PROCESS SAFETY

FUNDAMENTALS

WE RESPECT HAZARDS

Incident investigations show that lack of hazard awareness is an

underlying cause of many process safety events. It is important that we Tips for Managers:
understand the process safety hazards that we face at our facilities and Take time to discuss major
be aware of the harm they could generate if we lose control of them. accident hazards with front-
Typical hazards include flammable liquids and vapours, combustibles, line workers.
toxic chemicals, asphyxiants, corrosives, pyrophorics, and high
Check that risk assessments
pressure/temperature.
address both personal and
When we routinely work close to process safety hazards it is easy process safety hazards.
to become desensitised to them. Some companies call this risk Encourage front-line workers
normalisation. This can lead to us not treating the hazard with sufficient not to become desensitized
respect and us being less thorough about how we control them. Often, to process safety hazards.
people underestimate the potential impact of process safety hazards,
particularly if they have not been directly involved with a major accident.
Additional guidance:
Pictures or videos of previous process safety incidents can help to • Energy Institute:
reinforce the sheer size of the potential consequences of our hazards. It Reflective Learning video
is good for teams to discuss the process safety hazards at their facility – ‘Removing the hazards’
and whether they fully understand the potential impacts. It can be • Step Change in Safety:
helpful to ask your company’s process safety specialists to explain the Major Accident Hazard
facility’s process safety studies. Understanding videos and
tool packs
Another common concern is that it can be easy to focus on personal
• Safer Together
safety issues at the expense of process safety. Sometimes personal
videos and other tools
safety issues are more obvious and readily spotted and that can lead to
process safety hazards being missed. It is important to recognise that • CCPS Beacon August 2019
both personal and process safety are vitally important and that we need • US Chemical Safety
to give due attention to both. Teams are encouraged to be alert for risk Board: Preliminary
assessments that do not cover all the process safety risks associated Animation of Philadelphia
with an activity. Energy Solutions Refinery
Fire and Explosions
Depending on your company management systems and legislative
• US Chemical Safety
framework you will find guidance on major hazard analysis in
Board: Winterization
documents such as: Safety Cases, PHAs (Process Hazard Analysis),
Safety Message
Safety Reports, Corporate Risk summaries, and other internal
resources.

For more information on Process Safety Fundamentals, please visit www.iogp.org/PSF

 PROCESS SAFETY
FUNDAMENTALS

WE APPLY PROCEDURES 1

Many of the operations or activities we perform on our facilities are

complex and/or have the potential to release hazardous materials if they Tips for Managers:
are not performed correctly. Step by step procedures are developed to Verify that procedures are
perform these tasks safely and prevent unwanted or hazardous situations. up-to-date, effective, and
It is good practice to use procedures on site and use job aids (e.g., sign off) easy to use.
to confirm that key steps have been completed in the correct sequence
Follow up if concerns about a
as the activity proceeds. Each company or asset may want to consider
procedure are raised.
which of its activities or tasks are “critical” and require the higher level of
assurance that “sign off” for each step of a procedure gives to the process. Ensure that personnel have
Typically, activities such as startup/shutdown of a facility, or particularly time to become familiar with
hazardous activities like pigging, are considered “critical” procedures. the plant, its equipment, and
its procedures.
Before starting a procedure, it is good practice to discuss the task Discuss Emergency Response
ahead and how it is expected to proceed. The team involved can discuss procedures with front-line
the key steps, particularly those which are irreversible, and what will be staff during site visits.
expected at those stages to confirm readiness to proceed further.
Additional guidance:
In most cases existing procedures will be accurate, however if you Refer to local company
identify issues with the quality or completeness of the procedures such guidance on procedures and
as a lack of clarity on a task or missing/incorrect data, then this should consider linking to Human
be raised so they can be addressed as part of your MOC process. Factors guidance
It is easy to become complacent about an activity that has been performed Center for Chemical Process
many times before without hazardous or unwanted outcomes. However, no Safety (CCPS). Guidelines for
matter how experienced we are, it is easy to make a mistake, and therefore Writing Effective Operating
it is important to apply the procedures thoroughly, every time. and Maintenance Procedures.
New York. 1996.
If you cannot complete or follow the procedure as it is currently written
US Chemical Safety Board:
or you think there is an issue with the procedure, halt the activity and
Fire in Baton Rouge
raise the issue with your supervisor. If you think there is a better way of
performing an activity/task discuss it with your supervisor and raise a
formal change request.

