1. Process Safety Management (PSM)
Module 1 - Review of Industrial Catastrophes Related to PSM
July, 2010
[Adapted from State of Ohio – Dept. of Commerce, Div. of Labor & Worker Safety]

2. History of PSM Catastrophes
A series of catastrophic releases of chemicals leading to fires, explosions and fatalities have occurred in chemical processing plants around the world over the years.
These incidents lead to the passage of the Process Safety Management Rule in 1992.

3. Purpose of the PSM Standard
This standard contains requirements for preventing or minimizing the consequences of catastrophic releases of chemicals that are:
- Toxic,
Reactive,
Flammable,
Explosive
These releases may result in toxic, fire or explosion hazards
A number of catastrophic accidents have occurred resulting in loss of life and great property damage.

4. Ammonium Nitrate Explosion Oppau, Germany – Sept. 21, 1921
Photo Source:
Since the accident happened so long ago, very few photos were taken and survive.
Photo shows Crater and Destruction at plant following explosion. At 7:30 a.m. on September 21, 1921, two powerful explosions occurred at the BASF plant in Oppau, Germany.
Hazardous material: Ammonium sulfate & ammonium nitrate (50/50)
Facility type/Transport: Chemical plant (fertilizer)
Deaths: (differing numbers on reported fatalities)
Injuries: ?
Evacuation: None
Accident description: About 7:30 a.m. on September 21, 1921, two powerful explosions occurred at the BASF plant in Oppau, Germany. The explosions destroyed the plant and approximately 700 nearby houses, and killed 430 persons. The explosions occurred as blasting powder was being used to breakup storage piles of a 50/50 mixture of ammonium sulfate and ammonium nitrate. This procedure had previously been used 16,000 times without mishap. The enormous pile (4,500 tons) of ammonium sulfonitrate (ammonium nitrate - ammonium sulfate) fertilizer salt was detonated apparently by the blasting charges, even though blasting had been done many times previously, 450 lives were lost, more than 700 homes destroyed, the buildings housing the plant disappeared entirely - with a mammoth crater 250 ft. in diameter and more than 50 ft. deep - the shock was felt 150 miles away – official cause of the explosion was undetermined.
Photo shows crater and destruction at plant following explosion. At 7:30 a.m. on September 21, 1921, two powerful explosions occurred at the BASF plant in Oppau, Germany.
Hazardous material: Ammonium sulfate & ammonium nitrate (50/50)
Facility type: fertilizer manufacturing
Deaths: (differing numbers on reported fatalities)

5. Ammonium Nitrate Explosion Texas City, Texas – April 16, 1947
Link to accident report:
SUMMARY (Source: Fire Prevention and Engineering Bureau of Texas)
A fire discovered by stevedores preparing to resume loading of ammonium nitrate aboard the S. S. GRANDCAMP at Warehouse (Pier) "O", about 8 A. M., April 16, 1947, resulted in the first of two disastrous explosions at 9:12 A. M., April 16, 1947 which destroyed the entire dock area, numerous oil tanks, the Monsanto Chemical Company, numerous dwellings and business buildings. The second explosion resulted from a fire in ammonium nitrate aboard the S. S. HIGH FLYER which occurred some sixteen hours later at 1:10 A. M., April 17, 1947.
Damage to property outside the dock area was widespread. Approximately 1000 residences and business buildings suffered either major structural damage or were totally destroyed. Practically every window exposed to the blast in the corporate limits was broken. Several plate glass windows as far away as Galveston (10 miles) were shattered. Flying steel fragments and portions of the cargo were found 13,000 feet distant. A great number of balls of sisal twine, many afire, were blown over the area like torches. Numerous oil tanks were penetrated by flying steel or were crushed by the blast wave which followed the explosions. Drill stems 30 feet long, 6 3/8 inches in diameter, weight 2700 pounds, part of the cargo of the S. S. GRANDCAMP were found buried 6 feet in the clay soil a distance of 13,000 feet from the point of the explosion.
Only brief mention is made of the fire protection features such as automatic sprinkler systems and the fire department. The initial explosion disrupted the sprinkler systems and the water supply to them, destroying all of the fire equipment owned by Texas City and wiped out much of the personnel of the department who were endeavoring to extinguish the fire aboard the S. S. GRANDCAMP.
The loss of life was high. All firemen and practically all spectators on their pier were killed as were many employees in the Monsanto Chemical Company and throughout the dock area. At this date, April 29, 1947, 433 bodies have been recovered and approximately 135 (many of whom were on the dock) are missing. Over 2000 suffered injuries in varying degrees, among whom were many school children injured by flying glass fragments and debris in school buildings located about 6000 feet distant.
The loss of property excluding marine (which was not ascertainable) is estimated to be $35,000,000 to $40,000,000. Time for rebuilding the various docks, warehouses and the chemical plant is expected to take one to two years.
This aerial photograph , looking south over Monsanto Chemical Co., was taken about 30 minutes following the blast of the ship S. S. GRANDCAMP during loading of ammonium nitrate. The accident damaged more than 90% of the city's buildings and killed nearly 600 people.
Source: Fire Prevention And Engineering Bureau Of Texas

