etc. Models (e.g.
SAFER) can also be used to calculate the areas impacted by
fires, toxic chemical releases, explosions, etc. for events such
as holes in pipes, stack releases, and spills. Using this analysis, emergency preparedness plans are made, and the level
of community evacuation needed is judged. Many companies
do not have software available or the required expertise to
use such software and do not plan there emergency
response accordingly. These limitations cause difficulty in
implementations of PSM regulations.
As per PSM recommendations, mechanical integrity of all
process equipment, piping system, and process controls should
be checked. The main problems observed are that main equipment is missed in the inspection schedules (as indicated by
Figure 2 incident) and sometimes the inspection cannot be
done because at the time the inspection is planned the machinery is running (pumps/ compressor). Also, some times when an
inspection (e.g., vibration) is scheduled, then the equipment is
not running and is on standby; therefore, the required inspection cannot be done. Also, inspection of low switches (e.g.,
lube oil low-pressure tripping) cannot be done in a running
plant, because these cannot be isolated if machinery is running
and some machines do not have stand by machines. So this
inspection will cause a reduction in production and management usually does not allow such inspections. Similarly, some
interlocks such as of conveyors can only be checked when they
are stopped, so in continuous running plants you may have to
wait a whole year for check interlock operation.
Some things are difficult to inspect, for example, glands
of valves and mechanical seals of pumps because these
require a lot of effort for inspection. So valve glands and mechanical seals should have proper schedule for replacement,
but again it is difficult to maintain records in fertilizer plants
where many thousands of valves may be present.
It is difficult to remove insulation of all lines or vessels for
inspection, because when removed, insulation is damaged and
you have to do it again. Sometimes inspection methods are not
correct and many inspections occur without any useful output.
It is also observed that in some plants relief valves/pressure
safety valves (PSVs) calibrations were not done for more than 5
years because of short turn around durations and poor inspection management. Figure 2 also indicates that the absence of
inspection schedules was one major cause for incidents. Why
Published on behalf of the AIChE
DOI 10.1002/prs
March 2013
Figure 2. Incident investigation.
has not somebody developed inspection schedules for these
motors? One reason may be the work load on the staff or the
small number of staff available for maintenance. Hence, factories should have proper level of maintenance staff and staff
must follow vendor recommendations for all machinery inspections and/or replacement of parts.
example, a change from chromate base treatment to phosphate base. But this change is usually not updated in operating procedures. Most of the companies have operating procedures. However, some common missing data and or
activities identified in operating procedures are given in Table 1. This table also shows the efforts required to implement this PSM element.
With passage of time and increasing production demands,
organizations change systems may be due to technology
changes or due to mitigation of hazardous chemicals, for
DOI 10.1002/prs
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Published on behalf of the AIChE
The most important element of PSM is the audit-not infrequent official audits but many internal audits to check that
Process Safety Progress (Vol.32, No.1)
Table 1. Upgrades required for compliance with the OSHA PSM regulation.
Specific procedures for jobs covering both maintenance and operation aspects are not present. No specific procedures
for specific jobs exist, e.g. specific procedure for motor painting or pump painting does not exist. Similarly for pump
bearing oil replacement, alignment checking and for mechanical seal replacement different procedures are not
Detailed shut down procedures and emergencies procedures are missing
Operating procedures do not mention the hazards of operation e.g. in order to stop a circulation pump for a vessel,
the vessel level should be low, otherwise it can overflow and result in splashing
Effect of parameter (Temp, pressure, flow, level) variations on plant and mitigating actions are missing
Procedures for some activities such as pump, filter or lube oil cooler change over are missing
Details of Plant startup after turn around are missing
Hazards of specific materials such as insulation materials, diatomaceous earth and asbestos are missing
Procedures for some activities are missing e.g. entry into empty vessel/reactor for inspection
Actions in case of loss of electricity/cooling water or partial failure of electricity/cooling water
Parameters/conditions at reduced plant operation and parameters upper and lower limits
Replaced chemicals and lubricating oils are not mentioned
Plant control system changed from PLC to DCS operation but related instrumentation and alarms data is not updated
Table 2. Different things checked in daily safety audits.
Damaged earth (grounding) cables of motors/exchangers
Damaged insulations of hot pipes or steam tracing lines
Missing ladder cages/safety locks
Missing motor fan covers
Steam condensate leakages from height in the walkways
Motors coupling guards not properly fixed
Uncovered pits
Hanging sheets (metallic or asbestos) from height
Over-head cranes hanging chains not fastened properly
process is used as required [2]. Different type of internal
audit schemes may be used to check the effectiveness of
PSM elements. These are: daily safety audit, work permits
audit, and behavior observation audit. In a daily safety audit,
conditions against the safety are checked as listed in Table 2.
Work permit audits are done to check the appropriateness
of work permit system. The purpose of the behavior observation audit is to check safe and unsafe behaviors of people
regarding the use of PPE, tools and equipment, and work
methods. Figure 3 depicts the safe and unsafe behaviors in X
Factory for 15 months.
Some people resist audits as is shown in the trend for the
category “reaction of people.” The factor is more common in
industries in which highly experienced workers are present.
Companies can form teams consisting of safety personnel,
operations, and those involved with regulatory compliance.
Such teams can schedule their own audit schemes or can
conduct combined audits with the PSM audit. Such audits of
different PSM elements including findings and corrective
actions are given by Michael R. Green [28].
new facility because of overtime issues, shortage of manpower, or time limitations to run the facility. The other issue
is that proper operating procedures, startup procedures,
emergency handling procedures, and safety considerations
are not always completed before startup of new facility as
recommended by OSHA.
