Global HSE Conference | Sept 26-27 | New Delhi | India

1. Hirak Dutta
Executive Director
Oil Industry Safety Directorate
27th Sept, 2013

2. Agenda
 Size of Petroleum Industry in India
 Pillars of PSM
 Systemic approach in PSM
 Ignoring warning signals & its consequences
 Key Lessons
 OISD’s focus in ‘Process Safety Management’
 Cornerstones of PSM

3. Size of the Petroleum Industry in India
Once a petroleum product deficit country, India today is exporter of
petroleum products with earnings to the tune of US $ 60 billion per
annum
CAPACITY Current Projected
(2016-17)
Total Installed refining capacity ~ 215 MMTPA 310.9 MMTPA
Crude oil production capacity ~ 38 MMTPA 41.1 MMTPA
Gas Production capacity ~ 43 BCMPA 90.1 BCMPA
Volume of POL handling ~ 152 MMTPA 186.2 MMTPA

4. Petroleum Industry in India
 India is the 4th largest consumer (at 569 Million Metric
Tonnes of Oil Equivalent) in the year 2011, after China,
US & Russia.
 Petroleum Industry plays a vital role in providing energy
security, and contributes towards the overall growth of
the country.
 Oil & gas Installations normally operate within high
temperature & pressure envelope; handling highly
hazardous & inflammable HCs.
 Therefore, preservation and safety of these vital National
assets are of paramount importance.

5. Process Safety
Management

6. Pillars of Process Safety
Process Safety
Operational
Integrity
Maintenance
Integrity
Asset
Integrity

7. Design
Construction
Startup
Shut down
Emergency
Handling
System &
Procedures Best
Practices
Warning
Devices Engineered
Safety
Devices Safety
Equipment Fire Fighting
Facilities
Event
Systemic Approach in Process Safety
Management
 Learn from Near Misses
 Mock Drills
 Task Observation
 Accident-Incident
 Change Mgmt. System
 Continuous training &
Education
 Work Permit
 Internal Audit
 Review of P&ID
 QRA/HAZOP
 Inc. best engg. Practices
 Safety Instrumentation
 3D Model Review
 PSV
 ESD
 BOP
 SCSSCV
Hazards
 HC Detector
 Alarms in Control
Room
 SOP
 Simulator
 Pre-com Check list
 Blow down System
 Equipment Spacing
 Deluge

8. Accidents do not
happen just like
that…

9. Prior to any major accident there are always
warning signs which, had they been responded to,
would have averted the incident.
But they weren’t.
They were ignored.
Very often there is a whole culture of denial
operating to suppress these warning signals.
Professor Andrew Hopkins

10. Warning signals
 Process equipment not functioning as intended.
 Frequent process excursions outside the safe operating
envelope.
 Continuing Operation with impaired safeguards.
 Critical safety systems kept in bypassed mode or not
functioning as intended or not tested.
 Frequent process upsets.
 Tolerance to failure to follow company’s systems and
procedures.
 Failure to learn from near misses or previous incidents.
 Minor incidents not being reported.
 Repeat findings occur in the subsequent audits.
 Inadequacies in safety management system like failure to
perform hazard analysis, failure to recognize & manage
change, inadequate follow up on warning signs/ indicators.

11. Warning signals
Common response by organization
Ignores signals on the premise that these
can be addressed later
(or if the problem escalates).

12. Illustration on failure to recognize
warning signals
Buncefield
• Failed to recognize that the level gauges were not working properly/
instrumentation system not working.
Bhopal
• The critical safety system was kept bypassed / not working properly for a
long period/ No MOC/ improper maintenance.
Richmond, California
• 70 % metal loss in gas oil draw-off line from CDU; under the
insulation corrosion; pointed out by inspection.
MHN
• Inclement weather - cyclonic conditions; Dynamic positioner of rescue
vessel perhaps impaired.

13. Illustrations on failure to recognize
warning signals
Pemex, Mexico
• Ignored the early signal i.e. drop in the pipeline pressure
noted in the control room due to rupture of the LPG
pipeline.
Piper Alpha
• Short-cuts in Maintenance activities - PSV of the
condensate pump removed but the end flange blinded
loosely - hand tightened; Failure to communicate the same
by shift operator to the next shift personnel; continued
operation with improper fire fighting facilities.
Jaipur
• Instrumentation cable was impaired /equipment not
meeting good engineering practices.

14. Strategy for response
Recognize a warning sign
Focus resources and efforts
on gap liquidation
Investigate the
situation to find
facts
Follow up to
ensure the issue is
addressed
Response
Strategy

16. CAUSE
Total
Incidents
Non adherence
to SOP 24
Equipment
Failure 11
Non adherence
to Work permit
system
7
Miscreant
activities 8
Lack of
Supervision 6
Slip/fall,
Negligence 14
Total
70
Non
adherence
to SOP
34%
Equipment
Failure
16%
Non
adherence
to Work
permit
system
10%
Micreant
activities
11%
Lack of
Supervision
9%
Slip/fall,
Negligence
20%
Major Incidents:2012-13
(In plant)

17. Reasons for accidents
 Risks are not identified; even where HAZOP study has
been carried out mitigation measures not taken.
 Improper focus on Asset Integrity Management;
poor reliability.
 Disregard to the extant systems & procedures.
 Inadequate personnel competency
 Violation of standard operating procedure.
 Knowledge gap & poor supervision.

18. Key Lessons: OISDs experience

19.  Holistic approach to HSE and Asset Integrity
Management is needed to avert major accidents.
 Hazardous industry like ours must ensure that the
lessons learnt from the accidents are incorporated
into the safety management system.
 High concern/focus on achieving throughputs and
maximizing GRM negatively impacts safety: Safety
should not be subservient to achievement of targets.
 Benchmarking the safety performance parameters is
needed to achieve improvements in Process Safety
Management.
Key Lessons

20. Key Lessons (contd.)
 When near-miss / accidents occur:
 Diagnose the systematic failure.
 Don’t look at only what went wrong but recognize
the hazards & way to control the same.
 Objectively carry-out accident-incident
analysis:
 Not for fault finding purpose
 To identify root causes
 To improve the system & avoid recurrence.

21.  Building a safety culture through inspiring leadership
at all levels is a must.
 Focus should be more on leading rather than lagging
indicators.
 Always adhere to inherent safety principles.
 Safety is 24X7 activity; yesterday’s good safety
performance does not guarantee todays safety.
 No substitute for high diligence thus employee
engagement is foremost.
Key Lessons (contd.)

22. On the following drivers:
 Procedures for operation and maintenance (SOP)
 Hazard Identification
 Risk reduction Action Plan
 Focus on leading indicators
 Management of change
 Permit to work
 Plant integrity
 Critical controls (bypass policy)
 Incident investigation
 Process safety training
 Emergency preparedness
OISD’s Focus

23. Cornerstones of Safety

24. Safety
Cornerstones of Safety
Employee Engagement
Managing Asset Integrity
Risk Assessment & Hazard Study
Adherence to System & ProceduresAccident Incident Analysis
Management of
Change

26. Thank you for your patience
Questions?