6. Major PSM related incidents 1974 - 2001
Source: Wharton Risk Management and Decision Processes Center of the University of Pennsylvania.

7. Seveso, Italy
The Seveso accident happened in 1976 at a chemical plant manufacturing pesticides and herbicides. A dense vapor cloud containing tetrachlorodibenzoparadioxin (Dioxin) was released from a reactor, used for the production of trichlorofenol.
Commonly known as dioxin, this was a poisonous and carcinogenic by-product of an uncontrolled exothermic reaction. Although no immediate fatalities were reported, kilogram quantities of the substance lethal to man even in microgram doses were widely dispersed which resulted in an immediate contamination of some ten square miles of land and vegetation.
More than 600 people had to be evacuated from their homes and as many as 2,000 were treated for dioxin poisoning. This lead to the European “Seveso Directive” to try to prevent similar incidents.

8. Cyclohexane Release & Explosion Flixborough, England – June 1, 1974
20” bypass piping fabricated on-site from shop stock. This pipe ruptured and released cyclohexane which exploded.
Accident Summary (Source: UK Health and Safety Executive, Hazardous Installations Directorate)
At about 16:53 hours on Saturday 1 June 1974 the Nypro (UK) site at Flixborough was severely damaged by a large explosion. Twenty-eight workers were killed and a further 36 suffered injuries. It is recognized that the number of casualties would have been more if the incident had occurred on a weekday, as the main office block was not occupied. Offsite consequences resulted in fifty-three reported injuries. Property in the surrounding area was damaged to a varying degree.
Prior to the explosion, on 27 March 1974, it was discovered that a vertical crack in reactor No.5 was leaking cyclohexane. The plant was subsequently shutdown for an investigation. The investigation that followed identified a serious problem with the reactor and the decision was taken to remove it and install a bypass assembly to connect reactors No.4 and No.6 so that the plant could continue production.
During the late afternoon on 1 June 1974 a 20 inch bypass system ruptured, which may have been caused by a fire on a nearby 8 inch pipe. This resulted in the escape of a large quantity of cyclohexane. The cyclohexane formed a flammable mixture and subsequently found a source of ignition. At about 16:53 hours there was a massive vapor cloud explosion which caused extensive damage and started numerous fires on the site.
Eighteen fatalities occurred in the control room as a result of the windows shattering and the collapse of the roof. No one escaped from the control room. The fires burned for several days and after ten days those that still raged were hampering the rescue work.
Source: UK Health and Safety Executive, Hazardous Installations Directorate
On June 1, 1974 the Nypro Co. site at Flixborough, England was severely damaged by a large explosion. Twenty-eight workers were killed and a further 36 suffered injuries. It is recognized that the number of casualties would have been more if the incident had occurred on a weekday, as the main office block was not occupied. Offsite consequences resulted in fifty-three reported injuries. Property in the surrounding area was damaged to a varying degree.

