CCPS安全领导力和管理培训之操作程序.ppt

1 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers OperationsOperatingProcedures Writtendocumentthatprovidesthefollowing ThestepsneededtoperformataskTheorderinwhichthosestepsaretobeperformed ifimportant Anyuniquewarningsorcautionsassociatedwithaparticularstep PurposeofOperatingProcedures 2 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers WhereYouNeedOperatingProcedures Operatingproceduresshouldaddressthefollowingscenariosfortheproductionunit andwherecomplexityand orcriticalitywarrant thesamescenariosasaboveforindividualpiecesofequipment pressors reactors etc 3 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers InitialstartupTemporaryoperationsNormalshutdownEmergencyshutdownNormaloperationEmergencyoperationsStartupafterturnaroundoremergencyshutdown WhyIsItImportant Withoutwrittenoperatingprocedures afacilitycanhavenoassurancethattheintendedproceduresandmethodsareperformedinsamemannerandsamesequenceby eachdifferentoperatoreachtimebysameoperator 4 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers ProceduresmustbeconciseandwithoutambiguityInformationintendedforeducationonchemistry generalhazards whytasksareperformedinacertainorderetc shouldbeplacedintrainingdocuments ContentofProcedures 5 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers ProceduresAreNOTTrainingDocuments Allproceduresarenotofsamelevelofcriticality importanceConsideranairlinerTake offandLandingProceduresSequenceforRe StartofIn flightEntertainmentSystemGuidelinesforStorageofOversizePassengerBags RiskRankingofProcedures 6 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers WhenProcedureis HighconsequenceofdeviationHighcomplexityLow ModerateconsequenceLow ModeratecomplexityNegligibleconsequenceLowcomplexity TierProceduresbyRiskRanking 7 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers Use Checklistformat In handwhenperformingtask Stepsinitialled Writtenformat butrequiredin handwhenperformingtaskWrittenformat Placeinproceduremanualforreferenceonly CertificationofProcedures When 8 CertificationshouldbedonebeforeprocedureisusedforfirsttimeRecertifyafteranymodification and orafteranestablishedtimeperiod Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers CertificationofProcedures 9 Certificationshouldbedonebyfieldobservationthattheprocedurecanbefollowed inthesequenceprovidedwithoutneedforsteps actionsnotprovidedintheprocedure Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers PortNealIA 1994 10 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers WhatHappened ExplosioninNH4NO3plantinneutralizerandrundownvesselsasaresultofacidicconditionsandhightemperatures 200psigsteamforsparging 4Fatalities 18injuredReleaseof5700tofNH3and25 000galHNO3 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers ContributingCauses LackofwrittenoperatingproceduresLackoftrainingonnewDCSsystemNoPHAconductedPoormechanicalintegrityprogram Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers DiscussionQuestion Howis Correctness ofaprocedurecertifiedinyourfacility Isitadequate 13 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers ManageRisk TrainingAndPerformanceAssurance Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers 15 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers OperationsTrainingandPerformanceAssurance Training PerformanceAssurance TrainingInstructioninjobandtaskrequirements methods andhazardsifnotdoneasinstructedPerformanceAssurance Certification Themeansbywhichworkersdemonstratethattheyunderstoodandretainedthetraining andcanapplyitcorrectlyinreal timejobsituations 16 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers WhyIsItImportant 17 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers TrainingandPerformanceAssuranceistheonlymeansbywhichafacilitycanbecertainthatanindividual understandsthesafeandexpectedprocedureforperformingatask understandstheconsequencesofdeviationfromtheexpectedprocedure isphysicallyandmentallycapableofperformingthetaskinthefieldconsistentwiththetraining Feyzin France 1966 18 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers WhatHappened MajorexplosionsandBLEVEsatLPGrefinery18fatalities 81injuredReleaseoccurredwhenoperatorwasdrainingwaterfrombottomofasphereIgnitionbyautomobileonnearbymotorway Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers WhatHappened SamplesfrombottomofsphereroutinelytakensobottomhadtobedrainedpriortosamplingBottomoftankhadtwo2 inchplugvalveswitha inchbleedvalvebetweenDrainlineheatedbysteamtracingbeneathinsulationProcedurecalledforopeningvalveclosesttovesselandthencrackingopenthebleedvalveandadjustdrawoffrateOperatoropenedthefarthestvalvefromtankandthentriedtoopentheclosestvalvetotank