Sometimes an activity or operation is not completed in one shift, and

it therefore is important to ensure there is an effective shift handover
process so that the new shift has accurate knowledge of the status of
operations and any issues they should be aware of.

If a hazardous situation occurs, it is also important to understand and

apply emergency response procedures. These need to be readily usable
in more stressful situations and regular practice drills help to reinforce
understanding and familiarity.

For more information on Process Safety Fundamentals, please visit www.iogp.org/PSF

 PROCESS SAFETY
FUNDAMENTALS

WE SUSTAIN BARRIERS

Most companies find it helpful to think about the mental model of the
barriers that we use to control process safety hazards. A barrier is a Tips for Managers:
risk control that prevents unintended events from occurring or stops Provide tools (e.g., bowties)
escalation to harmful consequences. to enable front-line workers
We can think about barriers as being either hardware or human to understand and visualise
barriers. Hardware barriers include primary containment, process the process safety barriers at
equipment, and engineered systems designed and managed to prevent their location.
hazardous releases or mitigate their consequences. Although people Discuss process safety
are involved with maintaining and testing hardware barriers, they do barriers with front-line
not rely on someone taking action when a demand is placed on the workers during site visits.
barrier. Human barriers, however, do rely on the actions of people when Ensure that systematic
a demand is placed on the barrier, for example response to a process barrier management
alarm. Both types of barrier are important, but hardware barriers are processes are in place and
typically considered to have greater reliability, if maintained correctly. that necessary resources
are allocated to test and
It is good for front-line teams to understand and discuss the barriers
maintain barriers.
that are in place on their facility, and how reliable and effective they are.
It is important that individuals feel able to speak-up if they believe that Implement approved
a barrier is weak or adequate. This can be also be done by practicing risk reduction measures
independent verification by coworkers. for degraded or failed
barriers and restore barrier
Many find that a bowtie diagram is a helpful visual aid when having this functionality as soon as
conversation. Another helpful tool is to develop and provide a simplified practical.
scenario diagram showing the equipment and important barriers
Additional guidance:
contained within the scenario.
Energy Institute: Reflective
Understanding the role that barriers play, and what could potentially Learning: I own my barrier
happen if a barrier fails, is important as it allows teams and individuals Reflective learning:
to understand the influence they have in sustaining barrier health. I keep my barrier strong
Process safety events can result from degraded or failed barriers. US Chemical Safety Board:
Degraded barriers include those that are inhibited, overridden, Animation of April 26, 2018,
bypassed, unreliable or unavailable. These should be addressed without Explosion and Fire at the
delay and normally require approval for continued operations. Often Husky Energy Refinery in
front-line workers will play a key role in sustaining and monitoring any Superior, Wisconsin
additional mitigations that are put in place whilst a degraded barrier is US Chemical Safety Board:
being restored. Blowout in Oklahoma
Safer Together Process Safety:
We all have a part to play

For more information on Process Safety Fundamentals, please visit www.iogp.org/PSF

 PROCESS SAFETY
FUNDAMENTALS

WE STAY WITHIN
OPERATING LIMITS

Equipment operated with process conditions (e.g., temperature,

pressure, level, flowrate) outside of safe operating limits (high or low) Tips for Managers:
can result in unstable and unpredictable operation and the potential Establish and document
for process safety incidents. It is therefore important to understand the safe operating limits for key
operating limits of the plant and stay within that operating envelope. It process variables and make
is useful for teams to discuss how these limits are documented at their them visible to front-line
site and whether the limits are clear and available. workers.
Overfilling and overpressure are the most common operating limit Regularly check that
excursions that lead to process safety incidents. One common type of personnel have the necessary
fatal process safety related incident occurs when a temporary source skills and knowledge to stay
of high pressure (e.g., pump, compressor, nitrogen bottle, etc.) is within operating limits.
connected to the process with inadequate overpressure protection. This Systematically investigate
can lead to catastrophic failure impacting those working in the area excursions outside operating
even if the release does not ignite. Teams are encouraged to think about limits.
occasions when temporary pressure sources are used at their facilities Demonstrate through
and confirm that strong process safety barriers are present. Bear in decisions that cost,
mind that these are usually abnormal activities when regular barriers production or schedule does
may not be in place. not override safety
IOGP Tier 1 process safety data also includes many examples of Additional guidance:
overfilling events. Confirming sufficient capacity for material transfers • IOGP Report 456 - Process
and monitoring the transfer whilst it progresses are important aspects Safety – recommended
of staying within the operating limits for level. Teams can discuss the practice on key
potential for overfilling at their facility and whether the requirement for performance indicators
monitoring transfers are realistic given other workload and distractions.
• Center for Chemical
Some potential operating limit excursions are less obvious for example: Process Safety Beacon
• C
hange in fluid composition – with the potential for corrosion and/ (November 2007):
or erosion. This could be sudden (e.g., sand breakthrough from Cold Embrittlement and
a well) or gradual (e.g., increasing water or hydrogen sulphide Thermal Stress
content of well fluids). • US Chemical Safety
• V
elocity changes due to lower operating pressure – leading to Board: Anatomy of a
excessive vibration or erosion. disaster