9. Methyl Isocyanate Tank Rupture and Release Bhopal, India – Dec
Photo Source: Indian state government of Madhya Pradesh
Source: United Nations Environment Programme
On the night of December 2-3, 1984, a sudden release of about 30 metric tons of methyl isocyanate (MIC) occurred at the Union Carbide pesticide plant at Bhopal, India. The accident was a result of poor safety management practices, poor early warning systems, and the lack of community preparedness. The accident led to the death of over 2,800 people (other estimates put the immediate death toll as high as 8000) living in the vicinity and caused respiratory damage and eye damage to over 20,000 others. At least 200,000 people fled Bhopal during the week after the accident. Estimates of the damage vary widely between $350 million to as high as $3 billion.
Report – The Accident in Bhopal: Observations 20 years later

10. Bhopal Aftermath
Photos: OTI
Summary of accident and effects
Source: American University, The School of International Service, Trade & Environment Database (TED) case study #233
The MIC in Bhopal was used for the production of various pesticides, mainly Sevin brand carbaryl insecticide and Temik brand aldicarb pesticide.
On the night of December 23, 1984, a dangerous chemical reaction occurred in the Union Carbide factory when a large amount of water got into the MIC storage tank # 610. The leak was first detected by workers about 11:30 p.m. when their eyes began to tear and burn. They informed their supervisor who failed to take action until it was too late. In that time, a large amount, about 40 tons of Methyl Isocyanate (MIC), poured out of the tank for nearly two hours and escaped into the air, spreading within eight kilometers downwind, over the city of nearly 900,000. Thousands of people were killed (estimates ranging as high as 4,000) in their sleep or as they fled in terror, and hundreds of thousands remain injured or affected (estimates range as high as 400,000) to this day.
The Bhopal disaster was the result of a combination of legal, technological, organizational, and human errors. The immediate cause of the chemical reaction was the seepage of water (500 liters)into the MIC storage tank. The results of this reaction were exacerbated by the failure of containment and safety measures and by a complete absence of community information and emergency procedures. The long term effects were made worse by the absence of systems to care for and compensate the victims. Furthermore, safety standards and maintenance procedures at the plant had been deteriorating and ignored for months. A listing of the defects of the MIC unit runs as follows: -Gauges measuring temperature and pressure in the various parts of the unit, including the crucial MIC storage tanks, were so notoriously unreliable that workers ignored early signs of trouble (Weir, pp.41-42). -The refrigeration unit for keeping MIC at low temperatures (and therefore less likely to undergo overheating and expansion should a contaminant enter the tank) had been shut off for some time (Weir, pp.41-42). -The gas scrubber, designed to neutralize any escaping MIC, had been shut off for maintenance. Even had it been operative, post-disaster inquiries revealed, the maximum pressure it could handle was only one-quarter that which was actually reached in the accident (Weir, pp.41-42). -The flare tower, designed to burn off MIC escaping from the scrubber, was also turned off, waiting for replacement of a corroded piece of pipe. The tower, however, was inadequately designed for its task, as it was capable of handling only a quarter of the volume of gas released (Weir, pp.41-42). -The water curtain, designed to neutralize any remaining gas, was too short to reach the top of the flare tower, from where the MIC was billowing (Weir, pp.41-42). -The lack of effective warning systems; the alarm on the storage tank failed to signal the increase in temperature on the night of the disaster (Cassels, p.19). -MIC storage tank number 610 was filled beyond recommended capacity; and -a storage tank which was supposed to be held in reserve for excess MIC already contained the MIC (Cassels, p.19).
Water entered tank 610 in foreground of picture reacting with MIC and caused an uncontrolled release of a vapor cloud.
Bhopal flare tower with corroded and missing section of pipe. Plant enclosed by fence in foreground.

