1. Seite 1 ©Prof. Jochum Capacity Development Programme in Industrial Disaster Risk Management Crisis Management: Avoiding and Mitigating Major Accidents Prof. Dr. Christian Jochum India, February 2009

2. Seite 2 ©Prof. Jochum Professional Profile Christian Jochum Born 1943 in Frankfurt a.M./Germany PhD in Chemistry, certified Safety Engineer Honorary Professor at Frankfurt University 28 years experience in large chemical/pharmaceutical company (Hoechst AG) –1969 – 1979 Pharmaceutical research and pilot plant operations –1979 – 1997 Safety department (Site and Corporate Safety Director and „Major Accident Officer“ since 1987) EHS – and crisis management consulting for different types of businesses and administration since 1997 Commission on Process Safety (formerly Major Hazard Commission) at the German Federal Minister for the Environment (Chairman since 1998) European Process Safety Centre (Rugby/UK): Director of Centre since 2007

3. Seite 3 ©Prof. Jochum European Process Safety Centre (EPSC) www.epsc.org Network funded by 40+ mainly European based (petro)chemical multinationals to develop best practice in major accident/process safety Objectives: Information/know how exchange Legislation (esp. Seveso II & ATEX) participation & co-ordination of EU funded projects Outputs: Internal reports & books User groups & public conferences EU projects & working groups Major topics 2008/09: Process Safety Indicators/Learning from Accidents Safety Critical Equipment Fostering Senior Management Involvement in Process Safety (with EFCE) LOPA Experience & Development

4. Seite 4 ©Prof. Jochum Mandated by the Federal Emission Control Act Advises government as well as plant operators and state and local authorities on process safety 32 members with different professional and educational background representing different stakeholders (“Round Table”) Any group needs “allies” to win votes Consensus intended, but majority decisions possible About 55 guidelines issued on different topics, e.g. Land Use Planning (Safety distances) Risk evaluation and perception Emergency Planning Industrial parks Provisions against terrorist attacks on chemical plants All publications of the Commission are available (partly in English) at www.kas-bmu.de Commission on Process Safety (Kommission fuer Anlagensicherheit [KAS])

5. Seite 5 ©Prof. Jochum Outline 1 1 Case Study: Hoechst Incidents 1992 Improving Existing Plants 3 3 Lessons Learnt 2 2 Conclusions 4 4

6. Seite 6 ©Prof. Jochum Case Study: Hoechst Incidents 19931 In 1993 three major incidents occurred at 2 Hoechst sites near Frankfurt/Germany within 6 weeks Feb. 22 Runaway reaction after an unnoticed stirrer failure. Emission of 10 tons methanol containing a possibly carcinogenic substance, contaminating a large residential area March 15 Explosion of methanol – air – mixture during maintenance in a process plant. 1 worker killed, 1 seriously burnt April 2 Major sulphur trioxide emission in a process plant The series of incidents caused a lot of public concern and nationwide media coverage.

7. Seite 7 ©Prof. Jochum Hoechst Incidents: Severe Consequences1 Although the Feb. 22 emission did not cause serious injuries, it led to the most serious consequences for the company and the most “lessons learnt”: Prevention would have been possible by a thorough risk analysis leading to a simple safety device (stirrer control acting on charging valve) Confidence in the company´s competence in emergency response was torn down by –Gross underestimation of the affected area –Incomplete knowledge of the hazardous properties of the emitted substance –Inadequate wording in the first press conference Aggravation of adverse reactions by neighbours, media and authorities by arrogant behaviour of site representatives long before the incident

8. Seite 8 ©Prof. Jochum Outline 1 1 Case Study: Hoechst Incidents 1992 Improving Existing Plants 3 3 Lessons Learnt 2 2 Conclusions 4 4

9. Seite 9 ©Prof. Jochum Hoechst Incidents: Lessons Learnt2 Crisis management assessment should cover all parts of emergency- and crisis- management... identify hazards comprehensively... pursuing the goal to define and train as much as possible in advance avoid or control risks communicate remaining risks mitigate consequences remediate damages restore trust

10. Seite 10 ©Prof. Jochum Hazards2 Hazards have to be identified systematically... eg. „classical“ EHS-hazards, loss of production,... Operation hazards Network hazards Environmental hazards eg. failure of utilities, supplies, transportation... eg. natural hazards, adjacent plants and traffic ways,... eg. densely populated areas/buildings, natural reserves,... Environmental vulnerability eg. plant vulnerability, neighbourhood/environment sensitivity, company image,... Terrorist threats... and transposed into scenarios.

