Incidentally

We have now completed our 1st deck of Incidents Cards based on 52 famous (and less well known) Process Safety (Loss of Primary Containment) events researched, evaluated & summarised by Peter Marsh of XBP Refining.

These have been peer reviewed by members of the IChemE Safety & Loss Prevention Special Interest Group.

Their work is documented as a Lessons Learned Database which is free to download by clicking the image below:

Click to download Major Process Safety Incident vs Root Cause Map

A 2nd deck is already in development which will visualise & operationalise the 100+ incidents investigated by the US Chemical Safety & Hazard Investigation Board.

Click to access the CSB Investigations

Cards

Key aspects of each Incident are illustrated as shown below

These are described on the Incidents Cards page which can be accessed via the icon below:

Cards have a Top Trumps layout similar to the SDS cards and can be used (played) in a variety of ways e.g. discuss if/how this incident relates to our operations or simply who holds the most ‘severe’ card is either the winner or loser – the prize or forfeit to be decided by the team.

The Process Incidents cards use the following iconography:

Hazards

Biological
Corrosive
Decomposition
Environmental
Explosive
Flammable
Compressed Gas
Irritant or Harmful
Health
Oxidising
Radiological
Toxic

Industries

Chemicals
Explosives
Consumer Goods
Food & Drink
Gas Processing
Laboratories
Life Sciences
LNG
LPG
Manufacturing
Metal Processing
Nuclear Power
Offshore Oil & Gas
Oil Refining
Onshore Oil & gas
Petrochemicals
Pipelines
Plastics & Polymers
Power Generation
Pulp & Paper
Rail Transport
Renewable Energy
Road Transport
Shipping
Tank Storage
Warehousing
Waste Treatment
Water Treatment

Contributing Factors

Using the Root Cause Map, Proximate (immediate) and/or Root Causes are indicated by up to 10 of the following Process Safety Management (PSM) elements (cards):

Leadership & Culture
Continuous Improvement
Information Management
Capability Management
Hazard & Risk Analysis
Process & Plant Design
Operational Integrity
Asset & Protection Integrity
3rd Party Management
Emergency Planning
Control of Work
Event Investigation
Change Management

For more information on all our cards & initiatives – please contact us. All materials (physical cards/boxes and digital cards/platforms) can be customised to match your technical & local languages – please visit our Options page for more details.

If you’d like to subscribe to future updates, please submit your email address below – many thanks for your interest.

Don’t Gamble with Safety

Inspired by playing cards created by ICI and Esso, we designed our decks to be informal as well as informative, fun as well as functional to provide Users (‘Players’) with a familiar format to learn through gamification e.g. to play ‘conventional’ card games with their teammates or co-workers.

However, we recognise (and respect) that different Cultures, Countries & Companies have specific restrictions or prohibitions on gambling & gambling materials.

To increase & sustain the awareness of frontline personnel to potentially hazardous events within these organisations, we’ve removed all gaming references but retained the same iconography to provide a clear consistent visual language that can be utilised on cards, magnets or digital platforms.

For example (as shown below) cards can be produced (in different languages) to challenge Users to consider (identify) Threats (Causes) and Barriers (Controls) associated with each hazardous event. This provides a useful introduction to Bowties and enhanced scenario understanding.

For more information on all our cards & initiatives – please contact us. All materials (physical cards/boxes and digital cards/platforms) can be customised to match your technical & local languages – please visit our Options page for more details.

If you’d like to subscribe to future updates, please submit your email address below – many thanks for your interest.

2022 Mary Kay O’Connor Safety & Risk Conference

We will be presenting “Process Safety Cards – Visualizing Knowledge & Operationalizing Wisdom” at the forthcoming Mary Kay O’Connor Safety & Risk Conference in College Station, TX .

This event, in association with the IChemE and C-RISE, has the tag line “Health to Human is Safety to System: Making Safety Second Nature” and we aim to show how cards can be used to embed & retain Safety (and Integrity) knowledge so that it can become second nature i.e. intuitive & instinctive.

For more information on all our cards & initiatives – please contact us. All materials (physical cards/boxes and digital cards/platforms) can be customised to match your technical & local languages – please visit our Options page for more details.

If you’d like to subscribe to future updates, please submit your email address below – many thanks for your interest.

