Examinations of major accidents often reveal prior similar near misses that were not effectively followed up. An example of a process safety near miss is operation on demand of the high level trip on a flammable liquid storage tank. Although no harm has occurred, the potential exists for a serious fire or explosion if the same event happens and the high level trip fails to operate, as occurred in the Buncefield accident.
After incidents, senior managers should ensure the correct assessment of the potential for serious consequences. They should have a competent specialist perform thorough analyses of all process safety near misses. These investigations should assess the immediate causes plus any underlying ones involved. The aim should be to identify PSM system weaknesses that contributed to the incident because correcting these deficiencies will prevent similar incidents.
Step 5. Monitor process safety performance.
A key conclusion from the Texas City investigation  was “BP primarily used injury rates to measure process safety performance at its U.S. refineries before the Texas City accident.” This reinforced a similar conclusion following incidents at the BP Grangemouth, U.K., refinery in 2003  and the need to develop key performance indicators for major hazards.
These reports have helped spur development of PSPIs to allow management of process safety at all levels up to the board room. The objective is to have appropriate leading (predictive) and lagging (failure) indicators that are reported and assessed in a manner similar to injury rates for personal safety.
Figure 2 shows a four-tier process safety pyramid based on an American Petroleum Institute recommended practice . This reflects the principle that responding to more frequent and less severe incidents toward the base can control rare process safety accidents at the top of the pyramid.
The key challenge for an effective PSPI system is to identify appropriate and risk-targeted tier-4 leading indicators. These should be based on investigation of process safety incidents that have highlighted weaknesses in risk control systems. They also should be “SMART,” i.e.:
Sufficient — having enough data to trend changes;
Measurable — allowing efficient collection of data;
Accurate — providing data that is accepted as a true reflection;
Reliable — collecting data that the workforce values; and
Targeted — focusing on high risk systems.
Step 6. Carry out site visits.
Senior managers must provide “felt leadership.” As Judith Hackitt, chair of the HSE, stresses: “Process safety cannot be managed or led from the comfort of the boardroom.” It is important that executives are seen and people believe they are serious about process safety. Having set policies and declared the importance of process safety to the organization, senior managers should “walk the talk.” For example, leaders should challenge staff at a facility posing major hazards with questions such as:
• What was the last serious process safety incident and what has been done to prevent recurrence?
• What safety systems are out of service or overridden?
• What safety-critical equipment inspections or proof tests are overdue?
• What equipment is running outside of design limits or inspection recommendations?
• What is the biggest process safety risk on site? Can you show me why the process is safe?
• What measures can you show me that verify proper management of process safety?
• What independent assessment have you had to show you’re managing process safety properly?
• Show me how you have learned from a recent major incident outside of the company.
• Show me how you manage process safety competence.
• How many safety systems have activated recently? Why and what have you done about this?
• Have you had any process safety incidents that human intervention prevented from becoming worse?
• What process safety experience and expertise do you have on site?
Senior managers must remain constantly vigilant to the risk of a major accident at their facilities. The lack of a previous incident is no guarantee that one could not happen tomorrow, so it is essential to monitor process safety performance and respond to warning signals.
Executives should critically review the key leadership principles outlined in this article to check that they are doing all that can be reasonably expected. They should treat this as a matter of urgency, to pre-empt the soul searching that would follow a serious accident at one of their facilities.
Senior managers also should take the six key steps cited to improve process safety performance. I believe that ensuring a strong response to near misses is the most important of these. Leaders should require a thorough investigation of near misses, to find weaknesses in the overall process safety risk control systems and learnings that can be used to implement focused improvements.
GRAEME ELLIS is principal lead consultant for ABB Consulting, Warrington, UK. E-mail him at email@example.com.
1. Baker, J. et al., “The Report of the BP U.S. Refineries Independent Safety Review Panel,” BP, London (2007).
2. “Buncefield: Why Did It Happen? The Underlying Causes of the Explosion and Fire at the Buncefield Oil Storage Depot, Hemel Hempstead, Hertfordshire On 11 December 2005,” HSE Books, Sudbury, U.K. (2011).
3. Schein, E. H., “Organizational Culture and Leadership,” 4 ed., John Wiley, Hoboken, N.J. (2010).
4. “Best Practice Guide: Process Safety Leadership in the Chemicals Industry,” Chemical Industries Assn., London (2008).
5. “High Level Framework for Process Safety Management,” Energy Institute, London (2010).
6. “Major Incident Investigation Report, BP Grangemouth Scotland, 29th May – 10th June 2000,” HMSO, Norwich, U.K. (2003).
7. “Process Safety Performance Indicators for the Refining and Petrochemical Industries, Recommended Practice 754,” American Petroleum Institute, Washington, D.C. (2010).