Process Safety Management

Why Process Safety Management Programs Fail?

A Case Study
Hema Divya

Abstract
Despite a plethora of rising regulatory framework, advances in quantitative & qualitative techniques in Process
Safety Management, accidents still do happen in the chemical & allied industries. A major reason is that process
safety culture is not adequately inculcated in top management to plant personnel. Process safety management
audits need to be carried out periodically to ensure that adequate safeguards to protect the plant are in place and
functioning properly. Using an incident that happened in the US, this paper analyses what went wrong and sum-
marises the key learnings. It also outlines the main elements of Process Safety Management, Risk based Process
Safety and Safety Audit.

Introduction

A
ccidents related to chemical process operations Safety Management of Highly Hazardous Chemicals.
have resulted in loss of human lives, assets, Its purpose is to prevent or minimize the consequenc-
business interruptions, and has negative repu- es of releasing hazardous chemicals in a facility or the
tation for the company. This paper highlights how de- environment surrounding a facility. Hazardous chem-
ficiency in compliance audit can lead to catastrophic icals are those that may be toxic, reactive, flamma-
incidents. Process Safety Management (PSM) program ble, explosive, or a combination of these properties.
is a performance standard and the paper will summa- Industries handling hazardous chemicals are required
rize the recognized best practice for performing safety to develop an effective PSM program that protects peo-
audit reviews using William Geismar Incident as a ple, assets, and the planet [1].
case study.
Elements of PSM
The regulation issued by the U.S. Department of
These elements are the minimum requirements ex-
Labor’s Occupational Safety and Health Administration
tracted from OSHA 1910.119 [1]
(OSHA), is designated as OSHA 1910.119, Process
Employee Involvement
All employees that play a role in facility operations
Hema Divya (B.Tech-Chem Engg, PG Dip-Petrochemical Process Safety should be involved in a PSM program. Each of the
Engg) works as a Process Safety Management Consultant at Kaypear following elements requires a competent and experi-
from 2019 where she provides PSM consultancy services to Oil & Gas enced team of individuals to drive each PSM element.
and Petrochemical industries. She has worked with both domestic and Process Safety Information (PSI)
international clients providing specialized relief system validation that The PSI element requires that employers collect and
includes risk mitigation services and has strong document highly hazardous chemical information.
knowledge of API 520, API 521, and ASME Section This information pertains to the chemicals, technolo-
VIII Div.1. She is a scribe and assists the PHA facili- gy, and equipment used in the process. This informa-
tator in noding of P&IDs, consolidation of risk reg- tion should be accessible to all employees.
ister, prioritization of action items, and generation
of technical reports. She is an Associate Member Process Hazard Analysis (PHA)
with Chartered Engineer Certificate from IEI (India). A PHA is performed by a team of engineering and

34 Chemical Industry Digest. December 2021

 Process Safety Management

maintenance experts that are able to identify, evaluate, least every three years to keep up-to-date with evolv-
and control hazards. ing practices and technology. It is furthermore imper-
Operating Procedures ative to have an auditing of the PSM elements to check
Companies should document all operational pro- the effectiveness in a periodical basis. This provides
cedures involving initial start-up, normal operations, opportunity for deficiency identification and course
temporary operations, and emergency shutdowns. correction.
Training Trade Secrets
Employees should be trained on procedures, safe- This mandate ensures that employees involved
ty factors, and health hazards specific to the job task. have access to the information about the process and
health risks they may encounter during the job.
Contractor
Companies should provide training and provide CCPS Risk Based Process Safety [2]
information about the hazards in the workplace to the The purpose of the Risk Based Process Safety (RBPS)
contractors. Guidelines is to provide tools that will help process
Pre-startup safety review safety professionals build and operate more effective
Companies are required to perform a safety re- process safety management systems. These guidelines
view before new or modified facilities begin produc- provide guidance on how to design a process safety
tion, specifically, whenever there is a change in process management system, correct a deficient system, and
safety information. improve process safety management practices.
Mechanical Integrity Elements of RBPS
Routine inspections are required for major process These elements can be designed and implement-
units and equipment, such as pressure vessels, storage ed at varying levels of rigor to optimize process safe-
tanks, piping systems, relief and vent systems, emer- ty management performance, efficiency, and effective-
gency shutdown systems, control systems and pumps ness.
to ensure the mechanical integrity of the component Commit to Process Safety
meets requirements. All inspections and tests need m Process safety culture
to be well-documented and must follow Recognized m Compliance with standards
And Generally Accepted Good Engineering Practices
m Process safety competency
(RAGAGEP).
m Workforce involvement
Hot Work Permit
m Stakeholder Outreach
This mandate requires that employer’s issue hot
work permits for personnel performing high- tem- Understand Hazards and Risk
perature operations on equipment. m Process knowledge management
Management Of Change (MOC) m Hazard identification and risk analysis
A company needs to have an organized and ef- Manage Risk
ficient process for managing procedural changes re-
m Operating Procedures
garding process chemicals, technology, and/or equip-
ment. m Safe Work Practices

