On e of the mos t c om m o n l y use d p r o c ess - PowerPoint Presentation

One of the most commonly used process hazard analysis techniquesOne of the least structured techniquesApplicable to a large range of systemsThe experience of the analyst determines if the technique will be successfulUseful when making a change to a process sectionCan be applied to a system at any point in its life cycle Ge ttingHazardsHazards fromRiskHazard & RiskFinalStartedIdentificationHuman ErrorAnalysis– Case StudiesThoughts Screening Level Checklist What-if FMEAFinal details of the What-if procedure 100 H A ZOP

Lists ways equipment can fail and the effect on the system.Bottom-up analysisUses a spreadsheet to detail each hazard, cause, frequency,consequence and proposed safeguardScreening Level Checklist What-ifFailure Modes and Effect Analysis101FMEAHAZOP Ge ttingHazardsHazards fromRiskHazard & RiskFinalStartedIdentificationHuman ErrorAnalysis– Case StudiesThoughts

Assess component failures and the hazards causedDevelop recommendations for better equipment reliabilityRequirementsProcess descriptions, drawings and operating procedureAnalysis ProcedureGo through the system process, starting with the introduction of the feeduntil the end of the processComplete the FMEA tableResults Recommend ations on safeguards to avoid hazards associated withequipment failures102Screening Level Checklist What-ifFailure Modes and Effect AnalysisPurposeFMEA HAZOPGettingHazardsHazards fromRiskHazard & RiskFinal Star t ed I dent i f i c ati o n H uma n E r r or Ana ly sis – Ca s e S tud i es Thou g hts

CrackRupturePluggedLeakFalse start or stopLoss of functionHigh or low pressureHigh or low temperatureOverfillingFailure to open or closeScreening Level Checklist What-ifKeywords for FMEA analysis•Failure to start or stop103 FMEA HAZOPGettingHazardsHazards fromRiskHazard & RiskFinalStartedIdentificationHuman ErrorAnalysis– Case Studies Thoughts

Chemical AChemical BReactor Ge ttingHazardsHazards fromRiskHazard & RiskFinalStartedIdentificationHuman ErrorAnalysis– Case S tudiesThoughtsPT PT What a r e some point of fa i l u r es in this c h emical s y s t em ? Sc r eeni n g Le v el Stor a ge T a n k 104 Checkl ist Wha t - if FM E A H A ZOP

Chemical AChemical BReactor PT PT What are the hazardous events that would arise if this valve failed? What ar e s o me po i nt of fa i lure s in this chemical syste m? Sc r eeni n g Le v el Stor a ge T a n k 105 Checkl ist Wha t - if FM E A H A ZOP Ge t t i ng H aza r ds H aza r d s f r om Risk H aza r d & R i sk F i n a l S ta r t ed I dent i f i c ati o n H uma n E r r or Ana ly sis – Ca s e S tud i es Thou g hts

Here is a FMEA example for valve failure on chemical B:Date: October 15, 2013 Plant: Chemical Toronto System: Reaction SystemPage: 7 of 25 By: MinervaScreening Level Checklist What-if FMEA HAZOP106GettingHazardsHazards fromRiskHazard & RiskFinal Start edIdentificationHuman ErrorAnalysis– Case StudiesThoughtsItemIdentificationDescriptionFailure ModesEffectsSafeguardsAction s3.1Valve on the chemical B solution lineMotor- operated and normally open for chemical B serviceFails closedNo flow of che mical B Car r y o v er of chemi c al A to the st o ra g e and released in t h e enclos e d w ork area F l ow in d icat o r on che m ic a l B l i ne Ch em ical A d e tector a n d alarm Co n sid e r alar m / shut d o wn of system f or low chemical B flowConsider using a closed stora ge tank or ensure adequate ventilation of enclosed w ork area

Very structured process hazard analysis technique thatis reliable for evaluating systemsEasy to learn and apply the techniqueCan be time-consuming and expensive as the technique doesn’t directly identify process sections where multiple faults could occurThe technique may not identify areas of human error inprocess sectionsProcedural review is not easyScreening Level107ChecklistWhat-if FME AHAZOPGettingHazardsHazards fromRiskHazard & RiskFinalStartedIdentificationHuman ErrorAnalysis– Case Stud iesThoughts

Structured brainstorm using guide words to identify hazards(health, safety and environmental) and operations in a system.PurposeSystematic identification of hazardsRequirementsProcess descriptions, drawings and operating procedureAnalysis ProcedureEvaluate deviations from normal operation as potential hazardsResultsUnderstand hazards and consequences for process sectionsRecommendations of safeguards as a protection against the hazards 108 Screening LevelChecklistWhat-ifFMEAHAZOPGettingHazardsHazards fromRiskHazard & RiskFinalStartedI dentificationHuman ErrorAnalysis– Case StudiesThoughts

Intentions How the process operations are expected to occurHazard Departures from the design intentionsCauses Ways the hazard might occur Consequences Results of the hazardSafeguardsProvisions for reducing the frequency or decrease the severity of the consequence of the hazardActionsSuggestions for the procedural changes, design changesor further study109 Sc reening Level Checklist What-if FMEABefore going through details of the HAZOP procedure,let’s review some relevant terminology:HAZOPGettingHazardsHazards fromRiskHaza rd & RiskFinalStartedIdentificationHuman ErrorAnalysis– Cas e Stud i es Thou g hts

LeakRuptureReactionStaticCorrosion or ErosionReliefSamplingTestingMaintenanceStart-upShutdownService FailureWhen performing a HAZOP there are several general hazardtypes of you should focus on:110Screening LevelChecklistWhat- if FMEAHAZOPGettingHazardsHazards fromRiskHazard & RiskFinalStartedIdentificationHuman ErrorAnalysis– Case S tudiesThoughts