11. Seite 11 ©Prof. Jochum Prevention2 Avoid or control risks Assess procedures Assess procedures Define safety measures Define safety measures Minimise hazards (  “Inherent Safety”) Engineering/organisation/human factor/“Security” update necessary? Assess safety measures Assess safety measures eg. Audit programs “Prevention is the best remedy”

12. Seite 12 ©Prof. Jochum Risk Communication2 Communicate remaining risks Internal External eg. training, drills Towards customers, neighbours, authorities – but careful regarding security risks! “who always claims `zero risk´, has no credibility in his ability to control risks!”

13. Seite 13 ©Prof. Jochum The bigger a corporation, the higher the expectations even for small sites Mitigation2 Mitigate consequences Internal emergency planning (above all organisation, equipment, drills) Cooperation with external services (neighbouring plants, public services) Important: ability to react fast!

14. Seite 14 ©Prof. Jochum Claim management 2 Remediate damages... do not handle damages as insurance cases only... fears may not be justified, but are always real... be prepared for problems of competency and competition (internal and external)... identify “free-riders” “well treated wounds heal better”

15. Seite 15 ©Prof. Jochum Confidence Management2 Restore trust... prepare the fundament before the crisis... communicate open and clear (possible conflict regarding terrorist threats!)... do not downplay fears... give the company one face You may lose trust in hours. Restoring trust needs years

16. Seite 16 ©Prof. Jochum Will the crisis management system be adapted to today´s frequent organisational changes? Crisis Management Systems: can the unpredictable be planned?2 Define as much as possible in advance, because...... crisis always happen at the wrong time and place... your regular organisation is not sufficient to handle crisis... all resources of the whole company have to be available in due time... public, media and authorities expect professional handling of crisis, too

17. Seite 17 ©Prof. Jochum Drills 2 Major incidents hopefully become less frequent. This makes drills even more important...... to train seldom used procedures... to reduce mental stress during incidents... to optimise emergency- and crisis- management The gap between resource consuming “full drills” should be filled with frequent “smaller” drills.... to make sure that necessary resources are available

18. Seite 18 ©Prof. Jochum Outline 1 1 Case Study: Hoechst Incidents 1992 Improving Existing Plants 3 3 Lessons Learnt 2 2 Conclusions 4 4

19. Seite 19 ©Prof. Jochum Plant & Process Safety: improvement of existing (“old”) plants3 Make best use of limited resources by a stepwise approach: 1.Have full knowledge about hazardous properties of all substances (e.g. Material Safety Data Sheets, data bases, etc.) 2.Identify and rank critical points (human- and eco – toxicity, hold-up of hazardous substances, reaction conditions, mechanical and physical hazards) 3.Document this in a safety study as a tool for use by the plant and by authorities 4.Focus improvements (manpower, money, additional safeguards etc.) and inspections on the most critical points 5.The higher the risk, the more independent safeguards (“barriers”) should be considered 6.Use the scenarios developed under (2) for emergency planning

20. Seite 20 ©Prof. Jochum Lagging Indicator Leading Indicator “Swiss Cheese Model” (after J. Reason, modified by Mike Broadribb, BP)

21. Seite 21 ©Prof. Jochum Plant & Process Safety: Use existing knowledge3 Most accidents and eco – incidents have a previous history... Preliminary events leading up to the accidents (failure of preliminary safeguards) have not been identified Prior to most major accidents similar smaller incidents or near misses have happened, but not evaluated... which should be used for prevention Raise the awareness of the workers Use the experience of workers –Encourage reporting of deviations, near misses and even minor incidents as well as suggestions for improvements. Consider contests and awards for groups working together –Have a system for following up such reports/suggestions

22. Seite 22 ©Prof. Jochum Plant & Process Safety: The Human Factor3 Workers are risks and resources for safety They have to know the risks to cope with Detailed written procedures are a tool both for workers and for management. They should... –describe the procedure as it is in the plant step by step –use a language and expressions which are understood by the workers (no scientific or technical paper) –highlight hazards, safety measures and critical process parameters (temperature, pressure,...) –make independent double checks mandatory for critical parameters and procedures –include start-up, shut-down, maintenance and process-specific information for emergencies Use other procedures (e.g. Quality) for safety purposes, too Include normal and abnormal situations in training

