Tag Archives: Chemical Safety Board

Chemical safety as social science

Chemical manufacturing safety is challenging to oversee consistently over time. A given manufacturing facility has many kinds of hazards, some common and some specific to plant activity. Specialized operations will produce hazards that manifest in ways ranging from obvious to obscure to counterintuitive. For those tasked with keeping operations free from injuries and mishaps, the hard part may be to keep everyone vigilant constantly.

I often compare safe practices to the handling of a rattle snake. Every time you pick up that snake, you have to be just as careful as the last time. Over time you may learn to predict or anticipate threatening snake behaviors, but you do not get to bank safety credits for past cautious behavior. Furthermore, it is necessary for you to change some of your basic behaviors around the rattler. For instance, you may want to alter your posture when standing near the snake so, if you lose your balance, you fall away from the snake, not onto it. Or, you may decide to bring the snake out only when there is not a crowd around you for fear of spooking the animal. A wrangler can cite many techniques to adopt when handling this venomous creature.

My views of safety policy and practices have evolved over time. In the academic and industrial lab facilities I have worked, safety policy varied from “don’t get hurt” to academic departmental policies with the unofficial “for god sakes don’t let a student get hurt” to highly professional facilities using “we reserve the right to dismiss you” if your accident involved a violation of policy. In these chemistry jobs I have functioned as a dairy processing lab chemist, student assistant, grad student, postdoc, assistant professor, chemical sales manager, senior scientist and process safety chemist. There has been some variety.

What allowed my successful navigation through these experiences with body parts intact? Skill from good training and a large shot of luck. And having been cautious by nature when it comes to hazardous energy and chemical hygiene doesn’t hurt.

In my estimation there is a large social/psychological component to safety anywhere. Safe operations in a chemical plant requires an alignment of behaviors that lead away from mishaps due to all manner of influences, predictable or otherwise. To oversee safety at a facility, one must use facts and the power of persuasion to convince people to behave in ways that might seem needless or unnatural. There is a large social component to safety. That said, the threat of dismissal doesn’t hurt.

In a US chemical plant, operational staff commonly undergo safety training on hiring and refresher training thereafter on a periodic basis. If an adverse event happens relevant staff may undergo a refresher training session as policy dictates. The range of safety topics will depend on the kind of activity happening at the facility.  Safety training has the goal of bringing and keeping staff up to par on recognition and prevention of some kind of undesired event that plays out as a near miss or an incident.

A core subject in chemical manufacturing facility is the matter of hazardous energy. Hazardous energy is manifested in numerous ways: High pressure, high temperature, electrostatic, rapid or runaway heat of reaction, compressed springs and energy of motion. Hazardous energy can emerge from the familiar and the unfamiliar.

Dangers emerging from “ordinary” hazards, i.e., the hazards everyone is accustomed to, can perhaps be most vexing. How does one convince people not to become complacent with familiar hazards, particularly those of low frequency high consequence?

Frequent training and thorough root cause analysis of actual incidents is probably the best approach to suppressing complacency. One need look no further than the military for an example. Military personnel undergo frequent training with an emphasis on situational awareness. A particular strength is the existence of protocols for many exigencies and the mandatory adherence to that protocol. The obvious problem of the military approach to training is that it is not aimed at producing material goods for a competitive market. Businesses cannot afford to lavish much downtime to training. Civilian safety training in business is conducted but at nothing like the frequency or scale that the military uses to maintain readiness.

A useful tool available to industrial safety is layer of protection analysis (LOP). There are companies that offer custom LOP services/instruction and outside assistance is often a good thing. Other resources exist as well. There are two kinds of layers- administrative and engineering. Administrative layers of protection include the process instruction document, various SOPs and work instructions, training as well as eyes-on active management. Engineering layers of protection refers to the equipment which protects against the effects of an excursion.  Each layer will have empty spaces where they are not protective. The idea is to lay down layers where the empty spaces do not overlap. Most would agree that engineering LOP are preferred over administrative LOP.