Teams can discuss other potential operating limit excursions relevant

to their facility. Where there are concerns, advice should be sought from
supervision and support groups. While there is always a desire to return
to normal operation as soon as possible it is imperative to investigate
and understand the causes of an excursion to enable prevention of
reoccurrence.

For more information on Process Safety Fundamentals, please visit www.iogp.org/PSF

 PROCESS SAFETY
FUNDAMENTALS

WE MAINTAIN
SAFE ISOLATION

It is important for every activity that requires breaking containment,

that an appropriate isolation plan for the specific activity is used Tips for Managers:
and followed. Some process safety incidents have occurred when an Monitor isolation practice at
isolation plan for a similar (but not identical) task has been used but did your location to verify that
not address all the relevant hazards. Isolation plans should therefore your local practice is safe
match the particular task and be based on up-to-date process safety and effective. Implement
information (e.g., P&IDs). improvement where issues
It is good practice to discuss isolation tasks and to raise concerns before are identified.
the task begins. This enables concerns to be raised and resolved safely. Respond and follow up
if isolation concerns are
If for some reason the isolations cannot be executed as planned, you raised.
should stop work and seek advice from your supervisor on how to
Regularly check that those
proceed safely.
performing isolations are
Concerns raised might include isolations that do not achieve positive effectively trained and
isolation, quantities of drained materials that are more or less than supported.
expected, or indications of the presence of significant residual pressure More information on good
or material. practice related to this
PSF can be found either
After breaking containment, it is important to remain vigilant to
in your local management
potential signs that might indicate that the effectiveness of the
system/procedures or in the
isolations, venting or draining arrangements have changed. This could
following industry guidance:
include difficulties with proceeding with a task (e.g., due to trapped
pressure or vacuum), more liquids arising, new smells, etc. Additional guidance:
• A
lways make sure that you are either in sight of, or in control of UK Health and Safety
the isolations you are using for your job. Before putting equipment Executive – The safe isolation
back into service, it is important to verify that the system is of plant and equipment
mechanically complete using your local practices.
• B
e vigilant about potential false pressure indications (e.g., line
plugs, hydrates, etc.).
• B
efore introducing hydrocarbons, it is good practice to perform a
gross leak test where possible.

For more information on Process Safety Fundamentals, please visit www.iogp.org/PSF

 PROCESS SAFETY
FUNDAMENTALS

WE WALK THE LINE

To avoid releases of hydrocarbons and other chemicals, we often need to

check that our process systems are ready for the next stage of intended Tips for Managers:
operation. Many fatal incidents in the IOGP process safety fatality data Regularly confirm that
have occurred when the process system was used but its condition was process safety information is
not as intended. This could be a valve inadvertently left in the wrong accurate and up to date.
position, a drain or vent left unplugged, or a piping joint not fully tightened.
Discuss walk the line issues
It is therefore important to check that systems are in good condition and
with front-line workers and
correctly set-up each time we start them up or make a significant change
follow up on concerns raised.
in their use. This involves a physical, systematic inspection of the system in
the field, sometimes in tandem with monitoring from the control room. Additional guidance:
It is important that the process safety information (e.g., P&IDs) that we • Center for Chemical
use to confirm readiness, is accurate and up to date. Process Safety Beacon
(August 2015):
Physically checking systems is not always easy due to difficulties in Operational Readiness
access or visibility. Teams are encouraged to discuss the challenges
of performing thorough walk the line checks and alert supervision to
readiness or documentation concerns.

