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									    2004 CSChE-PSM
    Summer Institute
       Process Safety
        Management
            prepared by:
           Graham Creedy
   Senior Manager Responsible Care
Canadian Chemical Producers’ Association
               Acknowledgements
• This lecture was developed by Graham
  Creedy for the Process Safety Management
  Division of the Chemical Institute of Canada,
  with funding from:
• the CIC Chemical Education Trust Fund
• Health Canada

  and the assistance of
• the Canadian Chemical Producers’
  Association.

   May 2004
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                   Overview
• How the philosophy of safety has evolved in the
  chemical industry
• What process safety management is and how it differs
  from traditional workplace safety
• Some of the key elements in process safety
  management and how they are applied
• Tools you can use, and when and how to use them
• How to get more information when you need it
• Developments likely to influence the way the thinking
  evolves in the future

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Safety Performance by Industry Sector
  Injuries & illnesses per 200,000 hours worked (2002)

   Services
   Finance, insurance & real estate
   Wholesale & retail trade
   Transportation & public utilities
   Petroleum and coal products
   Chemicals and allied products
   Printing & publishing
   Pulp & paper
   Textiles & apparel
   Food & food products
   Transportation equipment
   Electronic and electrical equipment
   Industrial machinery & equipment
   Primary metal industries
   Construction
   Mining
   Agriculture, forestry & fishing
                                            0.0      2.0       4.0   6.0   8.0   10.0       12.0

                Source: US Bureau of Labor Statistics (www.bls.gov/iif)
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    History of safety philosophy in the
            chemical industry
We can consider in four phases:
     – Late 19th – early 20th century
        • Origins of much of basic safety thinking in the
          explosives industry
     – Second world war through 50s and 60s
        • Concepts of loss prevention and investment in
          people
     – 70s and 80s (Process Safety Management)
        • Recognition of seriousness of consequences and
          mechanisms of causation lead to focus on the
          process rather than the individual worker
     – 90s and beyond
        • Realization of significance of sociocultural factors
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  Late 19th – early 20th century

• Objective: protection of capital assets

• Origins of much of basic safety thinking
  in the explosives industry



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             Ammonium nitrate explosion, BASF Oppau 1921
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Second world war through 50s and 60s

• Objectives: greater efficiency, better
  society

• Concepts of loss prevention and
  investment in people

• Rule-based

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                   Feyzin, France 1966
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           Crescent City, IL railroad incident and BLEVE 1970

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                   Nature of fires
• Flash fire

• Pool fire

• Boiling Liquid - Expanding Vapour Explosion
  (BLEVE)

• Unconfined Vapour Cloud Explosion (UVCE)

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CP Derailment
near Belleville,
Ontario
February 2003


Note the tank cars
in the right
foreground and
middle distance


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 Incident Pyramid:
                        1                            Serious/Disabling/Fatalities


                        10                           Medical Aid Case

                                                     Property Loss/1st Aid
                        30                              Treatment



                       600                           Near Misses

                                                     Unsafe Behaviors/Conditions
                      10,000



       A “proactive” approach focuses on
       these categories, but be careful – you
       may miss the really serious ones!

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 Key events – I: Flixborough




                   Flixborough, UK before the 1974 incident
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Flixborough, UK:

   simplified
     reactor
  arrangement

HMSO, from Lees




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                   Flixborough, UK 1974
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                   Flixborough, UK 1974

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Key events – II
•   1984 Mexico City
    over 650 dead

•   1984 Bhopal
    over 2000 immediate dead,
    plus many more from the
    effects
    OECD, ILO conventions,
    plus a wide range of                   Mexico City 1984▲   Bhopal plant ▼
    regulatory and voluntary
    action worldwide
    (Seveso II, SARA Title III)

•   1986 Basle
    major environmental
    contamination (international)
    UN Transboundary
    convention

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                   Pasadena, TX Vapour cloud explosion 1989
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              Pasadena, TX Vapour cloud explosion 1989

