Process Safety Management— The Case of the Disconnected Switch P O W E R P O I N T ® T R A I N I N G Background for the Trainer: This case and its training message primarily have to do with processes that use highly hazardous chemicals. Therefore it is most appropriate for workers involved with hazardous chemical processes. This session is probably not appropriate for workers who do not work around hazardous chemical processes. This training session presents a case study of an actual accident inspected and documented by the Occupational Safety & Health Administration (OSHA). The case presented in this training session is: Accident: 014419550 Report ID: 0728900 Inspection: 109327106 You may choose to present this training information in a lecture format or make the training presentation interactive by engaging your class in discussions that will help them identify facts of the case, potential causes of the accident, and future accident prevention measures. In either case, students will benefit by learning from a real-life scenario. Before beginning your training session, print and make copies of the one-page Case Study Student Handout, which is provided on the disc. The Case Study Student Handout can be used as a worksheet during the training session or as a take-away reminder once the training session is complete. Also, print and make copies of the Case Study Quiz, which is provided on the disc as a fully customizable Word document. The students can take the quiz at the end of the training session in order to help reinforce the information presented. Note that the same quiz is included at the end of this PowerPoint presentation as actual slides to review in class. Consider taking pictures of the Process Safety Management systems in your workplace: tanks, piping, monitoring devices, emergency shut-offs, etc. You can add these pictures to the presentation by inserting them into existing slides or creating new slides. Make sure the trainees understand the message as you go along. Ask questions periodically to test their understanding. Speaker’s Notes: Welcome everyone. Today we will review a case study of an actual accident investigated by the Occupational Safety & Health Administration (OSHA). This is an actual tragic workplace accident that had real-life implications for the worker, the worker’s family, co-workers, and the employer. The purpose of this training session is to teach and reinforce the importance of Process Safety Management in our workplace in order to prevent tragic accidents. In particular, it deals with how to follow the safe work practices described in our company’s Process Safety Management Plan. The intention is to learn from the accident and take steps to prevent a similar accident from occurring at our facility. Process Safety Management— The Case of the Disconnected Switch

Process Safety Management Process safety information Hazard analysis Operating procedures Employee training Mechanical integrity Incident investigation Emergency planning Compliance audits Speaker’s Notes: The Occupational Safety & Health Administration (OSHA) has established a standard called “Process Safety Management of Highly Hazardous Chemicals.” The major objective of this standard is to prevent unwanted releases of hazardous chemicals especially into locations that could expose employees and others to serious hazards. As part of Process Safety Management, your employer has compiled safety information about the process in which the hazardous chemical is used. Process safety information may include toxicity, permissible exposure limits, reactivity data, chemical stability, process flow diagram, intended inventory, upper temperature and pressure limits, ventilation systems, piping diagrams, safety systems, etc. An analysis of the hazards associated with the chemical process is also required–some of you may have been involved with that process. The hazard analysis consists of asking “What if …” The hazard analysis team looks at the consequences associated with equipment failure, human error, failure of administrative controls, potential for vandalism, natural disasters, or other occurrences that may upset the system. Every employee involved with the hazardous chemical process must receive training that includes an emphasis on safety and health hazards, emergency operations, emergency shutdown, and safe work practices. Another important part of Process Safety Management includes the mechanical integrity of the equipment involved with the process. Equipment includes tanks, piping components, relief and vent systems, emergency systems, and controls and monitoring devices. Mechanical integrity includes doing preventive maintenance, inspecting equipment, maintaining appropriate spare parts and equipment, etc. If your workplace ever has an incident that could reasonably have resulted in a catastrophic release of highly hazardous chemicals, you may be asked to be involved in the incident investigation. You may be asked to help determine what happened and how it can be prevented in the future. All employees must know what to do if there is an emergency that involves the process containing the hazardous chemical. OSHA requires employers to conduct audits in order to determine if they are in compliance with the requirements of the Process Safety Management standard. Employees are often asked to be part of the audit process.