11. Phillips 66 Houston Chemical Complex Pasadena, Texas – Oct. 23, 1989
This event and the Bhopal disaster triggered the development and subsequent promulgation of the PSM standard.
Accident Summary Source: OSHA April 1990 Report to the President
On October 23, 1989, at approximately 1:00 p.m., an explosion and fire ripped through the Phillips 66 Company Houston Chemical Complex in Pasadena, Texas. Twenty-three workers were killed and more than 130 were injured. Property damage was nearly three-quarters of a billion dollars. The accident resulted from a release of extremely flammable process gases that occurred during regular maintenance operations on one of the plant's polyethylene reactors. The evidence showed that more than 85,000 pounds of highly flammable gases were released through an open valve. A vapor cloud formed and traveled rapidly through the polyethylene plant. Within 90 to 120 seconds, the vapor cloud came into contact with an ignition source and exploded with the force of 2.4 tons of TNT.
According to the ASME:
An inspection after the accident showed that the air hose that supplied the air pressure to control the DEMCO valve actuator was improperly reversed. In addition, the system did not have double-block-and-bleed valves between the reactor loop and the DEMCO valves.
On October 23, 1989, at approximately 1:00 p.m., an explosion and fire ripped through the Phillips 66 Company Houston Chemical Complex in Pasadena, Texas. Twenty-three workers were killed and more than 130 were injured. Property damage was nearly three-quarters of a billion dollars. The accident resulted from a release of extremely flammable process gases that occurred during regular maintenance operations on one of the plant's polyethylene reactors. The evidence showed that more than 85,000 pounds of highly flammable gases were released through an open valve. A vapor cloud formed and traveled rapidly through the polyethylene plant. Within 90 to 120 seconds, the vapor cloud came into contact with an ignition source and exploded with the force of 2.4 tons of TNT.
This event and the Bhopal disaster triggered the development of the PSM standard

12. Summary of Chemical Accidents 1994-1999
This summary of accidents only accounts for a portion of the accidents during this time period because it only examined larger facilities that fell under the EPA RMP standard. Smaller facilities that fall under the OSHA PSM standard were not included in the statistics.
Source:
Kleindorfer, P., Belke, J., Elliott, M., Lee, K., Lowe, R., Feldman, H.,"Accident Epidemiology & U.S. Chemical
Industry: Accident History & Worst-Case Data from RMP*Info", Risk Analysis, Vol.23, No 4, 2003, pp

13. Recent Accidents
It was the terrible accident at Flixborough that led to major changes in the UK regulations and the Seveso Italy catastrophe that led to the EU Seveso directive, but both of these events had little impact on laws and regulations in the USA.
The Bhopal tragedy reinforced by the 1989 Phillips accident were needed before the USA the OSHA Process Management Standard (PSM) and EPA Risk Management Program (RMP) and industry trade associations adopted the Canadian Responsible Care program.
Accidents continue to occur even after the advent of legislation aimed at curbing PSM related catastrophes.
The following slides outline three recent accidents, one in Washington state.
Note: an investigation of an explosion at the Tesoro Oil Refinery that occurred in April, 2010 in ongoing at the time of this July, 2010 version of this course. Some details are on the L & I – DOSH Safety webpage

