Before Human Error

The Process-Safety Teardown Checklist

Twenty-four checks drawn from eight investigated disasters. Run them against your own site this week.

Current through Issue 08 · LyondellBasell La Porte

Download the PDF Get the weekly teardown

01

Givaudan Sense Colour

LOUISVILLE, KY · 12 NOV 2024 · 2 FATALITIES · CSB 2024-06-I-KY

The harmless-looking material nobody thought to reactivity-test.
- Reactivity-test your low-hazard materials at real operating and upset conditions.
- For anything that could run away, what scenario was the relief actually sized for?
- Does your PSM effort chase the scary-sounding chemicals, or the truly reactive ones?
02

Formosa Plastics

ILLIOPOLIS, IL · 23 APR 2004 · 5 FATALITIES · CSB 2004-10-I-IL

One bypassable procedure standing in for a real barrier.
- Count the independent protection layers on your top three scenarios. One operator is not one.
- Every bypassable interlock: is the bypass managed under MOC, or waved through by phone?
- A near-miss at a sister site is your finding too, not “not applicable here.”
03

Bayer CropScience

INSTITUTE, WV · 28 AUG 2008 · 2 FATALITIES · CSB 2008-08-I-WV

A startup pushed before the unit was ready to run.
- Your last post-turnaround pre-startup review: performed and closed, or just signed?
- New control interface: were operators proven competent before go-live, not during it?
- Is the hardest, least-familiar work running on 60-hour weeks and 18-hour shifts?
04

BP Texas City Refinery

TEXAS CITY, TX · 23 MAR 2005 · 15 FATALITIES · CSB 2005-04-I-TX

A low injury rate mistaken for a healthy process.
- Split your safety numbers. Can you name one process-safety metric you watch weekly?
- Your critical gauges: what is each one calibrated to see, and what is it blind to?
- Any relief or PHA study years overdue? That is a decision, not a backlog item.
05

Esso Longford Gas Plant

LONGFORD, VICTORIA · 25 SEP 1998 · 2 FATALITIES · ROYAL COMMISSION

The people who understood the hazard had been moved off-site.
- Can your shift read the early sign of your worst failure mode, or was it never taught?
- Did your last engineering reorg get an MOC review, or pass as an org-chart change?
- Near-miss log and HAZOP schedule: is your worst unit's study done, or just planned?
06

DuPont La Porte

LA PORTE, TX · 15 NOV 2014 · 4 FATALITIES · CSB 2015-01-I-TX

Every barrier already gone before the last valve was opened.
- Piping moved to clear a plug or restore flow: did that change ever get an MOC?
- Is your toxic-gas detection sized for toxicity, or borrowed from a flammability limit far above it?
- Count last month's alarms your crews treated as normal. That count is normalized deviance.
07

Aghorn Operating

ODESSA, TX · 26 OCT 2019 · 2 FATALITIES · CSB 2020-01-I-TX

A safety system that lived in one man's memory.
- Which alarms send a person into the hazard just to learn what the alarm means?
- Pull the calibration records for your toxic-gas detection. No records, no detection.
- Any energy-isolation step that is not written down is a program running on memory.
08

LyondellBasell La Porte

LA PORTE, TX · 27 JUL 2021 · 2 FATALITIES · CSB 2021-05-I-TX

Two sets of bolts on one valve, and nothing marking which held the process in.
- At one actuated plug valve, can you point out the pressure-retaining bolts in 30 seconds?
- Which valve work requires de-inventorying the process? Write that line down and sign it.
- Who can call a job “simple” at your site, and which requirements does that word turn off?

Eight investigations. Eight headlines that blamed an operator.

Not one of them held up.

Givaudan Sense Colour

Formosa Plastics

Bayer CropScience

BP Texas City Refinery

Esso Longford Gas Plant

DuPont La Porte

Aghorn Operating

LyondellBasell La Porte