Now imagine you are on the US Airways flight that had to be crash-landed in the Hudson. Wouldn’t the instructions about emergency landing on water have been useful? I guess there is a reason landing on water is one of the scenarios in the airline safety announcement.

Source: http://www.flickr.com/photos/27048731@N03/ / CC BY-NC-SA 2.0

The reason frequent travelers ignore the flight safety announcement is normalization of deviation… you have seen the message so many times that it begins to lose impact.

I’m therefore very surprised that organizations believe they can achieve effective safety training by having “canned” refresher e-courses.

These refresher courses are equivalent of airline safety instructions!!! Unless refresher courses are made more engaging, they cannot be effective. If a worker is asked to take the same refresher course year after year, I’m afraid he will fall into a “listen-and-ignore” mode.

In follow-up posts, I will discuss ways of increasing learning impacts from training courses. As an example, take a look at a recent safety instruction video from Virgin America that is different from routine safety announcement.

www.youtube.com/watch?v=eyygn8HFTCo

 Did you find the video engaging?

Photo Courtesy: http://www.flickr.com/photos/8177037@N06/ / CC BY-NC 2.0 ;

Step 1: Is Your Facility Covered?
Under CFATS, if a facility posses a chemical of interest (COI) above a certain threshold quantity (TQ), it must submit a Top Screen to assist Department of Homeland Security (DHS) in screening for high-risk facilities. DHS reviews the submission to make an initial determination if a facility is high-risk and categorizes it into a risk tier (Tier 1, 2, 3, 4).  To view COI and corresponding TQ click here.

If your facility has COI above TQ, you should have submitted top screen via Chemical Security Assessment Tool (CSAT) by January 2008.It is expected that around 40,000 top screens have been submitted to DHS.  DHS plans to track facilities by checking their business records to verify if they are covered and have not submitted top screen. Facilities that plan to have a COI above TQ on-site at some future time are encouraged to file a Top Screen.

Step 2: Understand the Risks
The results from the Top Screen allow DHS to assign facilities to a preliminary risk tier and make an initial determination of facilities at higher risks. High-risk facilities are notified by DHS and these facilities must complete a Security Vulnerability Assessment (SVA) - i.e. analysis of high-risk scenarios, threat characterization, and associated risk reduction measures. The actual determination of high-risk status and the actual Tier ranking is made by DHS after SVA is submitted.

Tiers 1, 2, and 3 must use CSAT SVA tool to conduct SVA. Following the submission of the SVA, DHS will determine if the facility is indeed high-risk and it will notify the facility of its exact risk tier.

Step 3: Developing Site Security Plan (SSP)
Facilities determined as high-risk by DHS following a review of their SVA should prepare a Site Security Plan (SSP). Instructions for preparing Site Security Plan (SSP) were released in May 2009.  SSP should document how a high-risk facility meets (or intends to meet) the requirements of the 18 Risk Based Performance Standards (RBPS).  RBPS guidelines include restrict area perimeter, screen and control assets, etc., and are intended to serve as a guidance. Preparation of SSP and submission thus appears to be a documentation exercise - it may be tedious but not difficult.

The RBPS document provides very general guidance on most topics but at the same time DHS is prohibited from providing specific guidance.  However, it is fair to say that RBPS guidelines reflect DHS’ view on various security measures.

Once the SSP is submitted, DHS will notify the facility if the SSP is approved, or if it requires revision. DHS will work with facilities on revisions. Once the SSP is approved it becomes essentially a contract between DHS and the facility and will provide the basis for future facility inspections.

The SSP does not correlate directly with the RBPS and thus at the end of SSP submission a facility owner is not able to analyze the additional work needed to meet RBPS requirements. Thus an on-going task for facility security manager would be to figure out gaps between their existing security measures in place and the RBPS requirements.

For detailed information on Chemical Security, please refer to an excellent blog by Patrick Coyle.

If you have any specific questions about applicability of chemical security regulations to your facility, please contact me.

The following table summarizes CSB performance in 2006-2007.

CSB is limited by budget and resources as to how many incidents it can investigate. GAO has recommended that CSB request the necessary resources from Congress to meet CSB’s statutory mandate or seek an amendment to its statutory mandate. Alternatively, GAO makes the following recommendations to help CSB cover more incidents.

• consider using the work of government agencies, companies, and contractors, to a greater extent to maximize the board’s limited resources;
• improve the quality of its accident-screening database by better controlling data entry and periodically sampling accident data to evaluate their consistency and completeness;
• publish a regulation requiring facilities to report all chemical accidents, as required by law, to better inform the agency of important details about accidents that it may not receive from current sources;

To download a pdf copy of the GAO report on CSB click on the link below:
Chemical Safety Board: Improvements in Management and Oversight Are Needed.

(Photo Courtesy of Amber on Flickr)

Eating a few fries this one time will not increase risks of a heart attack. Plus I like the fries from this joint. I’m ready to order!!