Examples of when to walk the line include:

• Material Transfers
• Equipment changes
• Handover from another work group
• Manual change in operational state - equipment idled on another shift
• Start-up after prolonged outage
• Changing direction of flow
• Return to operation after maintenance or turnaround.
• Changeover of equipment (e.g. relief valves, filters, pumps, compressors)
• Batch operations (e.g., pigging, bed regeneration)
• Temporary pipework in wells operations

What should we do: We physically verify the system is ready for intended
operation, for example:
• P&IDs and other relevant information are consulted.
• Equipment and safeguards are installed correctly and functioning.
• Plugs, drain valves, blinds and spades are installed.
• Locked open/closed valves are in correct position.
• Relief routes are not blocked.
• Unintended routes to atmosphere are isolated.
• Pressure is verified.
• If necessary, clear communication between the control room and
the field is maintained (e.g. confirming equipment tags before
performing an operation).

For more information on Process Safety Fundamentals, please visit www.iogp.org/PSF

 PROCESS SAFETY
FUNDAMENTALS

WE CONTROL IGNITION
SOURCES

If a hydrocarbon release does occur, we can often reduce or eliminate

the worst of the potential consequences by avoiding ignition. About Tips for Managers:
half of the fatal process safety incidents reviewed involved ignition, Regularly check that
so minimizing the likelihood of ignition can make a big difference in personnel understand
avoiding fatalities. Some sources of ignition may be quite obvious, the full range of potential
like hot work or nearby fired heaters, but others are less clear. The ignition sources and the
fatal incidents in the IOGP data show that ignition sources include hot requirements for ignition
work, static electricity, pyrophoric materials, ingestion into generators source control.
or other fired equipment, hot surfaces, lightning, defective electrical
equipment and vehicles. Staff are therefore encouraged to understand Additional guidance:
the full range of potential ignition sources that are relevant to their • IEC 60 079 series
facility and the measures in place to control them. • ANSI/API RP 505
Use of hazardous area classification/zoning is widespread in the • EI Model Code of
industry. But users should bear in mind that the flammable cloud from Safe Practice 15 -
larger releases can extend far beyond the classified/zoned areas shown Area classification for
on the area classification drawings. It is important to recognise this, installations handling
particularly if doing work in areas that are outside the formally classified flammable fluids
areas. The likelihood of getting a flammable cloud in these areas may • Center for Chemical
be low, but that does not mean that it cannot happen. Risk assessments Process Safety Beacon
and risk control measures will need to take this into account. (August 2016): A little
static can cause a big fire!
In preparing for and conducting work activities, consider and act on the
• Center for Chemical
following:
Process Safety Beacon
• I gnition sources can include vehicles, open flames, grinding (August 2014):
tools, pyrophoric materials, electrical equipment, hot surfaces, Ignition Sources
lightning, static electricity, and other portable electrical
equipment.
• R
eporting of defects in electrical equipment and other potential
ignition sources, such as cladding on hot surfaces, damaged EX
equipment, open wires, damaged grounding aids, is important in
controlling potential ignition.
• V
ehicle entry into areas with the potential for flammable release
should be avoided where practical. If that is not practical, vehicle
entries should be minimized and controlled.
• C
ontrol of work risk assessments should evaluate the potential for
flammable hazards even outside classified/zoned areas shown on
the area classification drawing.

For more information on Process Safety Fundamentals, please visit www.iogp.org/PSF