Define a systemExplain design intension of the process sectionSelect a process variableApply guide words to the process variable to develop a meaningful hazard Exa mine the consequence of the hazard assuming all protection failsList possible causes of the hazardId entify existing safeguards to prevent hazardAssess acceptabilit y of ri s k b ase d o n c on se qu e n ce , ca u se s a n d p r o tecti o n D e v e l o p act i o n items R e p ea t p r o ces s f o r a ll gu i d e wor ds R e p ea t p r o ces s f o r a ll p r o ces s v a ri a b l es R e p ea t p r o ces s sect i on s 111 Sc r eeni n g Le v el Checkl is t Wha t - if O v er view o f the Procedu r e FM E A H A ZOP Ge t t i ng H aza r ds H aza r d s f r om Risk H aza r d & R i sk F i n a l S ta r t ed I dent i f i c ati o n H uma n E r r or Ana ly sis – Ca s e S tud i es Thou g hts

FlowPressureTemperatureLevelTimeCompositionpHSpeedFrequencyViscosityVoltageMixingAdditionSeparationReactionWhat is meant by process variables?Be aware not all combinations make sense!Screening Level112Checklist What-if FMEAHAZOPGettingHazardsHazards fromRiskHazard & RiskFinalStartedIdentificationHuman ErrorAnalysis– Cas e StudiesThoughts

HAZOP uses guide words to identify process deviations whichcould lead to hazards:Guide Word + Process Parameter = Process DeviationExample: Less Flow No reaction113Screening LevelChecklistWhat-ifFMEAHAZOPGett ing HazardsHazards fromRiskHazard & RiskFinalStartedIdentificationHuman ErrorAnalysis– Case StudiesThoughtsGuide W ordsMeaningNo, notNot doing what was intendedMore (high, long, …) Less (low, short, …)Do ing more, or l e ss, of w h a t is i n te n d e d, qu a ntitative i n crease or decrease P a rt o f, As w e ll a s D o i n g it d i f ferentl y ; qua l i tati v e de c ea se o r i ncreaseReverse Doing something else; logical opposite of the intentOther Than Doin g something else; comp lete substitution

Example of hazards resulting from process deviationsProcess VariablesFlow, Temperature, PressureGuideword + Process Variable CombinationsNo Flow of Chemical A= No reactionHigh Temperature in reactor= degradation of productLow pressure in storage tank= flow out of reactor acceleratedChemical AChemical BReactor PT PT Stor a ge T a n k 114 Sc r eeni n g Le v el Checkl is t Wha t - i f FM E A H A ZOP Ge t t i ng H aza r ds H aza r d s f r om Risk H aza r d & R i sk F i n a l S ta r t ed I dent i f i c ati o n H uma n E r r or Ana ly sis – Ca s e S tud i es Thou g hts

Hazards are detectable with careful reviewEngineering facilities are designed and operated to appropriate standardsHazards can be controlled by a combination of equipment, proceduresThis technique is conducted with openness and good faith bycompetent analysts115Screening Level Checklist What -if FMEAThis technique makes some inherentassumptions…HAZOPGettingHazardsHazards fromRiskHazard & RiskFinalStartedIdentificationH uman ErrorAnalysis– Case StudiesThoughts

This identification procedure haslimitations:Requires a well-defined systemIt is time consumingProvides no numeric ranking of hazardsRequires trained personnel to conductFocuses on one-event failures116Screening LevelChecklistWhat-if FMEA HAZOPGettingHazardsHazards fromRiskHazard & RiskFinalStartedIdentificationHuman ErrorAnalysis– Case Studi esThoughts

AdvantagesCreative and open-endedRigorous and structuredprocedureVery versatileIdentifies both safety andoperational hazardsCan be time-consumingCritical that experienced analysts are involved in the processNo distinction between low and high probability and c onsequenc e hazards117What-if FMEADisadvantagesScreening LevelChecklistHAZOPThe aim of a HAZOP is to identify the cause of the p rocess deviation which could lead to hazards.GettingHazardsHazards fromRisk Hazar d & R i sk F i n a l S ta r t ed I dent i f i c ati o n H uma n E r r or Ana ly sis – Ca s e S tud i es Thou g hts

Screening Level Checklist What-if FMEA HAZOPoLow change of injury or death from toxic gas inhalation118Summary of Hazard Identification TechniquesWhat are the end products?A list of intrinsic hazardsA list of hazardous events and existing/ potential prev ent/mitig ation strategies:Event scenariosTheir potential causesExisting safeguardsPossible additional safeguardsA list of potential consequences and their frequencyLow chance of burn injuries or death,Moderate change of damage to pr ocess equipment,GettingHazardsHazards fromRiskHazard & RiskFinal Star t ed I dent i f i c ati o n H uma n E r r or Ana ly sis – Ca s e S tud i es Thou g hts

owners.119Screening Level Checklist What-if FMEA HAZOPSummary of Hazard Identification TechniquesHow are these techniques conducted?Checklists are often completed by a knowledgeable individualsuch as a design engineer.What-if, FMEA and HA ZOP hazar d reviews are done in teams involvement at minimum a facilitator, design engineer and representatives from the operations team (engineer, coordinator).It is always a good idea to review the results of a ny hazard review with representatives from the operations team and/or assetGettingHazards Hazar d s f r om Risk H aza r d & R i sk F i n a l S ta r t ed I dent i f i c ati o n H uma n E r r or Ana ly sis – Ca s e S tud i es Thou g hts

CheckpointProcess Hazard Analysis presentstechniques what purpose:Identification of hazardsMitigation of hazardsPrevention of hazardsA , B and CA and CHazards fromHuman ErrorRiskAnalysisGetting Star tedHazardsIdentificationHazard & Risk– Case StudiesFinalThoughtsAnswer: D120

CheckpointProcess Hazard Analysis should beconducted in parallel with:Common senseAn open mindA good understanding of physics, chemistryand thermodynamicsAll of the aboveNone of the aboveHazards fromHuman ErrorRisk Analysis GettingStartedHazardsIdentificationHazard & Risk– Case StudiesFinalThoughtsAnswer: D121