That was a relatively easy decision; however, there are certain decisions that are more complex and may have significant implications to your organization’s future including organizational safety.

For example, if your organization is deciding on future investments or acquisitions. One would think that the basis for such complex decisions would be financial metrics – return on investment (ROI), life-cycle analysis, Net present value (NPV). Clearly these economic figures incorporate cost-benefit analysis. However, in a real world situation one cannot mitigate all the risks in an investment and therefore some of the most complex decisions are influenced by various other factors – internal politics, stakeholder interests, lack of complete knowledge. How can we bring rationale to such decisions?

Group Decisions

Group decisions in particular are prone to be influenced by emotions rather than logic. It is therefore necessary that everyone in the group understands the basis of decision and agrees to conclusions being reached. Group decision situations can be very effectively dealt with using Multi-attribute decision analysis (MADA).

Let me give you a simple example. Say you are in the market looking for a car, first you have to decide upon criteria for buying decision. You come up with three main attributes you would want in your new car – price, mileage and safety. But which of these three is more important to you? Would you be willing to sacrifice safety for price? So you want to prioritize attributes. Then you go from one dealer to other and compare different models. Come decision time what you are doing is mentally creating a scorecards for cars you have looked at and figure out the winner based on price, mileage and safety.

The same thought process can be duplicated for group decisions. What attributes to select? How to weigh the attributes? All these decisions are taken by the group and thus the end result represents “Wisdom of the Crowds”.

Of course to do this methodically I recommend using Analytical Hierarchical Processing (AHP) to select attributes, decide their weights and then final outcome. If you need further information on this topic please contact me.

When Should you Consider Group Decision Methods?

I recommend one should look into group decisions when considering investment of $5-million or more when you are trying to answer one of the following questions:

• Which projects to fund and to what extent?
• How to adjust operations and maintenance resources?
• How to adjust funding levels as resource constraints change?
• What acquisitions best fit with organizations mission/goals?
• How to create an investment risk portfolio based on available knowledge?

Group decisions using MADA are an effective way of creating transparent decisions by efficiently capturing ideas of all stakeholders and providing a common decision platform.

I want to focus on a critical aspect of this risk communication – winning the trust of the community.

There are two major cognitive social psychology principles one must understand while planning a risk communication program:

1. If an individual has strong initial impressions of a hazard, then subsequent evidence will be influenced by these beliefs. New evidence will appear reliable if it is consistent with initial impressions. And similarly, new evidence will be dismissed if it is contrary to initial impression.

For example, if you are talking about risks from LNG terminals and the neighbors are concerned about explosion hazards or terror threats, you cannot simply dismiss them. I have noticed in some of these meetings citizens raising question about hazards and some PR firm answers LNG is a clean energy source. Within a minute this evidence will be dismissed!You have to acknowledging the hazards/risks consistent with initial impressions and then present your strategy for minimizing risks.

Remember people receive information from media, talking to other people, news, blogs, radio and all these come into account in risk perception. Without complete knowledge of the system, such as LNG terminal, decisions of a person are based on beliefs concerning likelihood of uncertain events. And we know these likelihoods are minimal – now all you have to do is show what steps are being taken in order to reduce the likelihood.

2. If an individual lacks strong prior opinions about a hazard, their risk perception will be influence by HOW the information is presented.

As an example, if a patient is offered a treatment option with 70% chance of survival (as opposed to 30% chance of death) he is more than likely to accept the treatment. Framing the statistics in terms of living rather than dying changes risks perceived by the patient.

So what does all this mean in context of developing a risk communication or crisis communication plan:

1. Realize you will have two distinct categories of people – people who have developed prior opinions and people who have no prior idea
2. Plan your presentation for both these categories.
3. For audience without a prior belief system educate them with past statistics.
4. Audience who have a prior opinion you have to acknowledge the hazards and focus on risk mitigation measures

You can keep the above guidelines and now you have to decide

• What information to communicate
• How best to put across the information
• Who should communicate

1. Morale of the workers:  The glooming uncertainty about jobs and increased level of anxiety leads to a disinterest amongst employees. It makes workers less productive and starts affecting their day-to-day decisions including the ones regarding safety.
2. Procedural risk mitigation: There are many potentially dangerous scenarios where procedures are put in place as risk mitigation measures. In a state of anxiety and worry, a worker is more likely to commit an resulting in serious consequences.
3. Loss of knowledgeable personnel: Trimming of workforce may result in loss of valuable tacit knowledge in the form of experienced employees.
4. Scheduled maintenance: As a cost cutting measure, an operating company may decide to delay planned maintenance. John Bresland of CSB talks about this issues in the video below:

www.youtube.com/watch?v=zR7j5fb-cm4

Recommendations for Managers

• Revisit your high risk scenarios that require procedural risk mitigation measures. It may be worthwhile to investigate automation instead of human intervention.
• Figure out ways to cheer employees and keep them in an upbeat mood. If you have any suggestions on boosting employee moral please write them in the comments section below this post.
• Here is a free e-book (Author: Wendy Mack) - How to Prevent Panic and Promote Productivity in Turbulent Times.

