Before Human Error

The Process-Safety Teardown Checklist

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

Current through Issue 16 · SS El Faro

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?
09

Bio-Lab Conyers

CONYERS, GA · 29 SEP 2024 · 17,000 EVACUATED · CSB 2024-04-I-GA

A correct fix, left in the room the hazard had already moved out of.
- Stand under your worst chemical and look up. What is it doing to that steel every day?
- Pull your most loaded building's design basis. Check the hazard class before the quantity.
- How many degraded safeguards stop a job here? No number means whatever you survive.
10

Enbridge Line 6B

MARSHALL, MI · 25 JUL 2010 · 843,444 GALLONS · NTSB PAR-12/01

An alarm that meant two things, and nobody required to go and look.
- Find your two-meaning alarms. Ask the operators, not the P&IDs, what each one signals.
- Take a corrective action from an old incident and test whether it would still fire today.
- Check the responders your emergency plan names against a map and a phone call.
11

T2 Laboratories

JACKSONVILLE, FL · 19 DEC 2007 · 4 FATALITIES · CSB 2008-03-I-FL

A second reaction nobody had measured, ten degrees above where testing stopped.
- Your most exothermic process: who put it in a calorimeter, and where did they stop?
- What pressure does your relief device open at, and what scenario chose that number?
- Find the near-miss you scaled up past. Was the fix understanding, or just that it stopped?
12

Phillips 66 Pasadena

PASADENA, TX · 23 OCT 1989 · 23 FATALITIES · OSHA REPORT TO THE PRESIDENT

One valve, two identical fittings, and a handover nobody re-verified.
- Take one standing isolation: when was it set, and who could have reached it since?
- Find one isolation where the open and close connectors accept the same fitting.
- Pull your recordable rate. Are contractor injuries in it, and what share of hours?
13

Imperial Sugar

PORT WENTWORTH, GA · 07 FEB 2008 · 14 FATALITIES · CSB 2008-05-I-GA

A housekeeping fix that sealed a hot bearing into a chamber full of sugar dust.
- Measure dust at height against the 1/32-inch layer criterion instead of eyeballing.
- Pull two years of work orders and find every cover or enclosure that got added.
- Ask how someone on the fourth floor learns to leave, then go and test it.
14

Williams Geismar Olefins

GEISMAR, LA · 13 JUN 2013 · 2 FATALITIES · CSB 2013-03-I-LA

A safeguard downgraded two tiers, then installed on half the equipment.
- Trace one isolable vessel's relief path with a valve line-up in hand, not the drawing.
- Pull three PHA items your tracker calls closed and verify the hardware in the field.
- Standby equipment: what do you believe is inside, and what instrument would disprove it?
15

U.S. Steel Clairton

CLAIRTON, PA · 11 AUG 2025 · 2 FATALITIES · CSB 2025-03-I-PA

Occupied rooms sited twenty feet directly above the gas line that failed.
- Measure from your control room and break room to the nearest flammable inventory.
- Your last PHA: is facility siting an actual evaluation, or a mention of the words?
- If your worst enclosed space fills with gas, can anyone stop it from outside the area?
16

SS El Faro

ATLANTIC OCEAN, BAHAMAS · 01 OCT 2015 · 33 FATALITIES · NTSB MAR-17/01

A captain steering by a 12-hour-old forecast, on a ship the rules let keep 1975 lifeboats.
- How old is your operators' data by the time it reaches the screen? Which source runs behind?
- Ask an operator one critical machine's limit and what happens past it. Is it in the procedure?
- Pick one thing that was there before you were. Who decided it was fine, and against what rule?

Sixteen investigations. Sixteen 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

Bio-Lab Conyers

Enbridge Line 6B

T2 Laboratories

Phillips 66 Pasadena

Imperial Sugar

Williams Geismar Olefins

U.S. Steel Clairton

SS El Faro