CheckpointFor routine plant operation, which ProcessHazard Analysis tool is the best to use?Screening Level followed by FMEAChecklist followed by HAZOPChecklist and What-ifScreening Level, What-if or HAZOPScreening L evel, Checklist, What-if, FMEA or HAZOPHazards fromHuman ErrorRiskAnalysisGettingStartedHazardsIdentificationHazard & Risk– Case Studies FinalThoughtsAnswer: E122

CheckpointWhich of the follow is false about checklistsas a hazard identification technique?The method is applicable to new systemsIt is possible to capture a range of historicalsystem knowledgeEnsures that common problems are n ot overlookedNew users are able to use the approachHazards fromHuman ErrorRiskAnalysisGettingStartedHazardsIdentificationHazard & Risk– Case StudiesFinalThoughtsAnswer: A123

CheckpointWhich best describes a failure modes andeffect analysis approach?Bottom-up analysisTop-down analysisHazards fromHuman ErrorRiskAnalysisGettingStartedHazardsIdent ificati onHazard & Risk– Case StudiesFinalThoughtsAnswer: A124

125Hazards caused by Human ErrorMaterials, equipment and electrical components in a process can be attributed to hazards. However, human factors can also cause errors which lead to hazardous events.What causes workplace injuries?4% are due to unsafe work conditions96% result from unsafe worker actions Unsafe behaviours are often repeated when observed as beingDzsafedz (ie not injured).GettingHazardsHazards fromRiskHazard & RiskFinalStartedIdenti ficationHuman ErrorAnalysis– Case StudiesThoughts

126John Foster (Dupont)Rail crossing Video – first time no injury, second attempt near missGettingHazardsHazards fromRiskHazard & RiskFinalStartedIdentificationHuman ErrorAnalysis– Case StudiesThoughts

What lies below the water?Major Facility Accidents (BP Oil Spill) Medical treatmentFirst aid careNear miss incidentsMost errors happen below the water, they are small and often go unnoticed by upper management. It is essential to focus on this level of hazards as they common ly propaga te into larger hazards over time.127The Safety IcebergGettingHazardsHazards fromRiskHazard & RiskFinalStartedIdentificationHuman ErrorAnalysis– Case StudiesThoughts

128Understanding Human LimitationsHuman error can be best prevent by understanding the main factorswhich mediate the limitations of human behaviour:AttentionPerceptionMemoryLogical ReasoningGettingHazardsHazards from Risk Hazard & RiskFinalStartedIdentificationHuman ErrorAnalysis– Case StudiesThoughts

129AttentionHuge amounts of information overloads humans in the workplace and attention on a task can only be sustained for short time, about 20 minutes.Workers are prone to fatigue and errors when their attention is not focu sed. Information Bottleneck – attention can only be focused on a small number of tasks.Habit Forming – If a task if repeated often then we tend to completed it without any conscious supervision. Regular, repetitive behaviours can cause mistakes .Ar e y ou st i l l foc u sed on h a za r d ident i f ic a tion? Und e r s t andi n g Huma n Limi tations T a k e a quick st r e t ch. Ge t t i ng H aza r ds H aza r d s f r omRiskHazard & Ri skFi nalStar tedIdent i f i c ati o n H uma n E r r or Ana ly sis – Ca s e S tud i es Thou g hts

PerceptionSafe interaction in the workplace requires correct perception ofhazards – information can be easily misinterpreted.Interpreting the senses – we interpret information we sense rather than perceiving it directly. Er rors ca n be minimised by making information more visual.Signal Detection – More intense stimuli cause more powerful responses. Danger signs in the workplace are purposely designed to provoked a response.Traffic lights signal to stop with a r ed li g ht ( m ost dan g e r ous) then y ell o w and f in a l l y g r een t o g o (no dan g er). Und e r s t andi n g Huma n Limi tations 130 Ge t t i ng H azards Hazards from Risk Hazard & Risk Final S ta r t ed I dent i f i c ati o n H uma n E r r or Ana ly sis – Ca s e S tud i es Thou g hts

131MemoryThe amount of information expected that workers remember cancause great stress.Capacity – Short-term memory has very limited capacity.Accessibility – It can be difficult to access details stored in our memory. Leve ls of processing – Learning material at great depth helps us more reliability remember information.Understanding Human LimitationsGettingHazardsHazards fromRiskHaza rd & RiskFinalStartedIdentificationHuman ErrorAnalysis– Cas e Stud i es Thou g hts

132MemoryTake a look at these risk related terms.Quantitative AnalysisLayers of ProtectionBow-tieEffect ModellingProbitFixed LimitStakeholdersALOHAContinual ImprovementRisk ManagementToxicityLearning LoopUnderstanding Human LimitationsGettingHazardsHazards fromRisk Hazar d & RiskFinalStartedIdentificationHuman ErrorAnalysis– Case StudiesThoughts

MemoryHow many of those risk terms can you remember?Understanding Human Limitations133GettingHazardsHazards fromRiskHazard & RiskFinalStarted Ident ificationHuman ErrorAnalysis– Case StudiesThoughts

134MemoryOn average, people can remember no more than 7 individual items at one time.If you were told these terms were grouped into three topics, it islikely your retention of this information would have been improved:Quantitative AnalysisBow-tieLayers of ProtectionEffect ModellingProbitFixed LimitRisk ManagementContinual ImprovementStakeholdersALOHAToxicityLearning LoopUnderstanding Human LimitationsGettingHazardsHazards f romRiskHazard & RiskFinalStartedIdentificationHuman Error Analysis – Ca s e S tud i es Thou g hts

135Logical ReasoningNot all people are good at logical thinking but technicalsituations require logical procedures.Severe implications can result from failures in reasoning anddecision making in engineering facilities.Understanding Human LimitationsGetting Haza rdsHazards fromRiskHazard & RiskFinalStartedIdentificationHuman ErrorAnalysis– Case StudiesThoughts