Take a Look at the Facts Terminal operator arranges for transfer of anhydrous ammonia Ammonia pumps from pipeline to two pressure vessels Background for the Trainer: Training Option: Pass out the Case Study Student Handout. You may have the students read the accident description to themselves before discussing it in the class, or you may use the bullet points on the slide and the speaker’s notes below to describe the accident. Speaker’s Notes: A terminal operator arranges for the transfer of anhydrous ammonia. The anhydrous ammonia is to be pumped from the pipeline into two 30,000-gallon anhydrous ammonia pressure vessels at the anhydrous ammonia and liquid fertilizer terminal. The high-level shut-off switch has been disconnected for three weeks. High-level shut-off switch has been disconnected for weeks

Take a Look at the Facts (cont.) Terminal operator working in compressor room unable to monitor process Pressure vessels overfill Speaker’s Notes: The terminal operator is working in the compressor room and not monitoring the transfer process. During that time, the pressure vessels become overfilled. © Business & Legal Reports, Inc. 0908

Take a Look at the Facts (cont.) Emergency relief valve releases 1,000 pounds of anhydrous ammonia Ammonia cloud drifts, sending six construction workers to the hospital for respiratory irritation Speaker’s Notes: The emergency relief valve releases about 1,000 pounds of anhydrous ammonia into the air. The ammonia cloud drifts southward onto another property, where another plant is under construction. As a result, six construction employees are sent to a local hospital. They receive oxygen as first aid for respiratory irritation. Another 18 construction employees are evaluated and released. © Business & Legal Reports, Inc. 0908

What Do You Think Went Wrong? Is the high-level shut-off a key part of Process Safety Management? Was the operator supposed to be monitoring the transfer? Could the operator have prevented this accident? Did the operating procedures allow transfer without the high-level shut-off? Did the emergency relief valve work properly? Background for the Trainer: Use the questions on this slide to elicit discussion. Training options: After reviewing this slide and the accident description, give the class 5-10 minutes to discuss the accident description in small groups, or ask the students to try to determine some of the facts, potential causes, and possible prevention measures. In either case, use the Case Study Student Handout as a way to encourage discussion as you go through this presentation. Speaker’s Notes: Let’s take a few minutes and, using the Case Study Student Handout, work in groups to try to determine the facts of the accident, potential causes of the accident, and possible prevention measures. Then we will review the case study together in class. Consider some of the questions on this slide when discussing the case study in your groups.

Let’s Review the Causes Operator not monitoring the transfer High-level shut-off switch disconnected Lack of communication and training Inadequate maintenance program Lack of back-up shut-down systems Background for the Trainer: Try to get the trainees to put themselves in the place of the person in the case study. What would they have done in this case? Point out how a near miss can turn into a catastrophe in the presence of emergencies. In this case, the operator chose not to monitor the chemical transfer process despite the high-level switch being disconnected. Speaker’s Notes: The operator was not monitoring the transfer of the anhydrous ammonia. According to the investigation report, the operator was working in the compressor room. Most chemical transfer procedures require the operator to be actively monitoring the transfer operation from a position in which he or she can take emergency action to shut down the operation if necessary. The fact that the high-level shut-off switch was disconnected also greatly contributed to the release of anhydrous ammonia. The high-level switch is a key safety component. A lack of communication or employee training could also have contributed to the accident. Maybe the employee was never informed that the high-level switch was disconnected. Maybe the employee was not properly trained in the safe operating procedures and did not know that transferring chemicals was not permitted when the high-level switch was disconnected. Maybe the employee was not trained in alternate transfer procedures. The fact that the high-level switch was disconnected for three weeks points to an inadequate maintenance program. Repairing key components in a hazardous chemical process should be given high priority. The wait may have resulted because replacement parts were on order and being shipped; however, replacement parts for critical components should be kept readily available. Many chemical processes will have back-up systems in case the primary system fails. There appears to be a lack of a back-up high-level system. The hazard analysis should have asked the question, “What would happen if the primary high-level switch fails or is disconnected?” Then the company should have pursued finding an answer to this question in order to prevent the release of anhydrous ammonia. Can you think of any other causes that may have contributed to this accident?

Employee Training Safety and health hazards Operating procedures Safe work practices Emergency response Nonroutine work Background for the Trainer: Be prepared to discuss the specifics related to the chemical processes at your workplace. Bring documents such as material safety data sheets, written procedures, written safe work practices, and emergency procedures. Speaker’s Notes: All employees, including management, production, and maintenance workers, involved with the highly hazardous chemicals need to fully understand the safety and health hazards of the chemicals and processes they work with. [Discuss the safety and health hazards associated with the chemical in your process.] All employees involved in the chemical process must understand the written operating procedures for normal operations, chemical transfer, emergency shut-down, etc. You should be trained so well that you can correctly conduct the procedures without having to look at the written procedures. [Discuss the written procedures for the chemical process in your workplace.] All employees should be trained in the safe work practices associated with the hazardous chemical process. Safe work practices include wearing personal protective equipment (PPE). You should know what PPE to wear for every operating and maintenance procedure associated with the process. [Discuss safe work practices and PPE required in your workplace.] All employees involved with the chemical process or working near the chemical process must know how to respond to emergencies. Some employees will need to be trained only to recognize an alarm, then how to evacuate, and where to meet. Other employees might receive additional training in how to respond to a chemical spill or release. [Discuss who is on your chemical spill response team and discuss how employees should evacuate if there is a release.] Employees involved with nonroutine work, such as changing a valve in a pipeline, must receive additional training. Procedures and safe work practices for doing this nonroutine work may need to be developed. Never attempt to conduct nonroutine work for which you have not been trained. [Discuss examples of nonroutine work associated with your chemical process.]