A large number of contractors are available who provide the
workforce for daily activities such as loading, unloading, and
packing. The major issue with contractor workers occurs when
contractor does not provide mandatory personal protective
equipment (PPE) to their workers. So screening criteria for hiring contractors should be used which includes contractor health
and safety records. It is also observed that contractors sometimes do not discuss safety with workers, for example, hazards
involved with insulation materials, paints, or asbestos sheets.
Contractors should be trained regarding the safety of its
workforce. Also, companies should have spare mandatory
PPE which can be issued to the contractor workers for
required job. Usually, contractor workers are less educated,
so they may not use PPE when they see no one is around.
Plant operation or safety engineers should discuss with them
how important PPE is to your health and safety, both for their
own life and for their family, to convince them to use all PPE.
Sometimes contractor workers perform nonroutine activities like vessel entry, welding, radiography, commissioning,
or services in an annual turnaround. It has been observed
that contractors do not inform the working shift engineers
and start welding and other activities. Actually, they should
always inform and consult the related shift engineers for
guidance and supervision. Engineers should also discuss
safety with them so that all safety precautions can be used
during any nonroutine work authorizations performed by the
PSSR is required after an MOC job, for new equipment or
for startup after a turn around. One problem in implementation is when the PSSR is not conducted before the installation of facility and it becomes difficult to implement the
PSSR recommendations after facility installation as the items
have not been agreed upon at the time of contract. After installation of an ammonia storage tank in a fertilizer plant,
when the PSSR was carried out, the following required items
were detected missing: A safety ladder required to operate
the valve installed at top of the storage tank, a platform, and
a supplied air mask at top of the tank.
The other difficulty in implementation is related to the
employee training. Employees are usually not trained at the
Process Safety Progress (Vol.32, No.1)
All employees must have proper training on the facilities
they are operating. If implementation of a PSM system is in
progress, then more training will be required regarding PHA,
MOC, incident investigation, PSSR, job safety analysis, emergency response planning and preparedness, near miss
reporting, mechanical integrity, and hot work permit. Newly
hired employees should be provided an overview of the process, health, and safety hazards associated with job tasks,
safe work practices, operating procedures, emergency operations, and emergency shutdown. Audits have identified that
newly appointed employees were not always properly
trained in operating procedures [28]. If the operation staff
Published on behalf of the AIChE
DOI 10.1002/prs
March 2013
Figure 3. Safe and unsafe behaviors trend indicating safety progress. [Color figure can be viewed in the online issue, which is
available at wileyonlinelibrary.com.]
works in rotating shifts, major problems have been observed
regarding the schedule of training especially when limited
number of spare staff is available. The other issue is that fire
fighting training is only provided to the fire fighters, not to
the all factory staff. However, a few oil refineries have training schedules for all working staff not just the fire fighters.
Also, training covering all aspects such as vapor cloud explosion, fire, toxic chemicals (ammonia, ammonium carbamate,
chlorine) release, heat radiation etc. is not always provided.
Also, often less training is provided regarding the hazardous
waste management and mitigation of toxic chemical spills.
The main issue observed in implementation is the
unawareness of many supervisors regarding the hazards
present which have resulted in accidents. A welding job was
performed in a small furnace and after welding job a dye
test was performed to check welding quality. The dye test
detected flaws, and welding was resumed without any sampling of the inside atmosphere. This clearly indicates that the
supervisor was not aware of the combustion hazards associated with dye check materials. It is clearly mentioned in
OSHA standard 1910.252(a)(2)(xiv)(B) that the supervisor
shall determine the combustible materials and protect combustibles from ignition [29].
The other main issue observed is that hot work jobs are
carried out usually without inert gas (e.g., N2) purging as
specified in OSHA standard 1910.252(a)(3)(ii). The main
problem behind it seems to be that the operations engineer
has to deal with many hot work permits at the same time.
He will be involved with conducting a JSA for said job, coordinating lab analysis, ensuring proper isolations or dismantling of electricity connections, depressurizing or venting of
equipment, and communications with management. Hence,
inert gas purging costs, time requirements, and the opera64
March 2013
Published on behalf of the AIChE
tions engineer’s tight job schedule are the main reasons
behind hot work jobs being done without inert gas.
Process safety information is the compilation of complete
and accurate written information regarding process technology, process equipment, and process chemicals. All such information should be available to all factory staff whether
working on PSM or not.
The main drawback observed in material safety data sheet
(MSDS) is that some chemicals are missing, for example, epoxy paints and their hazards are not mentioned. Exposure limits of various chemicals (e.g., ammonia) are given but concentrations which are dangerous for human beings for different
time intervals (e.g., AEGL-1, AEGL-2, and AEGL-3) are not
mentioned. Similarly, a chemical interaction matrix is not present in many companies and if present, it does not cover all the
chemicals used/present in plants. Also, chemical interactions
for all chemicals involved in a process factory are not covered.
Toxic effects of different materials involved is not known,
for example, toxic effects associated with insulating materials
(glass wool, low density fiber glass insulation, foam glass
insulation, fiber glass insulation), refractory materials (alkaline
earth silicate fiber, refractory castable), construction materials
(carbon steel, stainless steel during cutting/welding), different
acids, hydrazine, catacarb solution, and diatomaceous earth.
Usually, the effects of deviations from operating limits are
not in written form. Also, the consequences of such deviations that affect the process as well as HSE are not available.
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DOI 10.1002/prs
March 2013