136Design Principles for a Good SystemTo prevent hazards caused by human error, it is essential that asystem inhibit people from making mistakes easily.There are 6 design principles for creating a good system:User-centred DesignManaging InformationReducing Complexity VisibilityConstraining BehaviourDesign for ErrorsGettingHazardsHazards fromRiskHazard & RiskFinalStartedIdentificationH uman ErrorAnalysis– Case StudiesThoughts

137Design Principles for a Good SystemUser-centred DesignThere is often a difference in how the user thinks about the system and the system itself. This discrepancy happens because the system designer rarely becomes the system user.The design needs to think about the expectations and intentionsof the user.GettingHazards Hazar ds fromRiskHazard & RiskFinalStartedIdentificationHuman ErrorAnalysis– Case StudiesThoughts

138Design Principles for a Good SystemManaging InformationWe are easily distracted which cause us to forget essentialtasks.Maintenance tasks are an example of easily omitted tasks:At home – How large is your pile of laundry or dishes bythe sink?At an engineering facility the same issues arise. When worke rs are under time pressure, replacing worn gaskets can be overlooked.A simple solution to both examples would be to include these maintenance items on a daily checklist or put them into your calendar.GettingHazardsHazards fromRiskHazard & RiskFinal Start ed I dent i f i c ati o n H uma n E r r or Ana ly sis – Ca s e S tud i es Thou g hts

139Design Principles for a Good SystemReducing ComplexityThe more complicated a task, the more likely there will behuman error.By structuring tasks to be as simple as possible, our ability to manage information is improved.For example, this online module was organised into 6 sections that were placed in a logical sequence. This was done to redu ce complexity of the material and facilitate the learning process.GettingHazardsHazards fromRiskHazard & RiskFinalStartedIdentificationHuman ErrorAnalysis– Case StudiesThoughts

Design Principles for a Good SystemConstraining BehaviourIf it were possible for a system to inhibit a user from performing any dangerous actions then there would be no accidents. This is impossible as the real world is too complicated!ǮForcing functionsǯ is a concept that is useful when trying topush users to follow a series of steps.An example of constrained behaviour is acash machine.- Before you can walk away with your cash, the machine prompts you with lights and a sound to first remove your cash card. This prevents the user from walking away withouttheir card. 140 Ge t t i ng H aza r ds H aza r d s f r om Risk H aza r d & R i sk F i n a l S ta r t ed I dent i f i c ati o n H uma n E r r or Ana ly sis – Ca s e S tud i es Thou g hts

141Design Principles for a Good SystemDesign for ErrorsWhen a system is designed, you must assume that mistakes will happen. When these mistakes happen, it is necessary that essential systems be designed to recovery from these human errors.It should be difficult for the user to proceed with actions that are non-reversible. Ge ttingHazardsHazards fromRiskHazard & RiskFinalStartedIdentificationHuman ErrorAnalysis– Case StudiesThoughts

Design Principles for a Good SystemDesign for ErrorsBefore permanently deleting files from your computer, you are prompted asking if you are sure you want proceed.142GettingHazardsHazards fromRiskHazard & RiskFinalStarted Identif icationHuman ErrorAnalysis– Case StudiesThoughts

Visibilityo When the user is able to perceived how their actions will influencethe system, there are fewer human errors.Prior to the nuclear incident at Three Mile Island, an example of poor user visibility was reported. Experienced operators were not able to comprehend the implic ations of elevated reactor temperatures. Their inability to perceive the negative feedback that reactors elevated temperatures would have on the plant lead them to underestimate the situation’s severity.143GettingHazardsHazards fromRiskHazard & Risk F i n a l S ta r t ed I dent i f i c ati o n H uma n E r r or Ana ly sis – Ca s e S tud i es Thou g hts

144Human error cannot be blamed solely on the worker.The management team in an organisation play an important role in the overall safety at the facility. Decisions at this level are key to fostering a culture of safety – this thinking lays the foundation for accident prevention.A safety culture represents the values, attitudes, competencies and behaviour patterns of the workers and management team. This actions and beliefs drive quality of the organisationǯs health and safety programme s. A Cultu r e o f Safety Ge t t i ng H aza r ds H aza r d s f r om Risk H aza r d & R i sk F i n a l S ta r t ed I dent i f i c ati o n H uma n E r r or Ana ly sis – Ca s e Stud iesThou ghts

145A Culture of SafetyA shared perspective about the importance of safety and preventative measurements at all levels of an organisation is central to a positive safety culture.Factors that contribute to a positive safety culture:Felt LeadershipCommitment from the CEO and management Policies and principles of safetyAll illnesses and injuries can be prevented – the goal is zeroManagement is responsible for safetyAdherence to safety is a condition of empl oymentEmployee involvement is essentialGettingHazardsHazards fromRiskHaza rd & R i sk F i n a l S ta r t ed I dent i f i c ati o n H uma n E r r or Ana ly sis – Ca s e S tud i es Thou g hts

A Culture of SafetyFactors that contribute to a positive safety culture:Follow safe procedures – be seen doing it – believe itThis thinking influences employee through:Strong personal involvementSetting an exampleBuilding commitment to urg ency, accountability, willingnessSetting high standards and expecting no less from othersBehaviour based safety through peer observation146Stop ProgrammeHi!I see that you have your proper personal protectionequipment for the job you are doing; thatǯs good.I am however concer ned abou t h o w y ou a r e l if ti ng the eq ui pme n t, y ou c o u ld h u rt y o u rsel f . M a y I su g g est an al t e r nat i v e app r oach to lifting.Ge tting HazardsHazards fromRiskHaza rd & Risk Final Started I dent i f i c ati o n H uma n E r r or Ana ly sis – Ca s e S tud i es Thou g hts