Keys to Operating Procedures Accurately describe how to conduct job tasks Safe operating parameters Start-up and shut-down procedures Communicate procedure changes Handling upset conditions Background for the Trainer: Bring any written procedures your company has for your Process Safety Management program. Speaker’s Notes: Operating procedures must accurately describe how to conduct specific job tasks. Employees doing the actual work must inform their supervisor of procedures that do not accurately describe job tasks or of changes to systems that require changes in the written procedures. Operating procedures must also include safe operating parameters such as pressure limits, temperature ranges, and flow rates. Operators must also know what to do when the safe parameters are exceeded. In addition to normal operations, the operating procedures must describe how to safely start up processes and how to safely shut down processes. The start-up procedures might include how to heat up and increase the pressure of the system. The shutdown procedures will describe how to cool down and decrease the pressure of a system. Any changes in the written procedures must be communicated to all process operators before the change is actually implemented. Employees must inform their supervisor of any procedure changes that they made during the production process. Procedures must also be written for how to handle upset conditions so that employees know what to do in emergencies such as when a pump seal fails or when a pipeline ruptures.

Don’t Let It Happen to You Follow process procedures Monitor process Understand the function of process equipment Know emergency procedures Report any spill Speaker’s Notes: Let’s take a look at what we can do to prevent a similar incident from happening at our facility. Follow all the written procedures for the hazardous processes in your facility. Taking shortcuts with procedures will only result in accidents. Monitor the process at all times to make sure that everything is within the safe parameters outlined in the procedures. Understand the function of different equipment in the process such as pressure relief valves and high-level alarms. Know emergency procedures for shutting down processes and how to respond to a spill or release. Report any spill or release, no matter how small it may be. The incident must be investigated in order to prevent a future release or spill. Are there any questions? Thanks for your attention.

Quiz 1. Describe the major purpose of Process Safety Management. 2. What type of question is asked when analyzing hazards of the process? 3. How is mechanical integrity important in Process Safety Management? 4. Why is it important to monitor the process? Background for the Trainer: Remind employees that the quiz is to encourage further discussion and to help you, the trainer, be sure that everyone understands what was discussed. Print copies of the quiz for participants to take on their own, or go over the questions as part of the training session.

Quiz (cont.) 5. Describe examples of operating parameters that need to be watched. 6. What should you do if an operating procedure is not accurate? 7. Name some potential “upset conditions” in your process. 8. What could happen if you don’t follow operating procedures? © Business & Legal Reports, Inc. 0908

Quiz Answers 1. Q. Describe the major purpose of Process Safety Management. A. Prevent the unwanted release of hazardous materials. 2. Q. What type of question is asked when analyzing hazards of the process? A. “What if ...” © Business & Legal Reports, Inc. 0908

Quiz Answers (cont.) 3. Q. How is mechanical integrity important in Process Safety Management? A. Mechanical integrity includes preventive maintenance to make sure equipment is always in good working order. 4. Q. Why is it important to monitor the process? A. Make sure the process is operating safely and be ready to shut it down in an emergency. © Business & Legal Reports, Inc. 0908

Quiz Answers (cont.) 5. Q. Describe examples of operating parameters that need to be watched. A. Pressure limits, temperature ranges, tank levels, flow rates, etc. 6. Q. What should you do if an operating procedure is not accurate? A. Inform your supervisor right away. © Business & Legal Reports, Inc. 0908

Quiz Answers (cont.) 7. Q. Name some potential “upset conditions” in your process. A. Pump seal failure, pipeline rupture, tank overfills, etc. 8. Q. What could happen if you don’t follow operating procedures? A. A spill or release could occur and injure you and others. © Business & Legal Reports, Inc. 0908