 PROCESS SAFETY
FUNDAMENTALS

MOC
WE RECOGNISE CHANGE

Management of change (MOC) failure has been recognised for a long

time in the oil and gas industry as being a cause of process safety Tips for Managers:
incidents. It is normal for companies to have a management of change Verify that systematic
process in place, but despite this, the IOGP fatality data indicates that identification and
MOC continues to be linked to many fatal accidents. Most typically this is management of change
when a change was made without passing it through the MOC process, processes are in place and
meaning that it did not get thoroughly reviewed and risk assessed. This working effectively.
can be because it was not realised that the change needed a MOC, so it
Ensure that workforce
is important that teams understand and are sensitive to what changes
personnel and management
need to pass through the MOC process. This enables them to look out
are trained to recognize
for change and speak up if they see a change occurring that they think
change.
should be managed by the MOC process.
Additional guidance:
Whilst it is expected that companies will have an MOC process in place
Energy Institute, CCPS,
already, this PSF focusses on recognising change that needs to be subject to
OSHA, Process Safety
MOC. Sometimes changes that might appear quite small can have a large
Management Systems
impact on process safety, either by introducing new hazards or degrading
existing barriers. It is good for teams to discuss changes at their location and Center for Chemical Process
to involve others to help identify whether management of change is needed. Safety Beacon (July 2017):
Management of Change
Change, which can be permanent, temporary or emergency, is not Center for Chemical Process
limited to hardware modifications and can typically include: Safety Beacon (September
• O perating or maintenance procedure revisions 2016): Can you recognize a
• Changes to operating limits change?
• Changes to process operating conditions (e.g., temperature, Center for Chemical Process
pressure, flowrate, composition) Safety Beacon (October
• Equipment changes (non like-for-like replacement) 2012): Manage Temporary
• Change of chemicals or materials Changes!
Teams can review their local MOC process for guidance on what US Chemical Safety Board:
triggers their MOC process and discuss examples at their location. Fire from ice
It is recognised that there may be pressure to “get work done” but US Chemical Safety Board:
experience has shown that change must be systematically managed in Blocked in
all situations to avoid unwanted incidents. US Chemical Safety Board:
It is also important to remain alert to change that occurs slowly, ”CSB Safety Bulletin Says
perhaps over many years. This “creeping change” (e.g., gradual change “Managing Change” Is
in process fluid composition or gradual reduction in a team’s experience Essential to Safe Chemical
level) also requires evaluation. Taking time out to discuss creeping Process Operations”.
change or perhaps the impact of multiple small changes on the same August 28, 2001.
system, can be useful in avoiding incidents and teams can seek advice
or alert supervision if they have concerns.

For more information on Process Safety Fundamentals, please visit www.iogp.org/PSF

 PROCESS SAFETY
FUNDAMENTALS

WE STOP IF THE
UNEXPECTED OCCURS

We normally plan our activities carefully, thinking about how we expect

the activity to proceed and what could potentially go wrong. However, Tips for Managers:
in real life there are times when things do not occur as planned or Positively recognize people
expected. who stop to reevaluate a task
Often process safety incidents have occurred when an activity has if it is not going as planned.
deviated from the expected path, but those involved have continued Communicate to front-line
anyway or informally adapted the plan on-the-run. While this may be workers that they should
well-intended, to get the job done, it has the potential to lead down a pause and seek guidance if
path that has not been fully evaluated and risk assessed. an activity is not proceeding
as expected.
This process safety fundamental highlights the importance of
recognizing when things are not progressing as expected and being Additional guidance:
disciplined about stopping or pausing to understand what has changed • Center for Chemical
and why things are not as planned. Often this may need a change to the Process Safety Beacon
plan or an update of the risk assessment, or it may prompt consultation (July 2014): Persistence –
with others to seek specialist input. We should be ready to speak up Good or Bad?
and challenge in unexpected situations and engage with supervision to
discuss our concerns. Pausing or stopping a task may feel inconvenient
at the time but keeping an activity on plan and under control will avoid
incidents, keep people safe, and support good business performance.

For more information on Process Safety Fundamentals, please visit www.iogp.org/PSF

 PROCESS SAFETY
FUNDAMENTALS

WE WATCH FOR
WEAK SIGNALS

One characteristic of most major process safety incidents is that

before they occurred, there were noticeable indications that a problem Tips for Managers:
was developing. Examples of weak signals include unusual vibration, Be alert to weak signals and
ice unexpectedly forming on the outside of a pipe, weeps and seeps, respond pro-actively when
passing valves, reoccurring alarms, or abnormal field readings. It is these signals are raised.
good practice for teams to discuss examples of weak signals that they
have seen in their facility. Additional guidance:
Energy Institute Reflective
The key is to identify these “weak signals” and respond to them before Learning Tools:
something more serious occurs. Front-line workers are often those best Chronic unease
placed to pick up on weak signals as they become very familiar with
International Association of
what is normal and what is not. Personnel are therefore encouraged to
Oil and Gas Producers:
remain alert to these signals, even if they seem unimportant, so that
Weak signals video
they can be discussed and evaluated.

Operator rounds, visual inspections or just going about our routine work
at site, are times when we can use our eyes and ears to remain alert to
anything that seems out of place or different.

When weak signals are identified and reported it can be tempting to

dismiss them too readily. Weak signals can be a vital opportunity to act
early to avoid an accident, so it is important that they are persistently
explored to understand the cause.

It is important to remain constantly aware of the potential for process

safety incidents. Some companies describe this as maintaining a state
of “chronic unease”. Always being aware of our vulnerability to a process
safety event helps us to avoid having one!

For more information on Process Safety Fundamentals, please visit www.iogp.org/PSF