147A Culture of SafetyFactors that contribute to a positive safety culture:Tools to get the job doneExpertise in safety resourcesProcedures and developmentCommunication and motivationAudits and investigationsRitualsGettingHazardsHazards f rom RiskHazard & RiskFinalStartedIdentificationHuman ErrorAnalysis– Case StudiesThoughts

148A Culture of SafetyFactors that contribute to a positive safety culture:Good communication and shared goals that extend beyond the workplaceInstilled values and believes will be practiced by workers irrespective of what work they are doing, where they are doing it or who is watching.Practicing safe practices at home is important as off- the-job injuries cause personal suffering to the injured person and their family.GettingHazardsHaza rds fromRiskHazard & RiskFinalStartedIdentificationHuman Er ror Ana ly sis – Ca s e S tud i es Thou g hts

149SummaryHazards generated by human error can be understood through the factors governing the limitations of human behaviour: attention, perception, memory, logical reasoning.Designing a good system to prevent human error can be achieved following key principles: user-centred design, managing information, reducing complexity, visibility, constraining behaviour, and designing for errors.Once a good system is designed, instilling a culture of safety is essential to developing an organisation. In this culture, each employee exhibi ts a mindset and behaviour that ensures that their well-being leaving the workplace is the same or better than when they arr i v ed – a co m m i tm e nt t o z e r o inju r ie s . Ge t t i ng H aza r ds H aza r d s f r om Risk H aza r d & R i sk F i n a l S ta r t ed I dent i f ication Human Error Analysis– Case Stud i es Thou g hts

Checkpoint150What is the percentage of occurrences that unsafe worker actions the cause of workplace injuries?<5% of occurrences>15% of occurrences>50% of occurrences>75 of occurrences>95% of occurrencesAnswer: EGettingHazardsHazard s from RiskHazard & RiskFinalStartedIdentificationHuman ErrorAnalysis– Case StudiesThoughts

CheckpointHuman error can be blamed solely on theworker:TrueFalseAnswer: B151GettingHazardsHazards fromRiskHazard & RiskFinalStartedIdentificationHuman ErrorAnalysis– Case StudiesThoughts

CheckpointWhat are factors that contribute tolimitations of human memory?Capacity, processing levels and accessibilityCapacity, aptitude and processing levelCapacity and interest levelAnswer: A152GettingHazardsHazards fromRiskHazard & Risk Fin alStartedIdentificationHuman ErrorAnalysis– Case StudiesThoughts

CheckpointDesigning a system for errors is defined as:Inclusion of safeguards to prevent hazardousevents caused by human errorInclusion of safeguards to mitigate hazardous events caused by human errorIt should be difficult for the user to be proceed with actions that are non-reversibleEssential systems affected by inevitable mistakes from human error should be designed to recoverAnswer: C153GettingHazardsHazards fromRiskHazard & RiskFinalStarted IdentificationHuman ErrorAnalysis– Case StudiesThoughts

CheckpointWhat is meant by a Dzcommitment-to-zerodz?Zero worker sick daysZero worker accidentsZero workplace hazardsAnswer: B154GettingHazardsHazards fromRiskHazard & RiskFinalStarted Identif icationHuman ErrorAnalysis– Case StudiesThoughts

Hazard and Risk FrameworkSystem Def inition Risk AssessmentRisk AnalysisHazard IdentificationConsequence AnalysisFrequency AnalysisRisk EstimationStakeholderParticipation Risk Acceptability155GettingHazardsHazards fromRisk Hazard & R i sk F i n a l S ta r t ed I dent i f i c ati o n H uma n E r r or Ana ly sis – Ca s e S tud i es Thou g hts

o Low change of injury or death from toxic gas inhalation156Review of the end product from Process HazardAnalysisA list of intrinsic hazardsA list of hazardous events and existing/ potentialprevent/mitigation strategies:Event scenariosTheir potential causesExisting safeguardsPossible additional safeguardsSome analysis techniques ma y also generate a list of potential consequences and their frequencyLow chance of burn injuries or death,Moderate change of damage to process equipment,GettingHazardsHazard s fromRiskHazard & RiskFinalStartedIdentificationHuman Err orAnaly sis – Ca s e S tud i es Thou g hts

157Overview of the ProcedureIdentify the consequence of each hazardCategorise each consequenceEvaluate the frequency of each consequenceCategorise these frequenciesPrioritise hazards based on categorised consequences andfrequencies using a risk matrixUse the risk matrix to rank risks from each hazardDevelop action plans for high-risk events GettingHazardsHazards fromRiskHazard & RiskFinalStartedIdentificationHuman ErrorAnalysis– Case StudiesThoughts

158STEP 1Identify consequences of each hazardous event and classify each withrespect to relevant risk receptors:Employee safety and healthPublic safety and healthThe environmentProductionEquipment and machineryCompany reputation and market shareSTEP 2Categorise consequences according the level of event se verity.GettingHazardsHazards fromRiskHazard & RiskFinalStartedIdentificationHuman ErrorAnalysis– Case Studies Thoughts

159Categorise hazard consequences with these tables:GettingHazardsHazards fromRiskHazard & RiskFinalStartedIdentificationHuman ErrorAnalysis– Case StudiesThoughtsCategoryConsequences to t he P ublicConsequence to Employees1No injury or health effectsNo injury or occupational safety impact2Minor injury or health effectsMinor injury or occupational safety impact3 Injury or moderate health effectsInjury or moderate occupational illness4Death or severe health effectsDeath or severe occupational illness C ate go ry E n v ir on me n t Con se qu e n c es Con se qu e n c e to Pr odu ct i o n Lo ss Con se qu e n c e to M a r k e t S h a re Lo ss 1 < $1,000 < 1 w eek < 1 week 2 $1,000 - $10,000 1 w eek – 1 m onth 1 w eek – 1 m onth 3 $1 0 ,000 - $1 0 0,000 1 – 6 m onths 1 – 6 m onths 4 > $100 , 000 > 6 m onths > 6 m onths C ate go ry Con se qu e n ce s to C a p ital Lo ss , F ac ilit y /E qu i p me n t D ama g e 1 < $1 0 0,000 2 $100,000 - $1,000,0 0 0 3 $1,000 , 000 - $10,000 , 000 4 > $10,000 , 0 0 0