Incident Investigation m Asset Integrity and Reliability

Investigations should be performed on incidents m Contractor Management

that resulted in (or could have resulted in) catastroph- m Training and Performance Assurance
ic release. m Management of Change
Emergency Planning and Response m Operational Readiness
Companies are required to develop and imple- m Conduct of Operations
ment emergency action plans for the entire facility.
m Emergency Management
Emergency plans include procedures for mitigating
large and small releases. Learn from Experience
Compliance Audits m Incident Investigation

Individuals should recertify their credentials at m Measurement and Metrics

36 Chemical Industry Digest. December 2021

 Process Safety Management

m Auditing
m Management Review and
Continuous Improvement
Auditing [2,1,3]
Auditing is an element of most
PSM frameworks globally and is a
critical element which determines
the effectiveness of the PSM pro-
gram. Audits employ protocols
and checklists to verify compli-
ance with regulatory requirements
and industry standards. They help
to ensure programs are proper-
ly designed and implemented.
Audits identify program deficien-
cies so that recommendations can
be developed for corrective action.
Without regular audits, programs
will not stay current and will dete-
riorate, causing companies to face
increased health, safety, and envi-
Figure 2. Flow diagram of the process [4]
ronmental risks.
There are three main phases of ings, and preparing a report.
the audit:
• Pre-audit: Planning and organizing the audit, es- Case Study
tablishing the audit objectives, scope and protocol William Olefins Plant Explosion and Fire Incident [4]
and reviewing the design of the program by exam- About William Olefins Plant: The Williams
ining documentation. Geismar Olefins Plant, which employs approximately
• On-site audit: Conducting personnel interviews, 110 people, is located in Geismar, Louisiana, approxi-
reviewing records, and making observations to as- mately 20 miles southeast of Baton Rouge in the USA.
sess program implementation. Plant produces ethylene and propylene; these chemi-
cals are used in petrochemical industries to make vari-
• Post-audit: Briefing management on the audit find-
ety of products including plastics and antifreeze.
Process Description: Within the Williams Process,
is a distillation column called propylene fractionators;
it separates a mixture of propane and propylene. Heat
exchangers called reboilers supply heat to the frac-
tionator to boil the propane and propylene mixture,
which is essential to separation process. The reboilers
are shell and tube heat exchangers. Hot water flows
through the tubes, heating and vaporizing propane
that flows through the shell and back to the propylene
fractionator.
Incident Description: On June 13th, 2013, during dai-
ly meeting with operations and maintenance person-
nel, the Williams plant manager noticed that the water
flowrate through the operating reboiler had dropped
gradually over the past day. The operation supervisor
informed the group that he would try to identify the
Figure 1. Plant Layout from Google Earth problem. He went into the plant to evaluate the water