14. Ammonium Nitrate Explosion Toulouse, France – September, 21 2001
Accident occurred exactly 80 years after the Oppau, Germany disaster!
Brief Description
A huge explosion ripped through AZF (Azote de France) fertilizer factory in an industrial zone on the outskirts of Toulouse, southwest of France, at 10:15 am, Friday 21 September Immediately after the accident, 30 people were reported dead The total number of injuries was said to be 2,442. More than 350 people were in the plant at the time (266 AZF employees and 100 subcontractors).
The explosion had occurred in a warehouse in which granular ammonium nitrate was stored flat, separated by partitions. The amount is said to be between 200 to 300 metric tons of ammonium nitrate, which is used to make fertilizers. A spokesman for the Interior Ministry in Paris ruled out a criminal attack, saying the explosion had been caused by an accident following an "incident in the handling of products". The exact cause remains unknown.
AZF (formerly named ONIA) is the name under which Grande Paroisse, France's largest fertilizer manufacturer, sells its products. Grande Paroisse is owned by Atofina, the chemicals unit of TotalFinaElf - the world's fourth-biggest oil group.
The AZF site is one of 1,250 factories in France classified as high-risk. The site falls under the rules of the European Union's Seveso Directive.
Impact
The blast blew out windows in the city centre 3 km away and created a 50 meter- diameter crater with more than 10 meters deep
Telephone lines were immediately cut and the lines were affected as far as 100 km away.
Experts said the explosion was the equivalent to an earthquake measuring 3.4 on the Richter scale.
More than 500 homes became uninhabitable and almost 11,000 pupils are staying at home after some 85 schools and colleges were damaged.
22 people were killed on the site, 6 nearby and 1 died in hospital, regional officials said.
The force of the blast toppled two chimneys at the chemicals plant, which produces nitrogen and phosphate products used in the making of explosives.
The director of an ammunition factory nearby, owned by the Societe Nationale des Poudres et Explosifs, said there had been a second, lesser explosion there as a result of the original blast at neighbouring AZF, but nobody was injured.
An electrical goods store 300 meters from the AZF plant collapsed 45 minutes after the explosion. A nearby school was evacuated amid fears it too would collapse.
Flights to Toulouse were rerouted to other airports, according to a local crisis emergency centre.
Up to 6,300 tonnes of liquefied ammonia, 6,000 tonnes of solid ammonium nitrate and 30,000 tonnes of solid fertiliser were kept at the installation. Up to 100 firefighters searched for survivors through the wreckage from the blast, piled up to 10 meters high in some places.
A red cloud was seen near the factory following the blast on Friday. Police initially urged local people to stay inside their homes, because they thought it could be an ammonia leak, though later tests showed there was no danger of poisoning and the alert was lifted.
Sources: Planet Ark Environmental News UPDATE; Le Monde, Le Figaro, Liberation, BBC news, CNN news, The Guardian and The Times.
A huge explosion ripped through AZF (Azote de France) fertilizer factory in an industrial zone on the outskirts of Toulouse, southwest of France, at 10:15 am, Friday September 21, Immediately after the accident, 30 people were reported dead The total number of injuries was said to be 2,442. More than 350 people were in the plant at the time (266 AZF employees and 100 subcontractors).
The explosion had occurred in a warehouse in which granular ammonium nitrate was stored flat, separated by partitions. The amount is said to be between 200 to 300 metric tons of ammonium nitrate, which is used to make fertilizers. A spokesman for the Interior Ministry in Paris ruled out a criminal attack, saying the explosion had been caused by an accident following an "incident in the handling of products". The exact cause remains unknown.
Source: United Nations Environment Programme

15. BP American Refinery Explosion – Texas City, Texas
March 23, 2005
At approximately 1:20 p.m. on March 23, 2005, a series of explosions occurred at the BP Texas City refinery during the restarting of a hydrocarbon isomerization unit. Fifteen workers were killed and 180 others were injured. Many of the victims were in or around work trailers located near an atmospheric vent stack. The explosions occurred when a distillation tower flooded with hydrocarbons and was overpressurized, causing a geyser-like release from the vent stack.
Link to Chemical Safety board final report

16. Equilon Refinery Accident November 25, 1998
Equilon Oil Refinery – Anacortes, Washington, now owned by Shell Oil.
Multiple Fatalities – 6 workers killed
This was the worst worker fatality incident in the history of Washington State until the April, 2010 Tesoro Oil Refinery explosion where seven workers were killed. The Tesoro incident is currently under investigation as of July, 2010
Link to short history of Equilon incident