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           Third Phase (70s and 80s):
          Process Safety Management
• Objective similar to previous phase, but
• Recognition of seriousness of consequences
  and mechanisms of causation lead to focus
  on the process rather than the individual
  worker
    – 1976 Seveso – major environmental contamination
    – 1984 Mexico City – over 650 dead
    – 1984 Bhopal – over 2000 immediate dead, plus many more
      from the effects
    – 1986 Basle – major environmental contamination
      (international)
    – 1989 Piper Alpha – 167 dead
    – 1989 Pasadena – 23 dead
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            Development of
      Process Safety Management

• Re-examination of how major hazards are
  controlled
• Focus on the process and mechanisms of
  causation
• Management system approach
• Applicable to a wide range of situations – not
  just major hazards

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  Process safety management
Definitions
• Process safety is the operation of facilities that
  handle, use, process or store hazardous
  materials in a manner free from episodic or
  catastrophic incidents

• Process safety management is the application
  of management systems to the identification,
  understanding and control of process hazards to
  prevent process-related injuries and incidents
   CCPS: Guidelines for Technical Management of Chemical Process Safety


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  What is meant by “Process”?
• "Process" means any activity involving a
  highly hazardous chemical including
  any use, storage, manufacturing,
  handling, or the on-site movement of
  such chemicals, or combination of these
  activities
    US OSHA 1910.119 Process Safety Management Rule, definitions




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       Difference between PSM and
         traditional health & safety
Traditional workplace health and safety
    – Focuses on the individual actions while considering
      interaction with equipment
    – Occupational health exposures
    – Significant legal and regulatory mandate
    Objective: to eliminate injuries and illnesses to personnel,
      and protection of assets, production (and the
      environment)
Process safety management
    – Focuses on process: materials, equipment and
      systems
    – Individuals and procedures are considered part of the
      system
    Objective: to eliminate process-related incidents
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Functions of a management system

        Planning                                               Organizing
            Measurement         Direction




                                                                    Structure
                                  Leadership




       Controlling                                           Implementing
                                    Results

     CCPS: Guidelines for Technical Management of Chemical Process Safety

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 Features and characteristics of a management
           system for process safety
Planning                                          Organizing
    Explicit goals and objectives                      Strong sponsorship
    Well-defined scope                                 Clear lines of authority
    Clear-cut desired outputs                          Explicit assignments of roles and
    Consideration of alternative achievement           responsibilities
    mechanisms                                         Formal procedures
    Well-defined inputs and resource                   Internal coordination and communication
    requirements
    Identification of needed tools and training
Implementing                                      Controlling
    Detailed work plans                                Performance standards and
    Specific milestones for accomplishments            measurement methods
    Initiating mechanisms                              Checks and balances
                                                       Performance measurement and reporting
                                                       Internal reviews
                                                       Variance procedures
                                                       Audit mechanisms
                                                       Corrective action mechanisms
                                                       Procedure renewal and reauthorization
      CCPS: Guidelines for Technical Management of Chemical Process Safety
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    Strategic                         Managerial                        Task


                                                                  Planning
                                 Planning
                                                                 Organizing
 Planning
                                 Organizing
                                                                Implementing
                               Implementing
Organizing

Controlling                     Controlling                      Controlling


 Examples of PSM management systems concerns at
           different organizational levels
      CCPS: Guidelines for Technical Management of Chemical Process Safety

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           Scope (PSM elements)
1.    Accountability
2.    Process Knowledge and Documentation
3.    Capital Project Review and Design Procedures
4.    Process Risk Management
5.    Management of Change
6.    Process and Equipment Integrity
7.    Human Factors
8.    Training and Performance
9.    Incident Investigation
10.   Company Standards, Codes and Regulations
11.   Audits and Corrective Actions
12.   Enhancement of Process Safety Knowledge
      CCPS: Guidelines for Technical Management of Chemical Process Safety

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                        Personnel                      Process
                         Safety &                      Safety
                          Health




