(41bb) Catastrophic Warning Signs and Symptoms in Engineering Projects – be Aware & Beware!

The 1974 Flixborough incident investigation highlighted gaps such as lack of quality assurance checks on fabrication or installation except for leak check, absence of mechanical engineer to provide critical technical review related to design and lack of reference to RAGAGEPs for expansion bellows [1]. The 1984 Bhopal incident investigation revealed diminished design specification including use of low-quality construction material, cutting down on protection measures, lack of redundancy for critical safety measures and other gaps such as absence of emergency planning at local level prior to commissioning given the hazardous nature of the facility, not leveraging best practices from within the organization and application of lessons learnt from past incidents in new project [2].

Only several well established large multi-national organizations with extensive experience in operating hazardous facilities have their internal framework (what, when, who and how) to integrate HSE/Process safety in capital projects at different stages. CCPS Guidelines for integrating Process Safety into Engineering Projects is intended to help smaller and inexperienced organization with details on what needs to be addressed when and by whom. A common response in the industry to the question of whether you have integrated process safety considerations in projects is that we have planned for or completed the hazard analysis and risk assessment studies (e.g., HAZOP/SIL). While the need for integration of Process safety in projects is acknowledged, breadth and depth of integration at different project stages, ambit of process safety considerations varies with project.

For achieving excellence in process safety integration in capital projects, it is vital to focus on governance, processes, competencies, mindset and behaviors at different stages of the project. It is critical for an organization embarking on engineering projects to be aware of any warning signs and symptoms that could lead to catastrophic incident in future if it is not addressed systematically. This paper intends to highlight such warning signs/symptoms with examples based on observations in select areas (process hazard analysis, management of change, quality assurance, readiness to operate, project leadership and governance, project staffing, project documentation) made in different engineering projects as well as facilities transitioned to operational stage in diverse industry sectors (Oil & Gas, Refining, Mining & Metals, Chemicals, Waste management) in Asia Pacific.

Common Warning Signs and Symptoms

• Incomplete and poor quality of hazard analysis and risk assessment studies
  • Inadequate time and resource allocation
  • Poor quality PSI or design that is not frozen used as basis
  • Absence of Operations involvement and inadequate team participation
  • Insufficient competency and process safety experience among team members
    • PHA outputs not integrated effectively into operating procedures, emergency response plan
    • Poor understanding of the assumptions, boundaries and limitations stated in the reports resulting in ineffective implementation (e.g., conditional modifiers in LOPA studies, Test interval in SIL verification studies, QRA assumption register)
    • PHA conducted without consideration to both major internal and external incidents
  • Increased reliance/trust on contractors/vendors/licensors/consultants.
    • Inadequate oversight in selection of facilitators
    • Reliance on vendor or technology providers experience instead of specific study involving them
    • Use of contractors/vendors risk matrix resulting in inconsistent risk decisions
    • Use of facilitators without right set of facilitation skills along with relevant process and operational knowledge and experience
    • Owner requirements and expectations related to hazard analysis and risk assessment studies at different stages not included as part of contractual requirements
  • Risk assessments not completed or conservative and recommendations proposed primarily focused on training, procedures, alarms and preventive maintenance
  • Absence of baseline PHA immediately after initial months of operations
• Ineffective management of change
  • Inadequate level of competency among project team to assess the risks associated with change
    • Poor understanding of importance of MOC process and understanding of what constitutes change among EPC and Project team
  • Management of change limited to cost/schedule impact
    • Assessment of impact of cost/schedule
    • Major changes with impact on cost/schedule
  • Owner' Management of change process not defined and included as requirements for contractor to comply with
    • Reliance on contractors to define and drive MOC process according to their standards without review of its relevance and appropriateness
    • Absence of Change register for documenting changes
    • Weak ownership of MOC process by the project team
    • Incomplete update of relevant process safety information and project documentation
    • Lack of Participation of multi-disciplinary team or critical roles from vendors, technology or licensors or operation/Maintenance team

Mindsets and Behaviors – Underpinning strong reliance and trust on contractors/consultants/vendors and technology licensors

It is important to be aware of the prevailing mindsets and behaviors in the project team and implications it might have on the project execution and process safety integration. Some common mindsets and behaviors observed are listed below:

• “We do not see the need to conduct FEED HAZOP as technology provider has completed the hazard evaluation and has incorporated the best practices and safeguards based on their operational experience of plants built in the past.”
• “We have appointed experienced PMC to support our lean and inexperienced project team in reviewing the work and ensuring safe execution of the project on our behalf who has executed similar projects before.”
• “Our bidders have confirmed that they will comply with the requirements specified in the instructions to bidder.”
• “We believe that the EPC will provide all the relevant design basis information upon project completion.”
• “The EPC contractors have extensive experience executing similar or bigger mega projects in the industry sector and they are operating reliably and safely without any incidents”
• “The EPC has provided us with the quality assurance process that will be implemented in the project.”
• “The EPC has agreed to provide Independent PHA facilitators and QA inspectors.”
• “The EPC contractor has a very good LTIR and LTIFR.”

In the presentation, warning signs/symptoms related to quality assurance, readiness to operate, project leadership and governance and project staffing will be included. Specific examples from different projects will used.