surprise we had an incident -...
TRANSCRIPT
150 years
Surprise –
We had an incident
Hans V. Schwarz, BASF
Dordrecht, May 17, 2017
150 years
Process Safety Incidents
Process Safety
BP 2005 (Texas City, USA) Bayer 2008 (Institute, WV, USA)
Evonik 2012 (Marl) Nippon Shokubai 2012 (Japan)
2
150 yearsProcess Safety
Oct. 2016 incident in Ludwigshafen
Our worst incident in decades
3
Cut in the wrong pipeline with ignition puts neighboring pipelineunder fire, subsequent explosion, with 4 fatalities, 7 severely injured
Ongoing investigation of state attorney
Before the incident After the incident
150 yearsProcess Safety
Severity weighted PSI Rate, Cause distribution:
The trends before the severe incident
4
0
1
2
3
4
5
6
7
8
12 13 14 15 16
Ludwigshafen
PSI Severity Points per 1 mio working hours
Severity points / Year, div. by BASF manhrs/Yr.
Each incident gets 1, 3, 9 or 27 severity points
H1/2016
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
SE 2011 SE 2013 SE 2015
PSI Root Cause CategoryDistribution BASF SE
Operational Integrity
Asset Integrity
Design Integrity
Others or without Root Cause Evaluation
H1/2016
2011 2012 2013 2014 2015 2016
150 yearsProcess Safety
Incidents despite the organized approach
5
A good approach makes a very big difference vs a mediocre approach:
Major western companies with well developped safety management
systems have much less incidents than companies in the developping
world
Asian companies have already benefitted a lot from improving safety
management
Our methods generally work very well, and the result is a function of the
input
The learnings we still make are significant. There is no reason that we
cannot cut incident rates further to a fraction of today, even without
overwhelming costs
The focus is shifting to the work processes in maintenance and plant
operation
150 years
6
Process Safety
Incidents despite the organized approach
150 years
7
Process Safety
KPIs don’t capture infrequent causesS
eve
rity
(Co
nse
qu
ence
)
Frequency
of causeshigh
high
low
That‘s where we learn
from KPIs
• Learning from individual
incidents across the industry.
• Sensitivity to ‚weak signals‘
Nasty ‚surprises‘
too seldom to measure;
Sufficient number of
incidents to evaluate
statistically
150 years
8
Process Safety
Severe Incidents often have simple causes S
eve
rity
(Co
nse
qu
ence
)
Complexity Difficult to avoid
high
low
Work permits, procedures,
Discipline
Easy to avoid
HAZOPs,
Competence
Remaining risk
with good Safety
Management
150 years
Holistic approach to the control of hazards
Process Safety
Construction towards Specification
Maintenance and Inspection
Safe
Operation
Development / Engineering: Safe Design
Risk comes from technical, organisational, personal factors.
Incidents originate from weaknesses in any of these stages !
150 yearsProcess Safety
Avoiding nasty surprises requires structures
to deal with and respond to the unexpected
10
From historical incidents (Texas City, ….) and own experience we know that we need to
Strife for a culture, where
Hazards are understood and transparent
Information on negative impacts on safety flows freely from bottom to top.
Information on crtical issues is not filtered out.
Top management is in touch with reality of the plants
Incidents and weak signals are reported, weak signals are acted upon
Errors, mistakes can be reported and discussed without fear
Responsability is clearly assigned and involves all levels
Have good systems for Competence development, Maintenance, risk assessment,..
‚Practises‘ are at least as important as ‚mindset‘
Focus on High Reliability of work processes in Operations, Maintenance.
Deviations not accepted as ‚normal‘
150 years