Article based on Honeywell white paper. Contributors: Subhankar Dey - Senior Marketing Specialist, ASM Consortium, Peggy Hewitt - Director of ASM Consortium, Chris Morse - product marketing manager:
Research by the Abnormal Situation Management (ASM) Consortium - a joint R&D consortium led by Honeywell - indicates that in 59% of incident reports, the investigation team observed a strong need to address abnormal situations in procedure development.
Companies may have good procedures for operating within safe limits, but as soon as the process begins to deviate from the norm, into an abnormal situation, there are often inadequate procedures to help operators bring the plant back to normal operation.
In this context, a procedure is a clear set of instructions for safely executing activities for startup, normal operations, temporary operations, emergency operations and shutdown. Procedures when executed as proscribed should provide the same result under the same circumstances.
Operators must have a clear understanding of the operation if a consistent result is the desired outcome. For example, an emergency procedure will include step-by-step instructions that when executed by the operator should return operations to a normal state. In a state of emergency, the human mind is stressed and an operator’s ability to perceive and mentally process the abnormal situation affects their responses and actions.
Therefore, the successful execution of an emergency procedure depends on the operator’s ability to understand the procedural action fully, communicate flawlessly and respond correctly and immediately.
A study by ASM Consortium researchers on procedural execution failure modes during abnormal situations, shows that 40% of the procedural failures during an abnormal situation are due to poorly written procedures; 28% are because procedures are not followed; and 14% of are due to flawed reasoning while using the procedures.
In a recent speech. Jordan Barab, deputy assistant secretary of labor for the US Occupational Safety and Health, reported that over 70% of the citations fell into the top four PSM (process safety management) elements – Mechanical integrity, process safety information, operating procedures and process hazard analysis.
The problem in the operating procedures element was, according to Barab, the failure to establish and follow procedures for key operating phases, such as emergency shutdowns, and using inaccurate or out-of-date procedures.
Meanwhile, the International Atomic Energy Agency lists the “quality of documentation & procedures” and “compliance with regulations & procedures” among the common, key safety culture components in an organisation.
Ambiguity over operating procedures, though not the primary cause, was identified as one which led to ‘The Three Mile Island accident – the specific operating procedures applied to this accident are at the least very confusing and could be read by the operators in such a way as to cause them to take the incorrect actions they did.
Likewise, the Chernobyl nuclear disaster report also pointed to the ambiguity of the operating procedures of the ORM (operating reactivity margin).
The petrochemical industry has also experienced a number of major accidents attributed to operating procedures failure. BP’s internal investigation into the Deepwater Horizon Gulf of Mexico incident has recommendations to strengthen procedures.
Many managers in the process industry and manufacturing sectors are not creating the strong link between safety and effective procedures, nor are they creating a culture and environment where procedures are key elements to running safe and efficient plants.
Managers often believe that all procedures that are needed are in place and that plant workers are following these procedures. They believe that there’s no need for further investment to assure procedures are suitable and understood by the workforce.
This attitude leads to a situation where the procedures become outdated and operators start neglecting procedural operations — or take them for granted. The result can be poor operating efficiency or safety incidents due to inappropriate procedural practices.
Below is a short self-assessment you can take to help you decide if you need to invest more in effective procedures for your operations. If the answer is “No” to the six questions below in the left-hand column, then you may need to begin developing a justification for an investment in procedures.
Justifying Investments in Effective Procedures
1. Do we have all the procedures for operation documented - i.e. Safety procedures, start up and shutdown procedures, emergency response procedures, operating procedures and maintenance procedures?
It is important that that it is clear which procedure to follow under what conditions and circumstances. The procedures list can be consolidated based on what is mandated by industry standards and what is required by individual company policies.
2. Is all the information which the operator needs included in the procedure?
An effective analysis of the scope of the procedures and conditions under which they will be used is necessary to insure that the procedure is complete.
3. Is there proper management of change (MOC) in place for maintaining the procedures?
Operations are dynamic; small changes to equipment, personnel, and other processes may impact an existing procedure, so it is essential there is a process to manage the changes to procedures.
4. Are the procedures easy to access and can they be retrieved in an emergency?
During an emergency, if the procedures are not readily available, the operator tends to follow what he or she remembers as a procedure, not what is written. Electronic or automated procedures are important to manage
manage emergency situations when there is concern the operator may not know how to respond properly.