                                    Environmental
                                       Control




        CCPS: Guidelines for Technical Management of Chemical Process Safety




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                   1. Accountability
• Management commitment at all levels
• Status of process safety compared to other
  organizational objectives (e.g. output, quality, cost)
• Objectives must be supported by appropriate
  resources
• Plan for continuity in operations, systems,
  organization
• Be ready for exceptions
• Where freedom is allowed, make sure alternatives
  are acceptable
• Be accessible for guidance
• Communicate and lead

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 2. Process Knowledge & Documentation

• Inherent hazards and properties of materials
  involved
• Information needed to build and operate the
  process safely
• Information on protective systems
• Operating procedures for normal and upset
  conditions
• Risk management decisions
• Company memory (Kletz’ “10-year rule”)
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  3. Capital Project Review and Design
               Procedures

• Ensure that balance between production, cost, etc. and
  risk is made by conscious decision rather than default,
  at each stage of the project

• Greatest opportunity for impact on risk
  management
• Greatest opportunity to influence factors outside the
  company



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    Inherent Safety - Hierarchy
• “What you don’t have can’t leak!” (Kletz)
• Hierarchy:

           Strategic                               Inherent
           •Must be implemented early in
           process design
                                                   Passive

           Tactical                                Active
           •Can be implemented late in
           process design
                                                   Procedural
           •Characterized by repetition and
           high costs




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                     Inherent safety
• Minimize
   – Use smaller quantities of hazardous substances
• Substitute
   – Replace a materials with a less hazardous substance
• Moderate
   – Use less hazardous conditions, a less hazardous form of a
     substance, or facilities which minimize the impact of the release of
     hazardous material or energy
• Simplify
   – Design processes and facilities which eliminate unnecessary
     complexity and are forgiving of operating errors


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 4. Process Risk Management
• Know what the hazards are

• Understand the risks

• Decide what is acceptable, and meet it

• Control it there (or, better still, improve)

• Be ready if it happens

• If you can't do any of the above, get out of the
  business!

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                    Hazard and risk

• Process hazard
  – A physical situation with potential to cause
    harm to people, property or the environment

• Risk (acute)
  – probability x consequences of an undesired
    event occurring


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       Pre-screening using a list

• The first screen is usually a list of materials,
  either by
     – Name (chlorine, gasoline) or
     – Property (flash point, LC50 )
       plus
• Threshold quantity on site at any one time
• Usually specified by regulation (Canadian
  Environmental Protection Act, Section 200)

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     The Canadian Environmental Protection Act
    (CEPA) and control of major accident hazards

• Part 8 of the Act deals with environmental emergencies
• Regulation under Section 200 effective November 2003
• If a site has any of 174 listed substances in more than threshold
  quantity, must notify EC by February 2004
• If largest container of a listed substance also exceeds
  threshold, must:
   – develop emergency plan by June 2004 (plan must address
     prevention, preparedness, response and recovery)
   – implement plan, including testing, by November 2004

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    Sizing up the hazards

• Center for Chemical
  Process Safety
  (CCPS) guide
     – Easy to use
     – Describes hazard
       evaluation
       procedures
     – Explains when and
       how to use them

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                   What if/checklist

• Commonly used, but effectiveness depends on
  expertise of team and ability to spot hazards

• A team is much better than one person

• A good checklist can be found in the CCPS
  Hazard Evaluation guide, Appendix B

• If a hazard is not identified, subsequent
  control methods may be in vain!
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Index methods are good for rapid ranking
• Dow Fire and Explosion
  Index (FEI) for
  flammables

• Dow Chemical
  Exposure Index (CEI)
  for toxics

• Needs a few hours
  (small system) to a
  week (large, complex
  plant)

• Doesn’t need an
  engineering degree
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  Hazard & Operability Analysis
           (HAZOP)
• Rigorous, systematic questioning approach
  examines how deviations from design intent
  could lead to hazards and operating problems

