CCPSC, P.ENG. HEALTH, SAFETY & ENVIRONMENT ......as deviant, despite the fact that they far exceed their own rules for the elementary safety.” Dr. Diane Vaughan, Columbia University

PCS Restricted Information

Petrochemical Corporation of Singapore (Private) Limited

SIX SENSES FOR PROCESS SAFETYBERNARD L W LEONG, CCPSC, P.ENG.HEALTH, SAFETY & ENVIRONMENT MANAGER

CCPS ASIA PACIFIC REGIONAL TSC MEETING - SINGAPORE2 OCTOBER 2018

PCS Restricted Information2

Introduction

Upstream company of the Singapore Petrochemical Complex on Jurong Island

1. supply high quality ethylene, propylene, acetylene, butadiene, 1-butene, MTBE and benzene to companies within Island

2. provide common facilities and services such as berths, security and fire fighting services to ensure the efficient and safe operation of the Complex

Source: http://www.pcs.com.sg/


1977 – incorporation

1984 – first ethylene plant (cracker) in Southeast Asia on stream

1997 – second cracker unit on stream

Present shareholders

started as joint venture between Government of Singapore, Development Bank of Singapore Limited and Japan-Singapore Petrochemicals Co., Ltd (JSPC) [led by Sumitomo Chemical Co., Ltd.]

present two shareholders – (1) JSPC (50%) and (2) QPI and Shell Petrochemicals (Singapore) Pte.Ltd. (50%) [*QPI: Qatar Petroleum International]


Introduction



Incorporation of PCS – 10 August 1977

Reception on Incorporation of PCS - 14 August 1977

T FukudaJapanese PM Hon Sui Sen

FM

Lee Kuan YewPM

T HijikataPresident, SCChairman, JSPCVice-chairman, PCS



PCS 1st Ethylene Plant Start-up – 18 February 1984


Jurong Island

Petrochemical Corporation of Singapore (Private) Limited, PCSJurong Island

PCS operates for past 35 years


equipment can be restored after fatal accident, but loss of human life cannot be recovered

human error cannot be zero, but fatal accident can be zero

Beliefs obtained from manufacturing works

improper behaviour and unfortunate circumstances lead to injury and even fatality

human errors not always the cause, but are the result

proactive HSE management system can eliminate all real causes to potential incidents www.chemicalprocessing.com


What can “Six Blind Men and the Elephant”tell us about Process Safety ?

Six Blind Men and the Elephant


many parts of the world, Elephants provide functional utility, like transportation and heavy lifting (logging)

elephant is taught (controlled) to obey its owner and not run rampant…but an elephant is a large animal, and could easily break free and do whatever it wants…

trained elephant rarely does so... Why ?… how does the owner keep an animal that is 100 times his weight and size under control ?

Elephant analogy…


Elephant Size – processing

facilities Trunk – pipeline (elephant

trunk hold 10 litres) Detect presence –

warning signs Trumpeting – alarm

(“final” alarm) Stampede – catastrophic

incident

Elephant analogy…

Blind men Management Staff PSM system Work procedures Culture … etc

NOT SEEING THE BUG PICTURE

Need to work together….


Process Safety Management similar to keeping an Elephant (or Tiger) under control

You know the Elephant is dangerous (hazardous process) but you use it (operate) to make money

You have to care (maintain) for the Elephant to make sure it is useful and ensure the enclosure (containment) is suitable to prevent it from harming people

Have an effective Plan B (ERP) in case…

How to eat an Elephant ?


… how does the owner keep an animal that is 100 times his weight and size under control ?