5 Is everyone in the plant trained in the use of procedures?
Simulator-based procedure training, understanding of site policies and training on procedural changes are important for plant personnel.
6. Are the procedures easy to understand?
Procedures should be written and structured so that people can easily understand what they are expected to do. The field of human factors is growing and companies are investing in Human Factor Specialists to ensure that the abilities and limitations of employees are considered as they develop effective procedures, particularly in critical safety areas where human life and high costs can results from accidents.
To justify investments
It is impIortant to understand where procedures fit into the bigger picture of operational efficiency so that process manager can more easily show how the investment will provide a direct return back to the company:
Improve operator effectiveness
Today’s challenges in process automation include increasing need for better coordination and communication between plant personnel, more complex and automated control systems, not to mention higher expectations to run plants at their operational limits to maintain and grow profits.
All of these challenges can impact your ability to meet production targets and adhere to safety and regulatory requirements. With the complexity and pressure for profitability and safety, it is no surprise that decisions made by operators while running a plant or facing an emergency are prone to errors. Procedures that provide a structured approach towards managing such decision-making is an important investment consideration for plants that need to run more profitably, safely and efficiently.
Procedure Based Metrics
Plant managers need to convey to operators what’s expected of them when they encounter a challenge during routine plant operations. Plant managers are also expected to identify improvements in operations and channel them into actions. The best way to do this is through formal procedures. Procedures can also be measured for compliance.
The ASM Consortium recommends deriving metrics from the execution of procedures to find improvements, like measuring the number of operator interventions during procedure execution, or logging the incorrect use of procedures. An analysis of procedure metrics will give plant managers ideas to help them improve operations. These improvements may result in new procedures or in modifying existing procedures to make them better.
Improving Process Safety
Compliance with procedures is a key metric which safety regulators and legal bodies look at when an incident or accident is investigated. An abnormal situation or emergency condition can be avoided — and the loss of property and human life can be prevented—by following relevant procedures.
In such a condition, the impact on business from the loss of life and equipment, damage done to plants and costs associated with lawsuits, can be reduced by following procedural practices. These incidents can have a catastrophic affect on profit and reputation and should not be taken lightly.
Add to the bottom-line
Plant managers must justify to management new investments in plant operations. Investing in procedures can be justified because of the direct linkage to higher efficiency and safer plants.
In a PVC manufacturing plant, the stripper plays a critical role. The steam stripping column extracts the VCM (Vinyl Chloride Monomer) from the polymer. It recycles the VCM back to the process and sends the polymer to the centrifuge for dewatering.
To seek investment to deploy automated procedures for the stripper operation, two important metrics were considered: 1.) the number of annual planned and unplanned stripper outages, and 2.) the number of non productive hours while the stripper shuts down and the manual startup procedure is executed.
It was calculated that an automated procedure operation will reduce the time to restart the stripper by 80% per stripper shutdown. Assuming 30 startup/shutdowns per year and typical industry values for operating calendar and margins this equates to an annual saving through reduction in lost production of €49K.
In chemical plants, product transitions from one grade or product type to another are also common. The time interval of the product transition phase is critical because it directly affects profitability: A decrease in the transition time between grades leads to an increase in on profitable production.
Material produced during the transition may be off spec or be downgraded to a lower value product. Operators are expected to perform transitions by changing the operation modes quickly, safely to meet production plans while adhering to regulatory requirements.
With this in mind, an effective procedure operation using automated procedures can save up to 25% of the product transition time and free the operator for more value added tasks. For a typical polyethylene plant the transition time can be reduced by 25%. Assuming 100 transitions per year and typical industry values for operating calendar and margins, this equates to an annual reduction in cost of off spec production of €113K.
The modern-day challenge posed by increasing operational complexity and a shortage of skilled labor must be approached in a structured way to make process plants more efficient and safe. Procedures comprise one of these systematic approaches. Incorrect or outdated procedures—or even a poor understanding of operating procedures—can lead to incidents resulting in fatality, equipment damage, production loss, poor public image, and litigation.
Procedural operations are effective when they are: easy to understand, revised regularly, with proper management of change, and quickly accessible when needed. Investing in procedures can be justified most often through reduced downtime and higher throughput during transitions.
Improving a plant’s procedural practices can help industries face today’s challenges by improving operators’ performance, plant efficiency, and increasing process safety while at the same time increasing profitability.