160STEP 3Estimate the frequency range of each consequence.How many times per year will this hazard consequence happen?STEP 4Categorise consequences according the level of event severity.Three levels of severity can be selected:Least stringentMore stringentMost string ent GettingHazardsHazards fromRiskHazard & RiskFinalStartedIdentificationHuman ErrorAnalysis– Case StudiesThoughts

Categorise the frequency of hazard consequences with these tables – pick least, more and most stringent cases:161GettingHazardsHazards fromRiskHazard & RiskFinalStartedIdentificationHuman ErrorAnalysis– Case S tudies ThoughtsCategoryFrequency RangeDescription1< 0.02 / yearNot expected to occur during the facility’slifetime (about 50 years), but possible20.02 – 0.05 / yearExpected to occur no more than once during the facility’s lifetime30.05 – 1 / yearExpected to occur several times during thefacility’s lifetime4 > 1 / y ear Expected to occur more than on c e a y ear

Categorise the frequency of hazard consequences with these tables – pick least, more and most stringent cases:162GettingHazardsHazards fromRiskHazard & RiskFinalStartedIdentificationHuman ErrorAnalysis– Case S tudies ThoughtsCategoryFrequency RangeDescription1< 0.001 / yearRemote – A series of failures, with a low probability of occurring within the facility’s lifetime20.001 – 0.01 / yearUnlikely – A failure with a low probability of occurring within the facility’s lifetime30.01 – 0.1 / yearProbable – A failure which can reasonably be expected to o ccur once w ithin the e x pe c ted lifetime of the plant. 4 > 0.1 / y ear F r equent – A failure w hich can reasonab l y be expected to o c cur more than on c e w ithin th e fac i lit y’ s lifetime.

Categorise the frequency of hazard consequences with these tables – pick least, more and most stringent cases:163GettingHazardsHazards fromRiskHazard & RiskFinalStartedIdentificationHuman ErrorAnalysis– Case S tudies ThoughtsCategoryFrequency RangeDescription1< 10-6 / yearRemote – A series of failures, with a low probability of occurring within the facility’s lifetime210-6 – 10-4 / year Unlikely – A failure with a low probability ofoccurring within the facility’s lifetime310-4 – 0.01 / yearProbable – A failure which can reasonab l y be expected to o c cur on c e w ithin the e x pe c ted lifetime of the plant. 4 > 0.01 / y ear F r equent – A fai l u r e w hi c h can reasonably be expected to o c cur more than once within the facility’s lifetime.

STEP 5Rank each hazardous event with a risk matrix.Consequence Category164Frequency CategoryGettingHazardsHazards fromRiskHazard & RiskFinalStartedIdentification Human ErrorAnalysis– Case StudiesThoughtsHigh MediumLowVery Low

165Hazardous event categories in the risk ranking matrix.GettingHazardsHazards fromRiskHazard & RiskFinalStartedIdentificationHuman ErrorAnalysis– Case StudiesThoughtsHigh (H)Should be mitigated with engineering and/ or administrative c ontrols to a risk ranking of LOW or VERY LOW within a specified time frame (i.e. 6 months).Medium (M)Should be mitigated with engineering and/ or administrative controls to a risk ranking or LOW or VERY LOW within a specified time frame (i.e. 12 months).Low (L)Should be verified on a continuous basis to ensure procedures or controls are in place.Very Low (VL)No mitigation required.

Note: This is risk matrix is simplified. A complete matrix includes risk score for all riskreceptors (public, environment, employees, production, capital equipment and market share).166STEP 6 - Rank the risk association with each hazardGettingHazardsHazards fromRiskHazard & R iskFinalStartedIdentificationHuman ErrorAnalysis– Case StudiesThoughtsProcess AreaHazardous EventPotential CauseExisting Sa feguards to Prevent EventExpected Future Frequency(#/year)Risk ReceptorsMaximum Event Risk Score Comment s Re c ommended A ctions Public E mplo y ee Co nsequence Score Frequency Score Ri sk Score Co nsequence Score Frequency Score Ri sk Score Natural G a s Supply F i reball and jet f la m e f rom trans m iss i o n l i ne Abo v e g round pip e l i n e rupt u re f rom impact of hea v y machin e r y No n e 1/ 2 0 4 1 L 4 3 H H N o ph y sical impact prot e ction w here pipe co m es out of t h e g round Install coll i s i on prot e ction a t m ain inlet to p la n t process area; I m pro v e l i ne la b el l i n g and de v elop uni q ue colo u r coding f or pipin g . Natural G a s Supply G a s release w ith H 2 S traces Upstream f ai l ure to treat g as at source No n e 1 2 1 VL 2 1 VL VL No n e Ch e ck H 2 S in g as suppl y .

167STEP 7For each hazardous event, develop safeguards, including action plans for any interactions between adjacent units and the emergency response on site.GettingHazardsHazards fromRiskHazard & RiskFinalStartedIdentificationHuman ErrorAnalysis – Case StudiesThoughts

168SummaryRisk analysis estimates the risk from hazards to individuals,populations, property or the environment.This analysis follows the two steps:Hazard identificationDefinition of undesirable events and the type of potential damageRisk estimationMeasure of the level of health, property or environmental risksCon sequence and frequency analysesIt is important that no value judgements be included from risk analysis.GettingHazardsHazards fromRiskHazard & RiskFinalSta rtedIdentificationHuman ErrorAnalysis– Case StudiesThoughts

Checkpoint169Risk Analysis is best described as:Consequence and frequency analysesHazard identification and risk estimationHazard identification and risk acceptabilityHazard identification, risk estimation and risk acceptabilityAnswer: BGettingHazardsHazards fromRiskHazard & Ri skFi nalStartedIdentificationHuman ErrorAnalysis– Case StudiesThoughts