23. Seite 23 ©Prof. Jochum Safety Operating Procedures3 Examples for visualization of safety information AcetoneLadders

24. Seite 24 ©Prof. Jochum Emergency Preparedness3 Accidents may happen even in most modern plants. They cannot be planned, but they should be considered. Use the scenarios identified for prevention of major incidents for emergency planning and training, too Cover all relevant scenarios in the emergency plan Assign responsibilities rather than regulating details The emergency organisation is different from the normal organisation, but has to be empowered to use it Adjust the emergency organisation to the dimension of the incident (e.g. “blue, yellow, red alert”) Clearly document all available resources (site, company, neighbouring sites, authorities,...) for the different scenarios. Ensure that they can be used in emergencies (e.g. co-operative agreements) Before you rely on off-site resources, consider the time until availability Industrial zones with many companies close together need special attention (“domino-effects”)

25. Seite 25 ©Prof. Jochum Emergency Response3 The basic principle: the faster and more effective the initial response, the smaller the consequences for men, environment and economy. Provide the infrastructure for fast response (fire brigade, emergency control room, notification and availability of key personnel, etc.) Encourage immediate reporting of incidents (not to wait until own efforts failed...), do not blame for false alarms Site fire brigades (or shared with adjacent sites) usually are faster and more efficient than municipal brigades, which rather serve as a back-up If the fire brigade is (partly) staffed by operators be aware of the risks of understaffed production Better start with a higher level of alarm (worst case assumption) and grade it down later than vice versa Notify and involve public fire brigades and authorities as soon as possible Analyse every incident and the response without blaming anyone to improve the emergency organisation

26. Seite 26 ©Prof. Jochum The Role of Authorities3 The cooperation between authorities and companies at an incident depends on their cooperation before the incident. Open communication about risks and safety measures on a regular basis (e.g. in a local or regional committee) builds up trust which is urgently needed during emergency response Authorities need to know about the possible scenarios for major accidents to do their own preparations Authorities should have clear rules about their responsibilities in handling major incidents to avoid conflicts between the different agencies (e.g. labour safety, environment, civil protection, police etc.) Mitigation of consequences should come first, legal prosecution of individuals responsible for the incident later

27. Seite 27 ©Prof. Jochum Neighbours, Journalists and Environmentalists3 The basic issue: Neighbours and the general public share the risks of industrial sites, but not necessarily the benefits. Communication of relevant risks has to be done openly and in an adequate form (“not scientific”) prior to incidents (e.g. “neighbourhood councils”, brochures,...) –to build up trust in the competence of the company to handle risks –to enable the neighbours to react adequately during an incident The response of neighbours etc. to incidents is strongly influenced by the company´s response to requests and complaints prior to the incident Fast and open information after an incident is crucial Fears and worries of neighbours etc. have to be taken seriously even if they are based on emotions rather than science On the long term, conflicts with neighbours etc. endangers the “licence to operate” Committees with all stakeholders as the German Commission on Process Safety are an effective tool for cooperation and communication.

28. Seite 28 ©Prof. Jochum Outline 1 1 Case Study: Hoechst Incidents 1992 Improving Existing Plants 3 3 Lessons Learnt 2 2 Conclusions 4 4

29. Seite 29 ©Prof. Jochum Conclusions4 Investing in safe and eco-efficient plants pays off at least on the long term The (remaining) risks of industrial plants can be assessed and are the basis for scenarios for emergency planning The knowledge and experience of the operators should be used by all means Risks should be communicated as well as benefits to all stakeholders, esp. the neighbours The resources for emergency response (manpower, equipment, communications, organisation etc) have to be planned in advance and readily available in case of an incident. People usually accept the risk of a chemical/pharmaceutical plant, but not incompetence in handling it Authorities should involve themselves actively in emergency planning, balancing this out with their law enforcement duties Combined efforts will definitely lead to safer and more accepted plants, as the figures from Germany may show

30. Seite 30 ©Prof. Jochum Development of Accidents in Germany since 19504 „Arbeitsunfälle“ = occupational accidents „Wegeunfälle“ = acc. on the way to work

31. Seite 31 ©Prof. Jochum Thank you for your attention!