But what have we, as process safety professionals, learned from the experiences of the 20th century? How can we use that learning to make the process industry safer in the 21st Century?

20th Century Accident Data
Based on data from Lee’s Loss Prevention Handbook, 551 incidents occurred during the 81 years from 1911-1995.

• Out of these 551 incidents, 270 (49%) resulted in a zero fatalities
• 374 (68%) of the accidents resulted in less than four fatalities
• 18 incidents (3% of 551) resulted in 100 or more fatalities

A more elegant way to analyze the accident data is to construct a fN curve, where f is the cumulative frequency of incidents leading to N or more fatalities.

In this fN curve,

• The first point represents the 281 incidents that resulted in one or more fatalities.
• The last point is the Bhopal accident, which is estimated to have resulted in 4,000 fatalities

Based on the 20th century fN curve, we observe

• In the 1911-1995 time frame there were 100 incidents that resulted in 10 or more fatalities – an average of 1.2 incidents per year in which 10 or more people were killed.
• There were 18 incidents (3%) in which more than 100 people died – an average of 1 incident every six years.
• There were 3 incidents (0.54%) in which more than 1,000 died – an average of 1 incident every 28 years.

Prognosis for the 21st Century

How will the fN curve look for the 21st century? Without a crystal ball, a simplistic prediction is that the 21st century curve will be identical to the 20th century. So should we expect 551 process incidents again by 2099?

Here are my predictions regarding the safety performance of the process industry in our  current century:

• There will be a drop in incidents that result in 1-10 fatalities because of increased hard hat safety requirements and awareness among workers due to better access to hazard communication and training.

• In the last century, 18 incidents resulted in 100 or more fatalities. This number will decrease in the 21st century as risk mitigation measures for high consequence incidents become more reliable.

• I believe the frequency of incidents that result in 10-20 fatalities will remain comparable. Such incidents are typically a result of human error, siting issues, proximity to community, poor plant design, and maintenance/inspection programs. Based on my understanding, I do not envision elimination of these key safety issues within a matter of a few decades. Zero incident plants are not a reality.

Final Word

Every decade in the 21st century, the process industry will witness an incident that will result in at least 10 fatalities.

The first reported dust explosion was in 1890 in a sugar mill in Chicago. According to the CSB investigation, dust explosion has resulted in 130 deaths and 780 injuries since 1980. According to Combustible Dust Institute research of news reports, there were 200+ dust fires and explosions in the United States in 2008 alone. Following the 2006 recommendations from the Chemical Safety Board (CSB) to regulate “dust”, OSHA started investigating if the available dust explosion standards are adequate. After the 2008 sugar-dust explosion that killed 14 workers, OSHA has decided to regulate dust explosion.

A dispersed cloud of dust in a confined space when ignited can lead to an explosion. A major problem is workers are not aware of the hazard or they do not always know the dusts that can explode. Because dust explosions are manifestation of dust properties and confined space where the dust is released.  Dust comes as fine particles, chips, flakes made up of metals, wood, grains, foams, plastics, rubber, pharmaceutical drugs, coal, flour, or sugar.

There are existing NFPA standards aimed at dust explosions but the compliance is not mandated. It will interesting to see how OSHA approaches dust regulations.

An incident within this failure database implies unintentional release of gas and a release is classified in one of the three categories:

1. Pinhole crack - diameter of leak is 2-cm or less
2. Holes -leak diameter greater than 2-cm but less than pipe diameter
3. Ruptures - diameter of leak is pipeline diameter

According to the report, the main causes for pipeline releases are:

1. External interference: Activities such as digging, pipling, ground works, excavation, ploughing, slabbing, casing and sleeves may damage the pipeline.
2. Corrosion: It can be external or internal
3.  Material failure: Due to construction of material, defect specification
4. Ground movement: dike break, erosion, flood, landslide, mining

Relative percentage of incidents based on incident cause is presented in table below - 50% of the pipeline releases appear to be caused by external interference. Furthermore, when a pipeline is damaged by external interference there is a 75% chance that it will lead to a hole or a guillotine rupture.

Of the corrosion incidents reported, 79% are caused by external corrosion. Furthermore, 74% of the external corrosion incidents were due to pitting.

Biodiesel Fires and Explosions Map (click to view)

According to the map, there were  8 fires and 6 explosions in biodiesel facilities in the U.S in 3-year period (2006-2009). This translates to approx. 5 incidents per year.

Ethanol Fires and Explosions Map (click to view)

Based on the map, there were 22 fires and 11 explosions in biodiesel facilities in the U.S. in 10-year period (1998-2009). This translates to approx. 3 incidents per year.