TRIVIA time… some facts about Elephant control…Please Google yourselves… as some of the methods are controversial…

After “breaking the wild spirit”, the rest involves “methodical, repetitive training methods over several years” – which can be applied in process operations

The “secret” in Elephant control…


The “secret” in Elephant control…

… to extract most out of “functional utility”, plant operator/owner must “control” and “nurture” plant… reap its usefulness and not let it run out of control

CONTROL• keep parameters in check• measures in place

NURTURE• maintenance regime• ensure equipment integrity


Process plants notorious for hazards

… some risks unseen and go unchecked

… some harder to spot than others

… other risks so ingrained in day to day activities that they hide in plain sight and become the “obvious unobvious”

… others hide behind what appears to be “lower priority” improvements that turn out to be significant issues

Where is the Elephant hiding in your plant ?


Then…there is Normalisation of Deviation…..

“…means that people within the organization become so much accustomed to a deviation that they don’t consider it as deviant, despite the fact that they far exceed their own rules for the elementary safety.” Dr. Diane Vaughan, Columbia University


procedures, measures, rules, etc. dilute, distort deviate…


Elephants are quiet, so should your plant when it behaves normally

Detect presence of “elephant” listen for trees rustling or breaking listen to your equipment – pumps, motors, piping…

Trumpeting “elephant” is angry process alarms, sudden loud noises, relief valve lifting…

Stampede uncontrolled concerted running as an act of mass impulse uncontrolled / catastrophic Process Safety incident



Process Safety Management / Staff Management / Corporate Culture

understand hazards and risks effective controls in place to manage risks routine check/test to ensure “effective” is sustained

How about the Blind Men ?

3Rs

Retrain (also Retain)

Refresh

“Retreat” (Team Building, take a step back, reassess)


The enclosure/lock is strong enough (DESIGN)

Maintaining the enclosure/lock (MAINTENANCE)

No unauthorised changes to enclosure/lock

(MODIFICATIONS / MOC)

The enclosure/lock is not left open (PROCEDURES)

Nothing can crash into the enclosure (PROTECTION)

What to do if it escapes (EMERGENCY RESPONSE)

Restore SIGHT of the Blind Men


A word on Integrity and Reliability


work collaboration – ONE TEAM like the “Blind Men and the Elephant”, each person (or

department) strong in their area of focus, but if their work isn’t feeding into greater effort… doomed for failure

each blind man was right about his experience in the story, the blind men wouldn’t or couldn’t pool their

experiences to create the full picture collaborate and leverage knowledge and strengths of each

individual, and strong communication and coordination

Restore SIGHT of the Blind Men


“see things incorrectly”, something obvious, yet no one points it out or talk about it assume everyone notices it “under-reporting”

problems hidden from sight spend time “fire-fighting”

…one “not so fine day”… BOOM ! to solve a problem, you have to admit you have a problem

Pink Elephant ?


Where there’s Spark, there’s Ignition


see only what we want or expect to see filter out those that do not fit preconceived notions then again… we can’t see everything Analyse and Synthesise

Analysis – ability to break things down Synthesis – ability to connect separate pieces and recognise

patterns

How you are exactly like Blind Men

many process safety incidents attributable to system failures; failure to see whole picture by connecting separate pieces of puzzle (the ELEPHANT)


“intuitive sense”, chronic unease

Sixth Sense ?

* Black SwanJ.F. Murphy and J. Conner, Beware of the black swan: The limitations of risk analysis for predicting the extreme impact of rare process safety incidents, Process Safety Progress 31 (2012), 330–333.

we should naturally be aware (chronic sense of unease) and respectful of threats that Elephants(major accident hazards) may present but not forget the smaller Swans (Black Swan*) that also have the potential to cause harm


On the bright side, good to have memory of an Elephant past incidents, lessons learnt learning from other industries

Keep fresh “single page summary”, availability and accessibility refresher training

research suggests “two years an optimal length for knowledge retention, one year too short and repetitive but three years typically too long”

Sharing and Learning learning from internal incident, single perspective, from within if shared and discussed, there could be alternative views or

measures not initially apparent

Sixth Sense ?


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THANK YOU

Documents

CCPSC, P.ENG. HEALTH, SAFETY & ENVIRONMENT ......as deviant, despite the fact that they far exceed their own rules for the elementary safety.” Dr. Diane Vaughan, Columbia University