• Needs a lot of detailed information such as
  accurate, up-to-date Piping & Instrumentation
  Diagrams (P & IDs) and operating procedures

• Needs expert team and study leader

• Very powerful technique if properly used
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                     Fault Tree Analysis
• Focuses on one                                  Fire
  particular undesired                         breaks out
  event

• Seeks to determine
  combinations of causes         Leakage of                     Ignition
  (equipment failures and        flammable                     source is
  human errors) that can            fluid                      near fluid
  lead to that event

• Generally used where
  other techniques have                               Spark                  Employee
  shown a need for                                    exists                is smoking
  detailed analysis

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                   Caveats
• The main use of quantitative analysis
  is to understand risk and how best to
  reduce it – not to “prove” something
  is safe!

• Be careful about the assumptions
  made in the analysis

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                   Effects of dust explosion
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  West Pharmaceutical, Kinston NC 2003 - Dust explosion

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                   Typical steps in a dust explosion
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           Westwego grain elevator 1977 explosion

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         Scottsbluff, NE 1996 - sugar refinery explosion

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Caramel plant
explosion
Louisville, KY

2003




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                   Bradford, UK 1992 Allied Colloids fire
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      Warrington, UK 1993 - Sabotage attack at British Gas
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     5. Management of Change
•   Change of process technology
•   Change of facility
•   Organizational changes
•   Variance procedures
•   Permanent changes
•   Temporary changes
•   Note that none of the above cover latent
    errors

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        Active and latent failures
• Active
   – Immediately adverse effect
   – Similar to “unsafe act”

• Latent
   – Effect may not be noticeable for some time, if at all
   – Similar to “resident pathogen”. Unforeseen trigger
     conditions could activate the pathogens and
     defences could be undermined or unexpectedly
     outflanked

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      Avonmouth, UK 1996 toxic fire due to delivery error

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      Avonmouth, UK 1996 toxic fire due to delivery error
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6. Process and Equipment Integrity
 • Design to handle all anticipated conditions, not just
   ideal or typical ones
 • Make sure what you get is what you designed
   (construction, installation)
 • Test to make sure the design is indeed valid
 • Make sure it stays that way
    – Preventative maintenance
    – Ongoing maintenance
    – Review
 • Be especially careful of automatic safeguards

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                   Causative effect for a runaway reaction
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                   Thermal runaway
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           9. Incident Investigation
• keep the focus on what happened rather than on blame
• consider other possible consequences if the scenario
  had developed slightly differently
• consider broader implications and lessons, rather than
  narrowing the focus to a specific incident
• look for the root causes
• keep a sense of perspective
• follow through to ensure lessons are communicated and
  applied



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                 The ‘Swiss cheese’ model of
SSAP             organisational accidents                                                    2




                 Some holes due                                                      Hazards
                 To active failures




                                                                        Other holes due to
                                                                        latent conditions
                   Losses
                                  Successive layers of defences

                                     Reason’s “Cheese Model”
James Reason - The Management of Safety, SSAP Launch Event 17/02/2004
                                James Reason, presentation to Eurocontrol 2004

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                   Piper Alpha before 1988 incident
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             Piper Alpha partway through 1988 incident

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                   Piper Alpha oil rig fire 1988
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 Fourth Phase: 90s and beyond
• Realization of significance of sociocultural
  factors in human thought processes and
  hence in behaviours

    – At the individual level

    – At the organizational level




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Human factors in accident prevention
  • People, and most organizations, don’t intend to get hurt (have
    accidents)
  • To understand why they do leads us eventually into
    understanding human behaviour, both at the individual and
    organizational level, and involves:
       – Physical interface
            • Ergonomics
       – Psychological interface
            • Perception, decision-making, control actions
       – Human thought processes
            • Basis for reaching decisions
            • Ideal versus actual behaviour
       – Social psychology
            • Relationships with others
            • Organizational behaviour


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       Human behaviour modes
•   Instead of looking at the ways in which people can fail, look at how they
    function normally:

• Skill-based
     – Rapid responses to internal states with only occasional attention to
       external info to check that events are going according to plan
     – Often starts out as rule-based
• Rule-based
     – IF…, THEN…
     – Rules need not make sense – they only need to work, and one has
       to know the conditions under which a particular rule applies
• Knowledge-based
     – Used when no rules apply but some appropriate action must be
       found
     – Slowest, but most flexible


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 The Process Safety Management Guide
• Summarizes CCPS approach
  in handy, short booklet

• Available as free download
  from CSChE’s PSM division
  website, in English and French
  (or as booklet, for nominal fee)

• Website:
  www.cheminst.ca/division/psm



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       Site Self-Assessment Tool
• Hazardous Installations Self-Assessment Tool (HISAT)
• Available for free download in English and French from
  CSChE’s PSM division website
• Provides a “benchmark” for status of process safety
  management in a company, site or unit
• 101 questions
   – 11 on preparedness
   – 90 on prevention (PSM)
• Questions test level of (a) awareness and (b) use of
  PSM techniques
• Three levels: essential, enhanced, comprehensive
• Over-the-phone guidance provided by the PSM division
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    Assessing a company’s safety
            effectiveness
• What is the safety policy and culture (written, unwritten)?

• How are the following handled?
      – Establishing what has to be done
         • Benchmarking
         • Communicating
         • Assigning accountabilities
      – Ensuring that it gets done
         • Monitoring and corrective action
         • Evidence (documentation) and audit process
         • Resourcing – not only for ideal but for anticipated conditions
         • Balancing with other priorities

• How are exceptions handled?

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       CSChE’s PSM Division website




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AIChE’s Center for Chemical Process Safety




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• Lees’ Loss Prevention
  in the Process
  Industries is an
  excellent overall
  reference

    (though expensive, it
    can be found in
    technical libraries)


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• Useful guides are
  available from such
  organizations as:
   – OECD
   – UNEP
   – ILO
   – IChemE
   – OSHA
   – etc.


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                   Conclusion
• You are soon going to be out in the
  workplace

• Many of the people you are going to be
  working with should be aware of what you’ve
  learned today, but aren’t

• You can make a difference – it may well be
  that your intervention prevents one of these
  incidents!

• You may need tact as well as knowledge


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   The New Product Introduction Curve
  adoption
  Percent




• Can be applied to adoption of new ideas, e.g. PSM
• Categories differ by ability and more importantly, motivation
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    Dealing with a Safety (or Engineering) Problem
•   Finding out who you’re dealing with
     – Where is the organization on the curve? (generally, and re the specific issue or
       problem)
     – Where are the people you’re dealing with on the curve? (generally, and re the issue
       or problem)
•   Finding out what to do
     – “Benchmark” – don’t try to reinvent the wheel unless you’re sure there isn’t one
       already (or you’ve time and it’s fun to do so)
     – Find out what others are doing about it
     – Read the instructions
     – Identify/define the issue
     – If it’s likely to be regulated, check with government agencies, trade associations,
       web, internet
     – If not regulated but likely good industry practice, check suppliers, other users of
       same material or item, other users of similar items, other industry contacts – but
       test the info!!! (cross-check, ask if it makes sense)
     – Check standard reference works,(Lees, CCPS, etc)
•   Doing it
     – Try to think of all situations that are likely to occur (process, eqpt, people)
     – “KISS”, keep it user-friendly, show basis for decisions if practical to do so
     – Follow up afterwards to see how it’s working
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                       The Last Slide
•   Think about how safety philosophy has developed,          Human
    and the four phases:
     1. Protect the assets
                                                              System
     2. Rules, to protect people, assets and the               Rules
        environment
     3. Management systems, to ensure the rules work          Assets!
     4. Understanding the human aspect – individual and
        group

•   Be aware of the concepts rather than details you can look up
•   Watch for opportunities to apply them
•   Stay positive – don’t be too discouraged if your audience isn’t as
    receptive as you expected
•   Good luck with your future careers!

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