Chemical Industry Digest. December 2021 37

 Process Safety Management

ease of changeover of exchangers. In 2001, new valves

were installed on each reboiler to allow for operations
of only one reboiler at a time. The other reboiler was
on standby, clean, and ready to use. But unforeseen
at that time these valves introduced a serious hazard,
they isolated the standby reboiler from its protective
pressure relief valve located on top of the fractionator.
Deficiencies Identified
Management of Change (MOC)
• In 2001, Williams performed one MOC to cover
the installation of valves on the six quench water
Figure 3. Rebolier design [4]
heat exchangers identified in the 2000 proposal, in-
flowrates. The operation supervisor informed several cluding the propylene fractionator Reboiler A and
personnel that fouling within the reboiler could be the Reboiler B. The Williams MOC process required all
problem, that they might need to switch the reboiler. the members of different departments to consider
He attempted to meet with his managers so they could the potential safety implications of installing the
get necessary maintenance and operation personnel valves. They did this by answering checklist ques-
involved who would perform the work. But his man- tions used to prompt targeted analysis for each de-
ager was not available, so the operations supervisor partment. While MOC checklists can ensure con-
returned to the field and opened the water valves on sideration of common hazards, the Williams MOC
the standby reboiler. Hot water began flowing inside, reviewers nevertheless did not identify the seri-
but the valves blocking the reboiler from its protec- ous overpressure hazards introduced by installing
tive pressure relief valves remained closed. Unknown valves on the reboilers.
to the operations supervisor the standby reboiler con- • The MOC process is intended to provide a meth-
tained flammable liquid propane that had accumulat- od to identify and control all possible hazards pre-
ed when the reboiler was out of service. The hot wa- sented by a process change before making the pro-
ter heated the liquid propane confined inside the re- cess change in the facility. Williams, however, did
boiler and pressure increased leading to the rupture of not perform an MOC before installing and commis-
the reboiler. A Boiling Liquid Expanding Vapor Cloud sioning the new block valves on the reboilers. The
Explosion (BLEVE) resulted in the reboiler rupture. MOC was an after-the-fact activity for Williams to
The release fluid ignited to create a mas-
sive fireball.
Installation of block valves on the
shell side of exchanger: The water that
flows through the tubes of the exchanger
contain a small amount of oily tar which
condenses into the water earlier in the
process. Over time the oily tar from the
water builds up the walls of the reboiler
tubes, resulting in fouling. Periodic clean-
ing of tubes by shutting down, increases
the heat transfer efficiency. The original
propylene fractionator design had both
reboilers running simultaneously but in
that configuration the fractionator need-
ed to be shut down, when the reboiler
had been fouled and needed cleaning. To
prevent shut down of the propylene frac-
tionator each time the reboilers need to
be cleaned, a block valve was installed for
Figure 4. Propylene fractionator scheme at the time of incident [4]

38 Chemical Industry Digest. December 2021

 Process Safety Management

address a regulatory requirement rather than an ef- block valve on both reboilers were not complete.
fective tool used to identify and control new pro- Process Hazard Analysis (PHA): The block valves
cess hazards prior to installing the new equipment. were installed on the reboilers, to operate one reboiler
• MOC reviewers did not identify that the reboilers at a time. PHA done in the year 2001, could not iden-
required overpressure protection because of the in- tify the overpressure scenario caused by the block
troduction of the block valves in the shell side of the valves. Again, PHA was performed in the year 2006 as
reboiler. part of the revalidation cycle. The PHA team identi-
• The MOC reviewers incorrectly indicated that exist- fied the overpressure scenario and recommended car
ing operating procedures were adequate to account seal opening (CSO) of the outlet block valves. But, 2006
for the new valves, even though there was no pro- PHA action item was marked complete without car
cedure specifically for switching the propylene frac- seal open or lock open the block valve. In the year 2011,
tionator reboilers. Williams generic procedure was PHA accepted closure of 2006 action item and depend-
based on the assumption that all reboilers had the ed completely on previous documentation and recom-
process fluid on the tube side of the reboiler, which mended to update the P&ID which showed that block
was not the configuration of the propylene frac- valves were not car seal open.
tionator Reboiler B. As a result, attempting to use Relief System Analysis: In 2008, Williams per-
this generic procedure to start up Reboiler B could formed a relief valve engineering analysis, to ensure
be confusing to workers and could result in initi- the valves were properly sized for the equipment they
ating an overpressure scenario on the shell side of were designed to protect. The analysis identified that
Reboiler B, a pressure vessel that was not equipped the propylene fractionator reboilers did not have suf-
with a protective pressure relief device. ficient overpressure protection. The engineering firm
• MOC reviewers improperly indicated that the suggested two mitigation options:
change did not require a Process Hazard Analysis • Car seal open of the block valves in the inlet/outlet
(PHA), a more robust hazard evaluation option. of the reboilers shell side
• MOC reviewers selected incorrect responses re- • Installation of new relief valve to protect the shell
garding whether the new equipment met all ap- side of the reboilers
plicable codes and standards. As the overpressure Since, car seal open of the block valves was one of
protection did not meet ASME and API standards the action items during 2006 PHA, so, Williams as-
• MOC was not performed for the car seal open of the sumed that this was complete. Because the company
block valves which was one of the action items in did not fully implement the 2006 PHA action item, this
2006 PHA. overpressure hazard remained unmitigated.
Pre-Startup Safety Review (PSSR): Williams per-
formed a Pre-Startup Safety
Review (PSSR) as required by
process safety management
regulations following the in-
troduction of the block valves.
Conducting the Williams PSSR
required filling out a 21-ques-
tion form. Williams review-
ers either did not answer or in-
correctly answered key PSSR
process safety questions. PSSR
was not performed for the car
seal open of the block valves
which was one of the action
items in 2006 PHA, which
could have provided an oppor-
tunity to identify that the PHA
action item to car seal open a Figure 5. Timeline of Events