17. Events Leading Up to Incident
On Tuesday, Nov. 24, 1998, high winds cause power outage & complete refinery shutdown
A large vessel known as “Drum A” was about 1 hour into a routine charging cycle
46,000 gallons of hot coke 900 F became trapped in Drum “A”
The plant has a cogeneration facility which generates electricity. Because of the arrangement, they dump that power directly to the grid, and buy back their power from the local utility company. The refinery does not have the internal switching capabilities to utilize their own power they generate.
Since most of their equipment is electric and steam driven, the refinery lost all of their utilities. This included loss of the charge pump on the DCU as well as the emergency steam system designed to purge the lines up into the drum in emergency situations.
The Erie City boiler can be fired by natural gas or other fuels available at the refinery and can operate independent of the operations of other process units. The boiler contributes to the overall plant steam load at the refinery. The unit was taken out of service around July, 1998 and sat idle until following the incident at which time work regained momentum.
On the delayed coking unit, steam is an important commodity. In emergency situations, steam pushes heavy hydrocarbon through the one and only line into the bottom of the coke drums so that the contents can still be cooled with steam and water.
Coke Drum “A”

18. Coke Producing Process
Heavy oil from crude oil processing called vacuum residuum is heated and pumped into an on-line coke drum. Heavy long-chain hydrocarbon molecules are “cracked” under high temperature and pressure. The lighter hydrocarbons produced are carried to the top of the drum and over to a fractioning column for further processing.
Since no reaction is 100%, the remain long chain molecules combine to form a high carbon material called “coke” which ends up at the bottom of the coke drum and must be removed at the end of the cycle before the process can be repeated.
Coke is a heavy, dense black material similar to a charcoal briquettes.

19. Normal Coke Removal Operation
Drum A is cooled first with steam followed by water.
When acceptable temperatures are reached “safe work permits” are issued and acknowledged by the coke cutting contractor to unhead the drum.
A high pressure water wand is lowered into the drum, and coke is “cut” into chunks which flow out of the bottom of Drum A into a pit below.
The cooling steps are extremely important to ensure the drum contents are adequately cooled prior to vessel unheading.

20. Drum A Schematic
In this situation workers needed to get this coke out of the vessel. But, they couldn’t move any steam or water through the charge line (“DCU” line) to cool the hot coke in the drum because it was clogged with coke material that cooled and hardened during the power outage.
46,000 gallons of hot coke

21. November 24th - During The Day
Attempts are made to clear the DCU heater lines when steam is restored around 10:00 AM.
Operators are optimistic that steam made its way through the heater and up into the bottom of the “A” Drum.
Instead, it is likely the pressure relief valves were lifting and simply diverting steam to their blowdown system
Operators applied steam to the DCU lines. The interviews revealed that they were optimistic that steam was getting through, however, looking back, it’s likely that pressure relief valves were lifting, and simply diverting the steam to their blowdown system.

22. The “Night Orders”
Unit foreman writes the night orders and discusses at a 3 PM managers meeting on November 24th.
He says “…drum is cooling without water. Do not put water into drum. Day shift will un-head Wednesday morning.”
Little activity during the night shift, drum sits idle.
Several impromptu meetings held the next morning between unit foreman and operators.
Additional attempts made to clear the line into the drum without success.

23. Actual temperature of hot coke unknown
This picture shows the approximate locations of the available temperature indicators - one at the gooseneck, one on the overhead vapor line and one skin temperature sensor about a third of the way up (above the level of material in the drum). Employees had no way to actually determine the temperature of the material inside the drum. By all accounts no technical assistance was requested or provided to even estimate the temperatures. Later estimates were that it would take over 200 days for the coke to cool down to a safe temperature.
On November 25, unit foreman and operators review available drum parameters and conclude drum contents sufficiently cooled to un-head.
Top head of drum was removed without incident or indication of temperature of coke at bottom of Drum A.