SLOPE

Simple Layer of Protection Exercise

The CCPS book “Layer of Protection Analysis: Simplified Process Risk Assessment” has been the definitive reference for performing Layer of Protection Analysis (LOPA) since it was published in 2001.

LOPA is a simplified form of risk assessment which typically uses order of magnitude categories for Initiating Event Frequency (IEF), Consequence severity, and the likelihood (probability) of failure of Independent Protection Layers (IPLs) or Conditional Modifiers (CMs) to approximate the risk of a scenario.

Click for details

To help explain the principles to stakeholders (Operational and/or Management for example) who are less familiar with the concept, we’ve developed a simple card game or training exercise which can be played digitally (as shown in the video below) or physically with customised playing cards.

Click Watch on YouTube for Captions

The basic rules are relatively simple – the aim is to reduce the likelihood of a randomly selected hazardous event or scenario by assembling a collection of appropriate protection layers using order of magnitude frequencies & probabilities.

  • Up to 4 players can construct a Scenario (each are assigned a row).
  • Start by drawing (click to flip) from the Cause deck and place on the left-hand holder – this has a value according to the initiating event frequency (1 = Most frequent to 6 = Least frequent).
  • Draw a card from the Consequence deck and place on the 2nd from left holder – this has a value according to the tolerable/target event frequency (1 = Most tolerable to 6 = Least tolerable).
  • The aim is to create a Mitigated Event score to be equal to or less than the Target score. Subtract the Cause value from the Consequence value to get the gap which has to be closed by one or more Control cards
    • e.g. a Cause (card) with a value of 1 which could lead to a Consequence (card) with a value of 4 requires a risk reduction of 3. This could be a single Control with a value of 3 or several controls whose values add up to 3 or more.
  • Draw a card from the Controls deck and place on the 3rd from left holder – this has a value according to the risk reduction it provides (1 = Least effective to 3 = Most effective).
  • Players take it in turn to draw from the Controls deck to create their scenario. Once you’ve drawn a Controls card, play moves on.
  • The winner is the first to close the gap (or better i.e. if they reduce the risk more than required).

Rules:

  • If a Controls card has a zero value e.g. inadequate human response or ignition control, then they have to put the card in the bin (they can’t develop their scenario until their next turn) and play passes to the next person.
  • If a Controls card is similar to the Cause e.g. both BPCS or both Human, then they have to put the card in the bin and play passes to the next person.
  • If a Controls card is similar to another Controls card in their scenario e.g. both pressure relief or ignition control or SIF, then they have to put the card in the bin and play passes to the next person.
  • If a Controls card is not an appropriate mitigation measure e.g. reduced occupancy for an Environmental or Financial consequence, then they have to put the card in the bin and play passes to the next person.

Formats:

Tables can be configured in a number of different ways (click on images to enlarge):

Bowtie

  • Threats (Causes) on the Left
  • Consequences on the Right
  • Barriers (Controls) in between

PHA (HAZOP)

  • Causes on the Left
  • Consequences next right
  • Safeguards (Controls) to the right

LOPA

  • Consequences on the Left
  • Causes next right
  • Protection Layers (Controls) to the right

Variations:

  • Players have to describe the cards they’ve deal e.g. give an example from their experience. If they cannot give an appropriate explanation, they cannot play that card and it goes into the bin stack.
  • Cards can be customised to suit corporate or industry types & values e.g.

In this prototype, examples from the CCPS LOPA book have been used to illustrate the principles. .

Causes

Causes are taken from Table 5.1 (Initiating Events):

Note that the following Causes are not frequencies:

  • Crane Load Drop (per lift)
  • LOTO Failure (per opportunity)
  • Trained, Unstressed, Not Fatigued Operator Failure (per opportunity)

For simplicity, the game should assume that these occur at 1 lift or opportunity per year.

Consequences

Consequences are illustrative only.

Controls

Controls are taken from Table 6.3 (Passive IPL), Table 6.4 (Active IPL), Table 6.5 (Human IPL) & Figure 7.1 (Ignition Controls).

Guidance

Cards and games are not intended to replace proper analysis conducted by competent & experienced personnel. For more guidance on the principles of Layer of Protection Analysis, please click on the images below:

Click for details
Click for details

Cards (and digital game boards) can be branded to suit and physical cards can be created in magnetic format to play in a workshop environment.

For more information on all our cards & initiatives – please contact us. All materials (physical cards/boxes and digital cards/platforms) can be customised to match your technical & local languages – please visit our Options page for more details.

