Many companies rely on a process hazards analysis (PHA) done at the site construction and commissioning stage. The operating organization usually doesn't have access to the results of the PHA and the original analysis never is reviewed. The consequence is a lack of knowledge across the operating and maintenance groups about correct safety procedures. This can cause major incidents.
For example, I know of one manufacturer with high risk operations that limited process safety information and the PHA to select individuals. There was no broad communication beyond standard operating procedures (SOPs). Operators were told to do as instructed; they didn't question why or understand the consequences of not following procedures. They had scant knowledge about what to do in case of abnormal or emergency conditions. Because the operators were deemed to have inadequate technical and process knowledge, they also had little empowerment in decision-making. As a result, an event that could have been contained developed into a major incident. Situations like this point up the need to demystify process safety management (PSM) to create a learning organization with a high level of awareness across the company.
NORMALIZATION OF DEVIATIONS
Another factor that contributes to safety incidents is what has been called "normalization of deviations." This usually occurs when what begins as a one-time or temporary departure from prescribed procedure fails to result in negative consequences and, thus, becomes accepted practice.
Consider this process example: A pressure relief device was leaking a flammable material. A replacement wasn't available immediately, so, to avoid leakage, someone closed the manual valve leading to the relief device. The process continued to run with the manual valve in a closed position. Because this temporary solution appeared successful, it became a normal practice. However, one day a pressure buildup occurred — because the pressure relief device wasn't available, there was an explosion. This case illustrates that a culture tolerating serious and long-standing deviations from good safety practice can result in the normalizing of deviations. (For other examples, see "Work on Workarounds." )
Analysis of catastrophic incidents often indicates that numerous warning signals were missed prior to the incident. Many companies tend to downplay minor leaks or small fires and not evaluate them from a worst-case-scenario standpoint. This practice is a serious mistake and can become catastrophic when the same or similar incidents occur repeatedly (Figure 2).
However, warning signs may not always appear before a catastrophic incident. For example, a small leak of a flammable material can instantaneously produce an explosion, depending on the location and proximity to sources of ignition.
Chemical makers, by failing to take sufficient notice of unsafe acts and conditions as well as near misses, are losing opportunities to learn from minor incidents to prevent potential major or catastrophic events — and to create a learning organization that gains knowledge from its experience.
Manufacturers must demystify PSM to ensure all staff and contractors understand why they are doing what they do, and the consequences of failing to follow procedures.