CheckpointOnce hazards are identified, how is risk analysed?Consequences and frequencies are identified and evaluated through a risk matrixConsequences and frequencies are identified and evaluated through a risk matrix followed by a ranking procedureConsequences and frequencies are identified and evaluat ed through a risk matrix followed by a ranking procedure and development of action plansAnswer: C170GettingHazardsHazards fromRiskHazard & RiskFinalStartedIdentificationHuman ErrorAnalysis– Case S tudies Thou g hts

CheckpointHazard consequences are categorised with tables. Which of the following is not a standard table?Consequences to the publicConsequences to the workerConsequences to managementConsequences to capital lossConsequences to market shareAnswer: C171GettingHazar dsH azards fromRiskHazard & RiskFinalStartedIdentificationHuman ErrorAnalysis– Case StudiesThoughts

CheckpointHazardous events classed as medium risks should be managed in the following manner:No mitigation required, redesign system to ensure hazardpreventionShould be verified on a continuous basis to ensure that procedures and controls are in placeShould be mitigated with engineering and/ or administrative cont rols to achieve a lower risk ranking with 12 monthsShould be mitigated with engineering and/ or administrative controls to achieve a lower risk ranking with 6 monthsAnswer: C172 GettingHazardsHazards fromRiskHazard & RiskFinalStarted Ident i f i c ati o n H uma n E r r or Ana ly sis – Ca s e S tud i es Thou g hts

CheckpointValue judgements are a key componentto the risk estimation procedure?TrueFalseAnswer: B173GettingHazardsHazards fromRiskHazard & RiskFinalStartedIdentificationHuman ErrorAnalysis – Ca se StudiesThoughts

punch presses and paint-spray booths.174In a Canadian manufacturing plant of a global automotive company, many engineering activities are conducted in design, part production, assembly, testing and quality assurance areas. The plant produces and assembles vehicle parts including engines, pumps, fans and electronics.The manufacturing proc esses by 400 plant employees and some are performed using automated technologies and equipment. Use of people or machines to perform tasks is dependent on cost, time, quality and worker health and safety.The plant operates 3 shifts per day. There are production lines including machining equipment, conveyers and overhead cranes, Automotive C a se S tud y – Health Hazar d s Ge t t i ng H aza r ds H aza r d s f r om Risk H aza r d & R i sk F i n a l S ta r t ed I dent i f i c ati o n H uma n E r r or Ana lysis– Case Studies Thoughts

175Workers at the plant have reported several different health problems. The following information has been received by the head engineer:1. In a recently installed assembly area, workers have to bend to the ground throughout the day to attach several small parts onto a vehicle chassis. Some works developed lo wer back pain, likely due to repetitive bending. For one of the workers, the problem is so severe that he was advised by his doctor to stay off work for two weeks so his back can recover.The manufacturin g engineers who designed the assembly operation had wanted to use an automated system but this option was not deemed t o be e c o n omic. A manua l o p e r ati o n w as use d bu t industrial e r g o n om i c s w as n o t ta k en i n t o a c c o u nt bec a us e of a lack of expertise.Automotive Case S tudy – Health Hazar dsGetting HazardsHazards from Risk Hazard & RiskFi n a l S ta r t ed I dent i f i c ati o n H uma n E r r or Ana ly sis – Ca s e S tud i es Thou g hts

176Workers at the plant have reported several different health problems. The following information has been received by the head engineer:2. An increased incidence of respiratory illness has been reported over past month by workers operating near the paint-spray booths. Many of the paints and solvents used in the boo ths are known to be the cause of respiratory illnesses. Works are not supposed to be exposed to these substances because the paint-spray booths were designed to be ensured all materials exit the paint through a high-cap acity ventilation system. No tests have been carried out on the ventilation system or the plant air quality so it is uncertain w hether or not the r e h a v e bee n a n y p ai n t - sp ra y bo o th leak s . Aut o moti v e C a se S tud y – Health Hazar d s Ge t t i ng H aza r ds H aza r d s f r omRisk Hazar d & RiskFin alStarted Identif ication Human E rrorAna ly sis – Ca s e S tud i es Thou g hts

177Workers at the plant have reported several different health problems. The following information has been received by the head engineer:3. In an area of the plant where metal cutting occurs, works are required to wear protective eyewear. However, workers operating in this area have started to report minor eye injuries. It is common knowledge that workers do not routinely u se the pro tective equipment; the eyewear is frequently observed to be hanging on nearby hooks or loosely hanging around workers’ necks. Workers complain that they find the protective eyewear to be uncomfortable and do not think it is needed or important. The plant manager knows of thi s behaviour but overlooks it since enforcing the eyewear use seems to make workers unhappy and less productive.Automotive Case Study – Health Hazards Ge t t i ng H aza r ds H aza r d s f r om Risk H aza r d & R i sk F i n a l S ta r t ed I dent i f i c ati o n H uma n E r r or Ana ly sis – Ca s e S tud i es Thou g hts

185Automotive Case Study – SafetyLetǯs consider the same automotive facility again but this time weǯll look at a safety related concerns.GettingHazardsHazards fromRiskHazard & RiskFinalStartedIdentificationHuman ErrorAnalysis– Case Studies Thoughts

an incident would increase.186The head engineer wants to ensure that plant provides a safe and healthy environment. An engineering health and safety consulting company was hired to do a health and safety audit of the plant. The consulting companies report included the following issues:1. An expert on fires and explosions notes the ext ensive us e of natural gas in the plant could lead to an explosion in some circumstances. The potential for an explosion could develop if a sufficient natural gas leak. Which could lead to severe worker injuries or deaths. Detection of natural gas concentrations in the plant is monitored by sensors. Only one sensor is installed in the plant but not i n the mai n a r ea w he r e a c cumulatio n of natu r al gas w ould b e li k e l y t o o c cu r . In addition t o the c o n c ern f or the o n l y having the single sensor installed, the ex pert not ed the sensor was not connec ted to an automated natural gas shut-off system. Without a shut-off f eatu r e, the se v erity of Aut o moti v e C a se S tud y – Safety Ge t t i ng H aza r ds H aza r d s f r om Risk H aza r d & R i sk F i n a l S ta r t ed I dent i f i c ati o n H uma n E r r or Ana ly sis – Ca s e S tud i es Thou g hts