The terms “dangerous” and “hazardous” are often used interchangeably. I would argue that the word danger be reserved for the situation when all of the layers of protection around a hazard have been removed. This is an important distinction because our lives are filled with hazards that don’t fill us with dread fear. We tolerate this only because we contain hazards with layers of protection which prevent the consequences of the hazard. In order to keep working in an industrial setting, we all must come to terms with the contained hazards on site. Workers predisposed to chemophobia must become comfortable with the LOP in place, yet remain vigilant for uncontained hazards. The alternative for them is to work elsewhere.

Incidents should be followed closely by a Root Cause Analysis, RCA. There should be an SOP that specifies this action. With any luck, an expert conversation in the subject matter at hand will spark the insight of someone leading to the identification of failure modes related to the incident. The RCA will identify which dominoes fell in the event and will highlight the weak points and hopefully find the initiating event. Finding the incident initiating event is always a goal.

It is important to evaluate the existing LOP after the RCA and every effort should be made use the event to strengthen systems. The notion of LOP should be present early in the process of writing instructions for the manufacture of materials. Each batch or process instruction document should be critically evaluated and signed off by a variety of experienced people. This would include R&D chemists, chemists and engineers involved in process scaleup, Environmental, Health and Safety, production supervisors and plant managers. All can be reminded to evaluate the production document with LOPA in mind.

Inevitably, incidents and near misses stemming from unanticipated failure modes will occur. To provide added protection against the unexpected, imaginations need to be stimulated by conducting a PHA- Process Hazard Analysis. This must be done before a process is begun. It is a formal brainstorming session conducted by a committee of subject matter experts evaluating every step in a chemical process at the production scale for possible failure scenarios. These will be chemical, mechanical or safety systems related. In the PHA you ask the question: What happens if this component or action fails in the process? It is a detailed what-if map of the failure or event with potential consequences. Each potential consequence must be evaluated for risk and harm. Software is available to help people guide themselves through the process.

Finally, it should be noted that once the incident investigation is complete, learnings from the event should be applied going forward and archived where the results can be readily found.

Company gets public spanking from CSB

The US Chemical Safety Board (CSB) has publically expressed dismay and disappointment in a letter to Tesoro Corporation in San Antonio, TX. It is in regard the apparent unwillingness of the company to allow CSB investigators to come on site and continue with the investigation of an industrial accident or, if you prefer, incident. Apparently two workers were splashed with sulfuric acid and had to be choppered out for treatment.

From what I gather from the CSB letter, Tesoro doesn’t believe that the incident rises to the level of seriousness to justify a CSB investigation. That is my own interpretation.

At first blush it would seem that Tesoro has a point. While it is something that OSHA would cover, does it really necessitate attention by the CSB? By itself it seems questionable. But when you consider that Tesoro had an 7-fatality explosion and fire at its Anacortes refinery in April of 2010, perhaps the scrutiny seems less unreasonable.

The refinery explosion was determined to result from high temperature hydrogen attack within a 40 year old shell and tube heat exchanger. Catastrophic structural failure on startup after a scheduled tube cleaning resulted in an explosion and fire with immediate and delayed fatalities.

It seems to me that the failure of a high temperature heat exchanger after 40 years of service handling hydrogen and naphtha has more to do management policy on equipment service life than anything else. This speaks to prudent administrative and engineering controls on plant safety. A shell and tube heat exchanger has no moving parts to fail. It just sits motionless doing it’s function. There are no failing parts to replace other than leaky tubes and valves. Perhaps no one considered that the inherent nature of the gas and thermal cycling was deleterious to the integrity of the metal shell? Perhaps there was no enthusiasm to define official hours of operating life. Plant managers are always under pressure to minimize operating costs. This is especially true of plants producing high volume low margin commodities.

But here is the rub. Everything has a failure rate. This is especially critical for equipment under high temperature and pressure. The first layer of administrative control is for management to make allowances for materials in extreme environments. Anacortes is not the only recent incident where component failure has occurred in equipment performing under demanding conditions. Before the engineers can make equipment specifications for this, management has to conform to the notion that some parts of a plant should have better definition on service life. They should demand it of their design people and support engineering when the time comes to replace a component.

If the CSB believes that a company has weak administrative controls that influence plant safety, then I think they should investigate.