Risk Management in Practice - Coursework Example

Introduction The contemporary workplace is different from the workplace in traditional industries before the industrial revolution. There are so many risks that are both explicit and hidden. It becomes difficult to predict when an accident will happen or how it will happen. However, the increasing use of machines at the work place, coupled with the continuing dependency on chemical compounds, poses a great risk not only to the industries or companies themselves but to the workers in general. Risks of fires, deaths as well as injuries are common. In relation to that, on 23rd March 2005, a major explosion occurred at BP USA Texas City Refinery and on 11th December 2005, a major explosion occurred at the UK Buncefield Oil Storage Depot, Hertfordshire. These two refinery explosions had a great impact on how health and safety issues should be addressed by management in both countries. There are striking similarities and differences in both cases, and this paper aims to compare and contrast the two cases and provide a critical analysis of the causes of the incidents, the responses to them, the common themes and lessons learnt. BP Texas Incident Description On March 23, 2005, the isomerization unit (ISOM) of the refinery was restarted after a maintenance outage. This was done via the raffinate splitter in the ISOM, which is a distillation tower that takes raffinate-a hydrocarbon mixture- and separates it into light and heavy components (US Chemical Safety and Hazard Investigation Board, 2007). As it was being turned on, operations personnel overfilled the raffinate splitter for over three hours with flammable liquid hydrocarbons, contrary to startup protocols. Control instrumentation and critical alarms failed to give warning to the operators of the critical danger in the tower. As the tower overfilled, liquid sipped into the overhead pipe at the top of the tower. Pressure relief devices opened and a flammable liquid geyser resulted from a blowdown stack that was antiquated and had no flare system. The released flammables caused an explosion and fire. 15 employees died as a result of the incident and extensive damage was caused in surrounding areas. UK Buncefield Incident The Buncefield oil storage depot is a reservoir farm with various oil operating sites within such as Hertfordshire Oil Storage Limited (HOSL), British Pipeline Agency Ltd (BPA) and BP Oil UK Ltd. On December 2005, Tank 912 belonging to the Hertfordshire Oil Storage Limited (HOSL) site was getting filled with petrol. The tank was equipped with a level control form meant to alert employees of levels that the tank reached during filling. This control was an automatic tank gauging system (ATG) that displayed the rising levels of fuel to employees in a control room. The ATG malfunctioned and stopped registering rising fuel levels although the tank continued to fill up. Consequently, staff in the control room was not alerted as critical levels in the tank and eventually copious amounts of fuel overflowed from the top of the tank, forming a vapour cloud. This cloud ignited and caused a fire that lasted for five days. Over 40 people got injured and severe damage caused to surrounding areas (MIIB, 2008).. Analysis of the Root Causes of the Incidents Technical factors In the BP Texas incident (MIIB, 2008), the following show the technical causes(MIIB, 2008):- The tower level indicator was faulty, showing that the rising level was actually declining, and there were no other additional control and safety devices. Control alarms and indicators failed to work and did not warn operators in time. There was no supervision or technically trained personnel during startup, leading to startup safety protocols being ignored. Demanding 12-hour shifts probably led to fatigue among employees and poor shift turnover communication. Inadequate operator training program and staff layoffs created great job demands\ Use of outdated and inefficient processes which failed to address operational problems. Previously reported problems of the tower level indicator went uninvestigated by BP. Faulty equipment that was not repaired in time, despite recommendations. In 2002, BP engineers proposed connecting the ISOM blowdown system to a flare, but a less expensive option was chosen. Similarly, in the UK Buncefield incident, the major technical cause was failure f the alarm and control instruments to operate as the fuel levels in Tank 912 rose. Although the tank was fitted with two safety devices to guard against any incident, the technical operators did not fully understand the safety design. This is due to inadequate operator training and safety design testing. The ATG system supposed to alert employees in the control room of rising fuel levels in the tank, stopped working and this was not for the first time. Just like in BP Texas, previously reported faulty ATG indicator was not evaluated effectively. According to Kister (1990), when instrumentation do not provide accurate results, the likelihood of an accident occurring is high. Also, demanding work pressure by Buncefield supervisors which saw them work hectic 12-hour shifts with no scheduled breaks placed heavy pressure on them. Fatigued employees are likely to less flexible to think critically, have a low response rate to abnormal or changing circumstances and have impaired reasoning abilities (Rogers et al., 1999). In both cases, the level indication design was faulty. However, the BP Texas was not equipped with an automatic safety control to avoid overfilling like the UK Buncefield tank. This could have provided additional protection as the tower overfilled and possibly prevented it. Organizational factors In BP Texas, management practiced cost cutting measures and failed to implement quality equipment. The focus on level of personal injury rate to gauge process safety was an oversight on the management’s