40 Chemical Industry Digest. December 2021

 Process Safety Management

process safety training and knowledge to employers

and contractors aids in identifying catastrophic in-
cidents. Managements should understand the defi-
ciency and monitor the effectiveness of the PSM pro-
gram using leading and lagging indicators. PSM au-
dits should document their deficiencies with action-
able items with appropriate stakeholders. The audit
findings should be accessible to all the employers and
the PSM Team must coordinate the closure of all action
items. The recommendations provided in such audits
have to be implemented and verified by the PSM Team
within a reasonable timeline.
References
Figure 6. Car seal opening of the valve 1. United States, Department of Labor, Occuptional Safety and
Health Adminstration (OSHA), “OSHA 1910.119, Process
Key Learnings Safety Management of Highly Hazardous Chemicals,” 8
• Process Safety Management is a performance stan- February 2013. [Online]. Available: https://www.osha.gov/
dard which requires proper implementation and laws- regs/regulations/standardnumber/1910/1910.119.
upkeep of each PSM element. 2. Center for Chemical Process Safety (CCPS), Guidelines For
Risk Based Process Safety, A John Wiley & Sons, Inc. , 2007.
• Engineers and supervisors should make risk-based
3. Center for Chemical Process Safety (CCPS), Guidelines
decisions when having operational changes. for Auditing Process Safety Management Systems, Second
• A robust management of change program is essen- Edition, A John Wiley & Sons, Inc. , 2011.
tial and is one of the elements which companies still 4. Chemical Safety Board (CSB), “Williams Olefins Plant
struggle to implement. Explosion and Fire,” 19 October 2016. [Online]. Available:
https://www.csb.gov/williams-olefins-plant-explosion-and-
• Using the hierarchy of controls when evaluating fire-/.
and selecting safeguards to control process haz-
ards, whenever there is a process change. m

• Establishing a strong organizational process safe-

ty culture, ie. when proper procedures or check-
list for PSSR needs to be documented and approved CHEMICAL INDUSTRY DIGEST
by higher management. January (Annual) 2022
• Developing robust process safety management pro- issue highlights
grams and action item closure management. From
time-to-time action items needs to be tracked and
had to be closed within reasonable timelines. n Reviews and Surveys on all chemical industry seg-
• Ensuring continual vigilance in implementing pro- ments: Oil & Gas, refineries, petrochemicals, fertilizers
cess safety management programs to prevent ma- & other agrochemicals, downstream areas like drugs
jor process safety incidents. Example audit to be & pharma, colorants etc. Chemical plant & equipment
performed at regular intervals. and Consultancy engineering
• Car seal or locked (open/close) valves have to be au- n Spotlight on New Technologies & Developments
dited to ensure the integrity of the process. n Corporate Profiles & Interviews
Conclusions n Perspectives for the Future
Process Safety Management audits have to be per-
formed periodically, to identify if the current safe-
guards are enough to protect the plant from acci- For Advertisement & Subscription contact:
dents. A process safety culture is necessary to pre- Blockdale Media LLP
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Chemical Industry Digest. December 2021 41