If you’d like to subscribe to future updates, please submit your email address below – many thanks for your interest.

Lessons Remembered

The recent tragedy at Aqaba Port is a constant reminder that we need to be vigilant to the potential Loss of Containment events that may have long lasting effects on or in the community. Life continues to move on for all of us, however those directly and indirectly affected by this incident will never forget.

Industries have a long established culture of sharing Lessons Learned, however that learning may be static, stale or transient whereas what we really need is not just Learning, but Remembering (at or before the point/time of use/need) followed by appropriate Corrective & Preventive Action.

Potential

Safety Data Sheet (SDS) cards highlight the hazards associated with the assets & activities.

Chemical Safety Card (AR)
Chemical Safety Card (EN)

Problems

Loss of Containment (LoC) cards highlight how the integrity of equipment & transfer systems can be compromised or breached.

Process Safety (Containment Integrity) Card

Cards can be enhanced with QR Codes which direct the User/Player to more detailed information:

Click QR Code for sample information on Dropped Objects

Protection

Scenarios (in Bowtie format) visualise how Loss of Containment or Control can be prevented with an emphasis of Degradation Factors to highlight how barriers can be compromised:

Dropped Object Bowtie

The Consequences (Effects) fo the Loss of Control/Containment will depend on the materials handled (hazards & inventory) and the conditions (pressure & temperature) under which they are processed or stored. The right hand side of the bowtie is therefore asset/activity specific.

Predicaments

Incidents Cards summarise WHAT, WHEN, WHERE & WHO to provide accessible, portable & memorable tools to inform Novices and remind Veterans that they must be vigilant, not complacent – it can and might just happen to you and/or your colleagues:

Incident Card (AR)
Incident Card (EN)

QR codes on the cards direct the User/Player to more detailed information on the incident e.g. WHY:

Click QR Code for sample information on Aqaba Port

For more information on all our cards & initiatives – please contact us. All materials (physical cards/boxes and digital cards/platforms) can be customised to match your technical & local languages – please visit our Options page for more details.

If you’d like to subscribe to future updates, please submit your email address below – many thanks for your interest.

Managing the Safety of Processes

PSM Manual 1.0

Our Process Safety Management (PSM) cards have been updated to represent a full set of human characters to act as a reminder that we need people to execute the processes and procedures within PSM frameworks. Cards are organised into the following topics:

Organisation

Leadership, Culture & Communication
Continuous Improvement
Information Management
Capability Management

Analysis & Implementation

Process Hazard Analysis
Process & Plant Design

Operation & Maintenance

Operational Integrity
Asset & Protection Integrity
3rd Party Management
Emergency Planning & Response
Control of Work

Excursions & Modifications

Event Investigation
Management of Change

The PSM manual has been developed with the invaluable assistance of Ian Travers who has developed an online Process Safety Audit tool:

click icon for information on the Audit tool

The virtual manual is available on YouTube via the link below:

For more information on all our cards & initiatives – please contact us.

If you’d like to subscribe to future updates, please submit your email address below – many thanks for your interest.

Magnetic Attraction

To help embed and retain your key asset & activity integrity values, we’ve developed card size magnets that can be attached to a variety of metal surfaces.

Magnets provide the same opportunity to Visualize Knowledge and Operationalize Wisdom as our cards, however these weather-resistant designs offer both fixed and portable ways to inform and remind stakeholders in an accessible and memorable way.

Containment Integrity Magnet

Magnets can be deployed in a number of internal & external operational areas:

Meeting Rooms
Control Rooms
Lockers
Panels
Equipment
Plant

These can be produced to communicate a range of topics:

For more information on all our magnets, cards & initiatives – please contact us.

If you’d like to subscribe to future updates, please submit your email address below – many thanks for your interest.

Hazards 32

We’ve signed a sponsorship agreement with the IChemE to provide our Process Safety Cards at the forthcoming Hazards 32 Process Safety Conference

This will take place in the historic & beautiful spa town of Harrogate from 18-20 Oct 2022 and marks the return of this international event to a face-to-face format.

Each attendee will receive a special edition pack of our Loss of Containment cards in their delegate bag.

We look forward to meeting you there !

For more information on all our cards & initiatives – please contact us.

If you’d like to subscribe to future updates, please submit your email address below – many thanks for your interest.