24. The Tragic Results
Using hydraulic controls, employees lower the bottom head.
Coke spews out in a 360 degree fashion.
Coke is still at auto-ignition temperature.
46,000 gallons dumps in about 6 seconds and ignites enveloping six workers in flames.
= employees

25. The Cost Six Lives Lost Equipment Damage Lost Production
DOSH Citations
Third Party Lawsuits
Worker Morale
Standing in the community
Lost life and the lives those people touched was the biggest cost that you can’t attach a value to (except for attorneys)
Citations- WISHA citations ultimately cost the company 4 million dollars in the form of a settlement agreement.
lost production and equipment damage estimated to be in the 10 to 20 million dollar range.
Third party lawsuits totaled about 45 million dollars
DOSH citations ultimately cost the company 4 million dollars in the form of a settlement agreement. Lost production and equipment damage estimated to be 10 to 20 million dollars. Third party lawsuits totaled about 45 million dollars.

26. Lessons Learned Management of Changes Emergency Preparedness
Operator Training
Procedural Development
Permit Systems
MOC- It’s not enough to just have a system to manage changes. The system has to be alive and well. At the first suggestion of a procedural change, the system should have been triggered. Audit your own programs to ensure your managing changes (this includes equipment, procedures even manpower issues)
Emergency Preparedness- Review your emergency operating procedures-do they cover all the credible events. (PHA’s should cover this in detail and flush out the deficiencies)
Operator training - Is the training adequate. Do operators know the true hazards of the process they’re operating. What about responding to upsets and unusual operating conditions.
Procedures-Are they current and accurate? Have they been effectively communicated to operations?
Permit Systems- If you don’t have them, develop them. In this case the system was seriously flawed. It was acknowledged that they thought drum parameters were adequate for deheading when they really had no way of knowing the temperature.
MOC- It’s not enough to just have a system to manage changes. The system has to be alive and well. At the first suggestion of a procedural change, the system should have been triggered. Audit your own programs to ensure your managing changes(this includes equipment, procedures even manpower issues)
Emergency Preparedness- Review your emergency operating procedures-do they cover all the credible events. (PHA’s should cover this in detail and flush out the deficiencies)
Operator training - Is the training adequate. Do operators know the true hazards of the process they’re operating. What about responding to upsets and unusual operating conditions.
Procedures-Are they current and accurate. Have they been effectively communicated to operations.
Permit Systems- If you don’t have them, develop them. In this case the system was seriously flawed. Both parties acknowledged drum parameters were adequate for unheading when they really had no way of knowing the temperature which brings us to the next issue.

27. To Do List Audit your facilities !!
Encourage participation from the trenches.
Document deficiencies and establish target dates for correction.
Investigate the small stuff and fix it.
Review operation procedures to ensure as many “what if” scenarios are included.
Ensure upper management is included in the decision-making for unusual situations.
Establishing some comprehensive audit protocol and implementing a plant wide audit is one of the most proactive things you can do. Make sure your management systems are alive and well. Of course if you’re a covered facility, every three years (at least) is the standard. Accept the bad stuff with the good stuff, after all your looking for was to improve!
Make sure you involve line employees. They are important contributors to the audit process.
Documents the deficiencies you find and establish target dates for correction. Hold people accountable.
Develop a system for investigation near misses and minor incidents look for true root causes and contributing factors and resolve them. Again, hold people accountable for their ultimate resolution.

28. Resources for More Information
American Institute of Chemical Engineers
International Institute of Ammonia Refrigeration
The Chlorine Institute
AcuSafe – Internet resource for safety & risk management information
DOSH Directive – Chemical Facility Process Safety Management NEP
DOSH Directive – Process Safety Management
Your Own Industry Organization
For auditing guidance there are a number of excellent resources or places to begin. For PSM the OSHA CPL is a good starting place. AIChE, IIAR, and CI.
Ask you own specific industry groups for assistance.
Click here for videos of recent chemical plant explosions and accidents
U.S. Chemical Safety Board