CH00ppi-x 4/10/02 12:48 PM Page i Serious Incident Prevention How to Achieve and Sustain Accident-Free Operations in Your Plant or Company CH00ppi-x 4/10/02 12:48 PM Page ii CH00ppi-x 4/10/02 12:48 PM Page iii Serious Incident Prevention How to Achieve and Sustain Accident-Free Operations in Your Plant or Company SECOND EDITION THOMAS E. BURNS an imprint of Elsevier Science Amsterdam London New York Oxford Paris Tokyo Boston San Diego San Francisco Singapore Sydney CH00ppi-x 4/10/02 12:48 PM Page iv Gulf Professional Publishing is an imprint of Elsevier Science. Copyright © 2002, Elsevier Science (USA). All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher. Recognizing the importance of preserving what has been written, Elsevier Science prints its books on acid-free paper whenever possible. Library of Congress Cataloging-in-Publication Data Burns, Thomas, 1946- Serious incident prevention : how to achieve and sustain accident-free operations in your plant or company / Thomas E. Burns.—2nd ed. p.cm. Includes bibliographical references and index. ISBN 0-7506-7521-7 (alk. paper) 1. Industrial safety. 2. Accidents—Prevention. I. Title. T55 .B83 2002 658.3’82—dc21 2001058497 British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library. The publisher offers special discounts on bulk orders of this book. For information, please contact: Manager of Special Sales Elsevier Science 225 Wildwood Avenue Woburn, MA 01801–2041 Tel: 781-904-2500 Fax: 781-904-2620 For information on all Gulf Professional Publishing publications available, contact our World Wide Web home page at: http://www.gulfpp.com 10 9 8 7 6 5 4 3 2 1 Printed in the United States of America CH00ppi-x 4/10/02 12:48 PM Page v Dedicated to America’s unsung heroes: Men and women who help prevent tragic events before they occur through their daily commitment to the prevention of serious, high-consequence incidents. CH00ppi-x 4/10/02 12:48 PM Page vi DISCLAIMER The information contained in this publication consists of facts, con- cepts, principles, and other information for developing and implementing a strategy for preventing serious incidents. This information is intended to provide general guidance in the development of effective safety-manage- ment processes. The information presented is not specific to the opera- tions of any company, facility, unit, process, system, or equipment, and neither the author nor publisher assumes any liability for its use. The information provided in this publication is not a substitute for company, facility, or unit-specific operating and maintenance procedures, checklists, equipment descriptions, safety practices, etc. DO NOT attempt to operate any facility, unit, process, system, or equipment based solely upon the information provided in this publication. ............................................D...I.S..C...L.AIMER Preface................................................................ ix 1 The Improvement Challenge ......................... 1 Serious Incidents of the Past........................................ 3 References................................................................... 18 2 The Barriers to Improvement ........................ 21 A Focus on Today’s Problems ..................................... 22 Limited Employee Involvement .................................... 22 Inadequate Measurement and Feedback..................... 23 Inadequate Recognition ............................................... 24 Limited Line Organization Ownership .......................... 25 Limited Personal Experience........................................ 25 Misguided Optimism..................................................... 26 Overcoming the Barriers .............................................. 27 References................................................................... 28 3 A Proven Process Improvement Model........ 29 Process Model For Serious Incident Prevention .......... 32 References................................................................... 36 4 Management Commitment and Leadership ......................................................... 37 Achieving and Sustaining Effective Leadership ........... 40 Achieving a Common Focus ........................................ 42 Allocation of Resources................................................ 43 Knowledge of Results................................................... 43 Reinforcement of Performance .................................... 44 Decisions Consistent with Objectives........................... 44 Commitment and Leadership - Closing Thoughts........ 46 References................................................................... 47 5 Employee Involvement................................... 48 Synergy ........................................................................ 50 Prison Break Exercise.................................................. 52 Teamwork..................................................................... 53 An OSHA Perspective on Employee Participation ....... 54 Leveraging the Power of Employee Involvement......... 55 References................................................................... 59 Employee Involvement on Teams ................................ 60 6 Employee Involvement - Developing Teamwork........................................................... 60 Effective Teamwork Techniques .................................. 61 References................................................................... 67 7 Understanding the Risks ............................... 68 Do Managers Understand the Risks? .......................... 69 Small Boat Operation: An Illustration of Risks.............. 71 Understanding More Complex Risks............................ 72 A Systematic Process of Risk Identification ................. 74 Understanding the Role of Human Error...................... 76 Classifying and Prioritizing Risks.................................. 78 Understanding the Risks - A Prerequisite for Success........................................................................ 81 References................................................................... 82 Managing Similar Risks with Varying Levels of Success........................................................................ 83 8 Identifying the Critical Work.......................... 83 Beyond Regulatory Compliance................................... 86 Identifying Critical Work................................................ 87 Causal Factors for Serious Incidents ........................... 88 Critical Work for a Tank Car Loading Operation........... 89 Sustaining Performance ............................................... 91 A Systematic, Knowledge-Based Approach................. 93 Process Safety Management Standard........................ 94 References................................................................... 95 9 Identifying the Critical Work - Management of Change.................................... 96 Unplanned Changes..................................................... 97 Planned Changes......................................................... 99 Management of Change in the Serious Incident Prevention Process ...................................................... 101 References................................................................... 102 10 Establishing Performance Standards......... 103 Corporate/Company Standards.................................... 105 Facility/Operating Level Standards .............................. 106 Explicit and Implicit Standards ..................................... 108 Standards - A Prerequisite for Measurement, Feedback, and Accountability ...................................... 109 References................................................................... 110 11 Measurement and Feedback ....................... 111 Performance Accountability.......................................... 113 Performance Measurement for Critical Work ............... 113 Feedback and Its Linkage to Reinforcement................ 120 Elevating the Visibility of Critical Work ......................... 121 Characteristics of Effective Measurement and Feedback Systems....................................................... 122 Measurement Systems................................................. 122 Feedback Systems....................................................... 123 Types of Measurement and Feedback Systems .......... 124 Safety Performance Indexing ....................................... 124 Essential to the Process............................................... 125 References................................................................... 125 12 Measurement and Feedback - Safety Performance Indexing....................................... 126 Establishing a Safety Performance Index for Prevention of Serious Incidents.................................... 127 References................................................................... 140 Reinforcement.............................................................. 141 13 Reinforcement and Corrective Action ........ 141 Corrective Action.......................................................... 148 Addressing Causal Factors .......................................... 148 Responding to Red Flags............................................. 149 References................................................................... 152 14 Improving and Updating the Process......... 153 Shared Vision............................................................... 155 Organizational Learning ............................................... 156 Employee Involvement................................................. 156 Transforming Concepts to Actions ............................... 157 References................................................................... 158 Management Commitment and Leadership ................. 159 15 Applying the Process Model - A Case Study................................................................... 159 Implementing Other Process Elements........................ 161 Chemical Handling Department Team ......................... 162 Chemical Handling Department Pipeline Operations ... 167 Chemical Handling Department: Tank Storage Operations.................................................................... 178 Chemical Handling Department: Warehouse Operations Team.......................................................... 179 Manufacturing Department - Serious Incident Prevention Processes .................................................. 182 HSE - Serious Incident Prevention Processes............. 183 QMI Site Management Team: Serious Incident Prevention .................................................................... 187 Benefits Achieved from the Serious Incident Prevention Process ...................................................... 189 References................................................................... 189 16 Responding to the Challenge...................... 190 Keys for Successful Implementation ............................ 192