Incident Infographics

Texas City Incident Card | Image Source: CSB

Today marks another anniversary of the BP Texas City Refinery explosion of March 23rd 2005.

There is no doubt that Incident Investigation reports provide valuable insight into the immediate and root causes of major accidents like this, however can you really digest & communicate all the key messages and apply the lessons which have been (painfully) learned?

The final CSB report was 341 pages long and inspired or instigated a number of related publications, including – perhaps most famously – ‘Failure to Learn‘ by Andrew Hopkins which (at 171 pages) is half as much again – undoubtedly invaluable but still quite a hefty read for time-poor stakeholders.

Learning is not necessarily the issue – it’s remembering/recalling those lessons just before they become relevant i.e. at the point of use (need) by frontline personnel, those who are interacting with hazardous materials or energy, who may benefit from taking a beat or pausing to reflect on what has happened in the past on the same or similar facilities.

Incidents Cards can be used to inform or remind personnel of related excursions, incidents or accidents with relative ranking of key information as well as QR code links to relevant material. These could be company or industry events that help facilitate discussions on the effects of loss of control.

Click for Incidents Cards

Incident Infographics can be digitally connected to cards; capturing and communicating the key points on a single page using Barrier Failure Analysis (BFA) diagrams, they provide a simple, but powerful, summary of the progressive failure (or absence) of barriers which allowed a threat to escalate to the ultimate consequences.

Barrier Failure Analysis (BFA ) overview

BFA also provides depth of understanding, where the ultimate or proximate (Primary) cause(s) of the barrier failure are explained by (or traced back to) related (and sometimes remote) Secondary or root (Tertiary) causes or initiating events.

The individual barrier failure types are explained below:

BFA Components

These BFA diagrams and infographics can be created for company or industry incidents to represent the key points (times) in the incident where barriers were called upon to act but were unable to prevent the outcome.

Knowing (and remembering) WHAT failed, HOW it failed and WHY it failed and then addressing the causes at source, could help avoid history repeating itself.

Here’s a relevant & timely example for the incident on this date 17 years ago:

For more information on Incidents cards and/or Incident Infographics & Barrier Failure Analysis– please contact us.

If you’d like to subscribe to future updates, please submit your email address below – many thanks for your interest.

CHASE – Cyber Challenges & Controls

Hybrid warfare is now (sadly) a reality, and the threat of digital attacks has placed national & local infrastructure assets on heightened alert, however there is a wealth of information available to help evaluate your cyber security vulnerabilities & measures.

The UK Health & Safety Executive (HSE) operational guidance (OG-0086) includes two clear statements associated with the Cyber Security of Industrial Automation Control Systems (IACS):

  • In order to defend a system, it is first important to know what needs to be defended.
  • Risk assessment, definition of the required countermeasures and on-going management of the countermeasures can only be achieved if the full scope of the IACS is understood and documented.

A common way to evaluate the IACS is to used a modified HAZOP/PHA approach with different deviations, however, like many techniques, this only provides analysis and may not be an effective way to continuously monitor the presence and performance of your technical and organisational measures.

Many of these measures rely on non or less technical personnel, so it’s vital that all IACS stakeholders (users) fully appreciate the impact of their acts, omissions or errors.

Using Data Integrity cards, cyber security knowledge (guidance) is visualised in a familiar, accessible & memorable way.

Click for Data Integrity Cards

Sample cards are shown below:

Click play button to start

The knowledge silos of Information Technology (IT), Operational Technology (OT) and Physical Technology (PT) are (sadly) a common & persistent challenge, therefore the cards can be supplemented & complemented by bowties to more fully understand the Threats & Consequences, the associated Barriers & (critically) their vulnerabilities i.e. to evolve Analysis into Assurance.

The use of cyber security bowties is not new, however they may focus only on the logical assets and not fully assess the relationships with, and indirect impact on, physical assets.

CHASE (Computer Hazard And Security Evaluation) is the application of bowtie techniques which exploits key features of BowTieXP including:

  • Bowtie Chaining & Relationship Diagrams
  • Audits & Surveys
  • Systems & Parts

The concept is summarised in the following extract from a webinar hosted by CGE Risk Management:

This offers significant advantages over worksheets and helps measure & sustain the effectiveness of elements critical to the integrity of your data & functionality.

For more information on Data Integrity cards and/or CHASE bowties – please contact us.

If you’d like to subscribe to future updates, please submit your email address below – many thanks for your interest.