role in BP’s safety culture and accident prevention procedures. In both companies, employees lacked a reporting culture. Personnel did not record safety problems, some possibly fearing retaliation, and faults with equipment and process safety was inadequately logged and thus not acted upon. The work environment at BP Texas is lax, as it allowed operators to ignore set safety procedures. By failing to institute regular maintenance checks, BP Texas forced operators to rely on past experience (usually passed down from veteran operators) leading to the development of an informal startup procedure to prevent delays. The design and operation of the sites was also significantly similar in both incidents. In both incidents, the fluids escaped from their containing vessels and caused considerable damage. If process safety measures regarding this would have been effected, including suitable site design to contain escaping fuel, the incidents may not been as catastrophic. In both cases, management did not respond to critical issues e.g. malfunctioning ATG in Buncefield and startup faults in BP Texas, in time. In both cases, the work environment is fairly similar (HSE, 2011). Ridley (2008) describes the working environment as “a general phrase that is given to any or all of the media, agents and conditions likely to occur in the workplace atmosphere which can impinge on the effectiveness of the operator”. In the two incidents, we observe that the agents and conditions affecting the employees are similar as they are both oil refineries. In the BP Texas incident, an underlying cause was that BP used inefficient methods to gauge safety conditions at the plant. For example, a very low personal injury count gave management a deceptive indicator of process safety. According to CCPS, process safety is “a discipline that focuses on the prevention of fires, explosions and accidental chemical releases at chemical process facilities.”It would have been more prudent to for the organization to major in Process Safety Management (PSM), which involves applying management fundamentals and critical tools to prevent accidents, rather than focusing on the injury rate as the most important indicator of safety measures (CCPS, 1992). The company also failed to prioritize planned inspection on safety measures regularly. Corporate Safety Culture Hopkins (2000) stated that studies relating to major hazards show that when incidents occur, the information concerning safety failures that led to the incident usually lie in the organization but decision makers either did not know, or did not heed prior warnings. In BP Texas, the organization lacked a reporting and learning culture and reporting news of faulty equipment was highly discouraged (Baker Report, 2007). This aspect is similar to Buncefield as employees here also did not often log faults and mishaps which meant that managers in both companies did not investigate incidents and apply corrective measures when necessary. In both companies, management did not provide adequate leadership. BP Texas management did not implement strict adherence to safety procedures during work activities. Also, both practiced cost-control measures that saw employees work hectic shifts with little regard to the effects of fatigue on employees’ work performance. Lessons Learnt and Recommendations In view of the causes that led to these incidents, a number of recommendations were put forward by review boards charged with investigating the respective incidents. According to the Baker Report (2007) and Major Incident Investigation Board (MIIB) report (2008), a number of issues that were seen in the BP Texas incident were common in the UK Buncefield incident. In both, management failed to deal with safety critical process controls. Operators in both cases depended on alarm controls to alert in case of overfilling, and Baker recommended that such should not be the case as overfill avoidance should be independent of normal operational monitoring. The lessons that other sectors can learn from these incidents are to evaluate what conditions are similar within their organizations to the causal effects of the incidents, for instance, aging facilities or poor safety culture and deal with that. Positioning the similarities and differences to your organization’s strengths and weaknesses, will help determine if the consequence levels are high or low. The two incidents proved how leadership had a great role to play in averting organizational disaster, and other companies should learn that engagement with employees is crucial in dealing with potential significant risks. References Buncefield Major Incident Investigation Board (2008). The Buncefield Incident 11 December 2005: The final report of the Major Incident Investigation Board. Available at: www.buncefieldinvestigation.gov.uk CCPS (1992) Plant Guidelines for Technical Management of Chemical Process Safety, AIChE. HSE (2011). Workplaces and work environment. Retrieved 9 August 2012, from: www.hse.gov.uk/nuclear/operational/tech_asst_guides/tast062.pdf Hopkins, A. (2000). Lessons from Longford, the Esso Gas Plant Explosion, Sydney, New South Wales: CCH Australia Limited. Kister H. Z. (1990). Distillation Operation. New York: McGraw-Hill. Mogford, John et al. (2005). Fatal Accident Investigation Report, Isomerization Unit Explosion Final Report, Texas City, Texas, USA, December 9, 2005. Rogers, A.S., Spencer, M.B., and Stone, B.M. (1999). Report 245/Validation and Development of a Method for Assessing the Risks Arising From Mental fatigue, prepared by the Defence Evaluation and Research Agency Center for Human Services, for the HSE, U.K. The Report (2007). The Baker Report into the Texas City incident. The BP US Refineries Independent Safety Review Panel U.S. Chemical Safety and Hazard Investigation Board (2007). Investigation Report Report , Refinery Explosion And Fire. Texas: Texas City Read More