Lessons Learned- How to Prevent the Next Major Incident

Since the Process Safety Management (PSM) standard was introduced by OSHA in the 1990’s, no other industry sector has had as many fatal or catastrophic incidents related to the release of highly hazardous chemicals as the Oil and Gas industry. If you’re not familiar with the PSM standard, it outlines 14 elements to follow which assist facilities in implementing management system requirements needed to prevent loss of containment and associated fire, explosion and loss of life incidents. In response to the large number of fatal or catastrophic incidents in the industry, OSHA initiated the Petroleum Refinery Process Safety Management National Emphasis Program (NEP), in June 2007. The purpose of the NEP was to verify the employers’ compliance with the required PSM elements. Since the start of this review over 10 years ago, the industry has made many improvements and advances but continues to have deaths and major incidents. We must take the lessons learned from other facilities and not repeat the same issues again and again.

This summary highlights 5 elements (5 of 14) of the PSM standard where OSHA issued the most citations during the NEP program review, with the Mechanical Integrity element being the worst actor.

■ Mechanical Integrity (MI) – 6 repeat findings
■ Management of Change (MOC) – 5 repeat findings
■ Process Safety Information (PSI) –4 repeat findings
■ Process Hazards Analysis (PHA) –3 repeat findings
■ Operating Procedures – 2 repeat findings

The 20 most cited reoccurring OSHA findings are as follows:

MI:
• Equipment Deficiencies not properly addressed
• Inspection, Testing and Maintenance Procedures not followed
• Thickness measurements not properly managed
• Inspection frequencies not properly managed
• MI Data not properly reviewed, and anomalies resolved
• Site Specific inspections and Tests not properly established

MOC:
• Changes in equipment design not properly reviewed and documented.
• Changes in operating procedures not properly reviewed and documented.
• Changes in Inspection & Test procedures not properly reviewed and documented.
• Changes to non-process facilities not properly reviewed and documented.
• Time limitations on Temporary Changes not established

PSI:
• Relief System Information not properly documented
• Facility Siting modeling and protection employees
• P&ID’s not accurate
• Relief System Design & Design Basis not documented or followed

PHA:
• Recommendation Resolution not properly addressed
• Facility siting factors not included in PHA review
• Human Factors not included in PHA review

Operating Procedures:
• Emergency S/D procedures not properly addressed
• Safe work practices not adequate

I will dive deeper into a few of these repeat OSHA findings in the future, but if you would like additional details the entire 2017 OSHA publication is available here.

Actions to Take:
1) Review the list of OSHA repeat findings and verify that your PSM or Company Management System addresses these repeat findings sufficiently.
2) If any of the repeat findings are of interest/concern, review the attached OSHA document for additional details.
3) If you are not familiar with your role in your companies Process Safety Management (PSM) program discuss with your supervisor or the PSM/Management System leader at your facility.

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