187The head engineer wants to ensure that plant provides a safe and healthy environment. An engineering health and safety consulting company was hired to do a health and safety audit of the plant. The consulting companies report included the following issues:2. Gas line maintenance is required every quarter; no evidence of maintenance had been found sin ce the gas lines were installed four years ago. This maintenance procedure involves checking for and fixing gas leaks. Workers also require training on procedures to prevent an explosion; this training had not been conducted and workers were not aware of the potential explosion hazard. No written procedure relating to ex p losi o ns w e r e f ou n d w i thin the p lant. Aut o moti v e C a se S tud y – Safety Ge t t i ng H aza r ds H aza r d s f r om Risk H aza r d & R i sk F i n alStart edIdentificati onH uman Er rorAnalysis – Cas e S tud i es Thou g hts

188The head engineer wants to ensure that plant provides a safe and healthy environment. An engineering health and safety consulting company was hired to do a health and safety audit of the plant. The consulting companies report included the following issues:3. The plant was found to contain toxic materials that can harm the health of people and an imals. The storage area for these hazardous substances was not found to be sufficient in containing the chemicals in the event of an explosion. Release of these substances could lead to illness or deaths among members of the public and could also harm the environment.Automotive Case Study – SafetyGettingHazardsHazards fromRiskH azard & R i sk F i n a l S ta r t ed I dent i f i c ati o n H uma n E r r or Ana ly sis – Ca s e S tud i es Thou g hts

194Hazard and Risk identification answers the following questions:What can go wrong? How? Why? What are the consequences?How likely are these consequences?What is the risk?GettingHazardsHazards fromRiskHazard & RiskFinalStartedIdentificationHuman Err orAna lysis– Case StudiesThoughts

195Finding HazardsHazards are commonly related to energy:Human errorKinetic energyPotential energyHeatElectricityIn addition to energy sources, human error can be attributed tomost workplace accidents.96% of workplace injuries are caused by unsafe worker actionsGettingHaza rds Hazards fromRiskHazard & RiskFinalStartedIdentificationHuman ErrorAnalysis– Case StudiesThoughts

196Human Error as a Cause of HazardsAs engineers designing a facility, we must be aware of the limitation of human behaviour. This includes a workers or operatorǯs attention span, perception, memory and logical reasoning abilities.When human error is identified as a hazard in a process, we must acknowledge that the worker cannot be solely blamed. An organisatio nǯs management team plays a key part in overall safety.Instilling a safety culture in an organisation is essential toreducing the number of worker caused accidents to zero.GettingHazards Hazards fromRiskHazard & RiskFinalStartedIdentificationHuman Err or Ana ly sis – Ca s e S tud i es Thou g hts

197Hazards, Risk, Sources and ReceptorsA hazard connects risk sources with risk receptors. Thesesystem components include:Risk sourcesIndustrial facilitiesRoadwaysUniversity laboratoriesRisk receptorsPlant Operators and workersStudents at a UniversityShareholders o Community o Environment o RegulatorsGetti ngHaza rdsHazards fromRiskHazard & RiskFinalStartedIdentificationHuman ErrorAnalysis– Case StudiesThoughts

198Hazard Identification MethodsProcess Hazard Analysis techniques are used to identifyhazards. Qualitative methods we discussed include:Screening Level analysisChecklistsWhat-if analysisFailure Modes and Effects Analysis (FMEA)Hazard and Operability Study (HAZOP)These techniques present a pro-active and systematic approach for the identification, mitigation or prevention of hazards from a process, materials, equipment or human error.GettingHazardsHazards fromRiskHazard & RiskFinalStartedIdentificationHuman ErrorAnalysis– Case Studi esThou g hts

199Generalised Process Hazard Analysis ProcedureBreak down the system into process sectionsIdentify the intrinsic hazards in each section (chemical, material, equipment, human)Evaluate the cause of each hazard to develop a hazardous eventAdditional steps for What-if, FMEA and HAZOPsDetermine the consequence of each hazardous eventEstimate the freq uency of each hazard consequenceGettingHazardsHazards fromRiskHazard & RiskFinalStartedIdentificationHuman ErrorAnalysis– Case StudiesThoughts

200Estimating RiskWe can use hazard-related frequency and consequenceinformation to determine the associated risk.Consequences and their frequency can be ranked in a matrixto estimate risk.Risk = Estimated consequences of a hazardous event xFrequency of the event’s occurrenceRisks are ra nked as very low, low, medium and highGettingHazardsHazards fromRiskHazard & RiskFinalStartedIdentificationHuman E rrorAnalysis– Case StudiesThoughts

201Risk analysisProvides an objective basis for comparing hazards,alternatives and risk control measurementsThis analysis procedure is also of great importance forresponse planning for emergenciesThere many types of risks that may be identified:Event RiskFacility RiskIndividual RiskSocietal Risk Volunt ary RiskImposed RiskSafety Risk EnvironmentalRiskEquipment RiskShareholder RiskGettingHazardsHazards fromRiskHazard & RiskFinal StartedIdentificationHuman ErrorAnalysis– Case StudiesThoughts

Hazard and Risk Framework S ystem DefinitionRisk AssessmentRisk AnalysisHazard IdentificationConsequence AnalysisFrequency AnalysisRisk EstimationRisk AcceptabilityStakeholderP articipation202GettingHazardsHazards fromRiskHazard & Risk Fina l S ta r t ed I dent i f i c ati o n H uma n E r r or Ana ly sis – Ca s e S tud i es Thou g hts