Guidelines for Managing Abnormal Situations

Cover
Title Page
Copyright
TABLE OF CONTENTS
LIST OF FIGURES
LIST OF TABLES
LIST OF EXAMPLE INCIDENTS
ACRONYMS AND ABBREVIATIONS
GLOSSARY
ACKNOWLEDGMENTS
PREFACE
DEDICATION
1 INTRODUCTION
1.1 Purpose and Scope of the Book
1.2 What Are Abnormal Situations?
1.3 The Business Case for Managing Abnormal Situations
1.4 Content and Organization of the Book
2 PROCESS SAFETY AND MANAGEMENT OF ABNORMAL SITUATIONS
2.1 Impact on Process Safety
2.2 The Case for Positive Management of Abnormal Situations
2.3 Adverse Outcomes of Abnormal Situations
2.4 Importance of Training for Abnormal Situations
2.5 Safety Culture and the Management of Abnormal Situations
3 ABNORMAL SITUATIONS AND KEY RELEVANCE TO PROCESS PLANT OPERATIONS
3.1 Focus Areas for Abnormal Situation Management
3.1.1 ASM Research Areas
3.1.2 Additional Focus Areas
3.2 Abnormal Situations Affecting Process Plant Operations
3.2.1 Process Control Systems –the First Line of Defense
3.2.2 Frontline Operators
3.3 Management of Abnormal Situations and Links to Risk Based Process Safety
3.3.1 Commitment to Process Safety
3.3.2 Understand Hazards and Risk
3.3.3 Manage Risk
3.3.4 Learn from Experience
3.3.5 Additional RBPS Elements Related to Management of Abnormal Situations
3.4 Procedures and Operating Modes for Managing Abnormal Situations
3.4.1 General Principles for Procedure Development
3.4.2 Operating Modes
3.4.3 Types of Material Being Processed
4 EDUCATION FOR MANAGING ABNORMAL SITUATIONS
4.1 Educating the Trainer
4.2 Primary Target Populations for Training
4.2.1 Front-line Operators
4.2.2 Operations Management
4.2.3 Plant Engineers/Technicians
4.2.4 Process Safety Engineers
4.2.5 Design Engineers
4.2.6 Environmental Health, Safety and Security (EHSS) Personnel
4.2.7 Technical Experts
4.2.8 Other Parties
4.3 Guidance for Organizing and Structuring Training
4.3.1 Organization of Training
4.3.2 Structure of Training Topics
4.3.3 Skills and Competencies of Trainers
4.4 Summary
5 TOOLS AND METHODS FOR MANAGING ABNORMAL SITUATIONS
5.1 Tools and Methods for Control of Abnormal Situations
5.2 Predictive Hazard Identification
5.2.1 Hazard Recognition for Abnormal Situations
5.2.2 HIRA Approach to Hazard Prediction
5.3 Process Control Systems
5.3.1 Process Trend Monitoring
5.3.2 Alarm Management
5.3.3 Big Data
5.3.4 Advanced Diagnostics and Artificial Intelligence
5.4 Policies and Administrative Procedures
5.4.1 Expectations of Policies and Administrative Procedures
5.4.2 The Relationship of Policies to Abnormal Situation Management
5.4.3 Process Metrics
5.5 Operating Procedures
5.5.1 Standard Operating Procedures
5.5.2 Emergency Procedures
5.5.3 Transient Operation Procedures
5.5.4 Preparing Written Procedures
5.6 Training and Drills
5.7 Ergonomics and Other Human Factors
5.7.1 HMI (Human Machine Interface) System
5.7.2 Control Room Ergonomics/ Human Factor Assessment
5.7.3 Crew Resource Management
5.8 Learning from Abnormal Situation Incidents
5.9 Change Management
5.9.1 Management of Change Guideline Tools
5.9.2 Management of Organizational Change
5.9.3 Pre-Startup Safety Review
6 CONTINUOUS IMPROVEMENT FOR MANAGING ABNORMAL SITUATIONS
6.1 General
6.2 Landscape of Available Metrics for Improvement
6.3 Abnormal Situations and Incident Investigations
6.4 Auditing
6.5 Management Review and Continuous Improvement
6.6 Summary
7 CASE STUDIES/LESSONS LEARNED
7.1 Case Study 7.1 – Air France, 2009
7.1.1 Background
7.1.2 Incident Overview – Air France AF 447
7.1.3 Speed Measurement on A330 Aircraft
7.1.4 A330 Flight Control Systems
7.1.5 Airbus Pitot Tube History
7.1.6 The Incident - Air France AF 447
7.1.7 Lessons Learned Relevant to Abnormal Situation Management
7.1.8 Epilogue
7.2 Case Study 7.2 – Texaco Refinery, Milford Haven, Wales, July 1994
7.2.1 Background
7.2.2 Incident Overview – Texaco Milford Haven
7.2.3 Outline Process Description of Milford Haven Refinery
7.2.4 Controls and Instrumentation
7.2.5 Some Relevant History at the Refinery
7.2.6 The Incident
7.2.7 Immediate Cause
7.2.8 Lessons Learned Relevant to Abnormal Situation Management
7.2.9 Epilogue
7.3 Case Study 7.3 – The Hickson And Welch Fire, 1992, Castleford, UK
7.3.1 Background
7.3.2 Incident Overview – Hickson and Welch fire
7.3.3 Outline Process Description of Meissner Plant
7.3.4 History of Meissner Plant Prior to Incident
7.3.5 The Incident
7.3.6 Immediate Causes
7.3.7 Lessons Learned Relevant to Abnormal Situation Management
7.3.8 Epilogue
APPENDIX A Managing Abnormal Situations – Training Materials
APPENDIX B ASM Joint Research and Development Consortium: Background
REFERENCES
INDEX
EULA