Summary Bullets
No incidents is not always good news
Historical practices and data can be misleading
Reviews beyond the surface of charts are necessary
Background
The monthly Key Performance Indicators (KPIs) for process safety incidents and near misses at a refinery had been very low for several years. The new Refinery Manager was pleased with this KPI, especially since in his first year it was zero. In his previous refinery where he had been the Operations Manager, the same KPI had been favorable but not that good. He asked the Process Safety Management System (PSMS) Coordinator how the KPI was derived. He learned that during acquisition negotiations five years earlier, the previous owner had been challenged by several potential buyers about the high rate of near misses. The near misses were not serious and no actual incidents had occurred, but the company attempted to lower their bid because of it.
What Happened
After the acquisition, the refinery began investigating and addressing near misses less formally. Consequently, when the KPI program was implemented, the near miss result was very positive.
Further review revealed during the previous two years several Safety Instrumented Systems (SISs) had been activated during plant upsets or transients. These had not been classified as near misses because, according to an e-mail, “the safeguards had worked as designed and that’s not a near miss because that was what they are supposed to do.”
Following this discovery, the facility revised the definition of the near miss KPI to align with the American Petroleum Institute (API) and Oil & Gas Producers (OGP) standard for near miss reporting. This standard recognizes that a SIS trip usually represents a close approach to the capability of the equipment to contain the process, and therefore truly is a near miss. By tracking these types of near misses, the facility would have an opportunity to learn about the process, culture, and PSMS without suffering any adverse consequences. As a result, the data reported monthly returned to values that were more typical for a large refinery.
This example shows both good and bad examples of the role of leadership in process safety culture. What are they?
Further review revealed during the previous two years several Safety Instrumented Systems (SISs) had been activated during plant upsets or transients. These had not been classified as near misses because, according to an e-mail, “the safeguards had worked as designed and that’s not a near miss because that was what they are supposed to do.”
Following this discovery, the facility revised the definition of the near miss KPI to align with the American Petroleum Institute (API) and Oil & Gas Producers (OGP) standard for near miss reporting. This standard recognizes that a SIS trip usually represents a close approach to the capability of the equipment to contain the process, and therefore truly is a near miss. By tracking these types of near misses, the facility would have an opportunity to learn about the process, culture, and PSMS without suffering any adverse consequences. As a result, the data reported monthly returned to values that were more typical for a large refinery.
This example shows both good and bad examples of the role of leadership in process safety culture. What are they?
Safety Culture Focus
Understand the basis for reports and data to understand the results—promote a questioning environment.
Historical reports may not be a true indicator of past performance.
Continuous improvement requires changes to accurately capture data.
Strong leadership supports changes for accuracy even when the data may be less favorable.
Safety Culture Focus Note
**Only 37% of those surveyed indicated management involvement was a strength in their organization.**
Source File
E.14.pptx
(326.84 KB)