Proactive Process Safety Management

By David Coote

Would the incident at BP Texas City, 2005, have happened if a proactive (*) approach to Process Safety management was in place?

What happened at BP Texas City, 2005?

During start-up of a process unit in the refinery, a column was over-filled and over-heated. The relief valves opened causing liquid and vapour to flow out the top of an elevated vent pipe into the atmosphere. These fluids formed an explosive gas cloud at ground level. An explosion occurred, 15 people were killed, and many others injured.

Key Issues (from investigation)

  • Operator inattention
  • Not following procedures
  • Supervisor absence
  • Communication –shift handover
  • Trailers (portable offices) too close to Hazards
  • Some instrumentation did not work
  • Abnormal Start-ups
  • Investigation of Previous Incidents
  • Blowdown Drum Vented Hydrocarbons to Atmosphere
  • Opportunities to Replace Blowdown Drum
  • Fatigue


  • The above issues have processes and procedures to control
  • Plant start-ups are known to be a dangerous phase of operation
  • The operator did not proactively ensure these processes and procedures were effective
  • If only one of these processes or procedures had been effective the incident could have been averted

For this (or any) incident, ask: did the operator know of any lack of effectiveness of these processes and procedures and possible implications?

  • if YES……then they did not proactively manage risk.
  • if NO…….then they did not proactively make themselves aware of the risks and then manage them.

(*) proactive PS means continually assuring the effectiveness of processes, procedures and people with respect to PS.

This note is not about the technical causes of MI’s but is about MHF operators’ responsibilities to do the right things to prevent a MI on their site.

What is going wrong?

After a MI, there is usually intense industry focus, however this inevitably wanes with the passing of time.

People become complacent and lose focus on PS, assuming all will continue to be OK.

Many actual major incidents (MI's) often have the same or similar root causes as past incidents.

The causes of most MI's are not new, but are not managed well enough to prevent a MI.

People in control of a site may not be fully aware of Process Safety (PS) issues or the impact of their management or decisions.

The investigation identified the following underlying cultural issues that were present in the BP Texas City refinery at the time of the incident.

What does it take to prevent a MI?

How does an operator maintain focus on PS when there has not been a recent MI in the industry or a near miss in the company or site? There should be a Safety Management System with processes and procedures in place to manage risk and to ensure that the people involved know their role and are competent, including those with control of the site. These processes and procedures won’t necessarily be fully effective and the organisation must pro-actively seek signs that risk is not being effectively managed and continually improve their processes and procedures.

Most everyone would be familiar with the Deming circle / cycle / wheel of: plan-do-check- act. It does need to be in place and going round at the right pace to pick up and correct issues effectively.

This proactive approach includes taking appropriate actions and communicating issues based on:

  • reviewing process safety KPI’s, incidents and near misses investigations, audit actions and risk reduction action plans, etc
  • using a tiered audit approach, including management observations in the workplace
  • having the right mindset: looking for areas to improve rather than assuming all is OK
  • creating the right culture: where people will be engaged and report issues up because they know they won’t be blamed or ignored, and where people know their actions to keep or make the site safe
  • providing PS expertise and regularly reviewing and revising the site’s safety assessment

Additionally, the people with decision making authority and control of the site need to be fully aware of PS risks and PS management and incorporate PS into management decision making.

What are the requirements and guidelines for people with this authority?

NSW has legislation in place to address this, aimed at preventing not only MI’s, but WHS harm in general.

Due diligence in relation to ensuring health and safety is defined for the first time in the WHS Act 2011. The WHS Act 2011 imposes a specific duty on “officers” to exercise due diligence to ensure that the PCBU meets its work health and safety obligations. This includes personal liability for “officers” . See Guidance For Officers In Exercising Due Diligence. Note that active involvement of “Middle Managers” and “Supervisors” is included.

Role of Safework NSW (SafeWork). Operators of Major Hazard Facilities in NSW need to be able to demonstrate to Safework that risks are being pro-actively managed, to reduce risks so far as reasonably practical. MHF Operators are encouraged to contact SafeWork for any support required.

Other benefits of effective PS management — see aiche/ccps slides