DischargeoccurredafteraniceplugblewoutOperatortriedtoshutoffflowbutwasunsuccessfulDidn tusetelephoneinareabecauseofignitionconcernsanddidn tdriveawaybutwalked800mtocontrolroom Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers ContributingCauses TheinitiallossofcontainmentLackofoperatortrainingTheIgnitionandInabilitytoProtecttheSpheresNomeanstocontroltrafficonthemotorway distancetomotorway42m PoorcommunicationsystemsbetweenfieldandcontrolroomDelayoffirefightingandinsufficientwatersupply Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers TrainingRequirements Training withCertification shouldbeprovidedtoallpersonnelresponsibleforoperatingthefacility Initialtraining beforeoperatingtheprocess Refreshertraining atleastevery3years Criticaltasksonshortercycle AspartoftheMOCforaprocess equipmentmodification whenwarrantedbythecomplexityofthechange TrainingandCertificationshouldbedocumented 22 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers Certification PerformanceAssurance TestingforRetentionofKnowledgeandAbilitytoCorrectlyPerformaTaskAllowseveraldaysbetweentheinstructiononatask andthetestingofperformanceonthetaskThe trainer andthe tester shouldbedifferentindividualsPhysicalabilitytoperformthetask aswellasabilitytoperformthetaskinreal lifeplantenvironment noise heat stress shouldalsobepartofcertificationcriteria 23 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers Questions Howdoyoutrainemployeesinyourcompany Whatisa passing grade Howdoyoudocumentthetraining Doyourefreshtrainingjustbeforeashutdownorstartup Howdoyougetemployeefeedback Whatdoyoudowithit 24 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers 25 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers OperationsSafeWorkPractices SafeWorkPractices Safeworkpracticeshelpcontrolhazardsandmanagenon routineworkAnon routineactivityisanyactivitythatisnotfullydescribedinanoperatingprocedureSafeworkpracticestypicallycontrolhotwork storedenergy lockout tagout openingprocessvesselsorlines confinedspaceentry andsimilarhazardousoperations 26 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers WhyIsItImportant Theinfrequencyofnon routineworkincreasesriskoferrorand orinabilitytorecognizeahazard Theseerrorsorfailuretorecognizeahazardcanleadtocatastrophicevents PiperAlpha removalofapressuresafetyvalveforrecertification Nitrogenasphyxiationduringconfinedspaceentryresultedin80fatalitiesinU S from1992 2002 27 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers 28 PiperAlpha 1988 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers HotWorkPermitFirepreventionandprotectionrequirementsLineBreakPermitWorkerexposureandspill releaseprotectionConfinedSpaceEntryPermitSuitableatmospheresandcollapseprotectionsystemsEnergy ElectricalLockout Lock Tag TryUnexpectedpresenceorreleaseofenergy 29 SafeWorkPractices Examples Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers DiscussionQuestions NametheManagementSystemsthatFailedatPiperAlphaWouldtheSystemsUsedatYourFacilityHavePreventedPiperAlpha IfYes How 30 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers 31 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers OperationsAssetIntegrityandReliability AssetIntegrityandReliability Thesystematicimplementationofactivities suchasinspectionsandtestsnecessarytoensureequipmentwillbesuitableforitsintendedapplicationthroughoutitslifeSpecifically workactivitiesfocusedon PreventingcatastrophicreleaseofahazardousmaterialorsuddenreleaseofenergyandEnsuringhighavailabilityor dependability ofcriticalsafetyorutilitysystemsthatpreventormitigatetheeffectsofthesetypesofevents 32 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers WhyIsItImportant DesigningandmaintainingequipmentfitforitspurposeandfunctionswhenneededisofparamountimportanceMaintainingcontainmentofhazardousmaterialsandensuringthatsafetysystemsworkwhenneededaretwoprimaryresponsibilitiesforanyfacility 33 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers AssetIntegrityandReliability Writtenproceduresshouldbedevelopedandimplementedtomaintainthemechanicalintegrityofequipmentincluding PressurevesselsandstoragetanksPipingsystemsReliefandventsystemsEmergencyshutdownsystemsControls alarms sensors andinterlocksPumps 34 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers AssetIntegrityPrograms AssetIntegrityProgramsshouldaddress WrittenproceduresTrainingformaintenanceactivitiesOverviewofprocessanditshazardsSafetyproceduresapplicabletotheemployee sjobCraftskillsInspectionandtestingFrequencyconsistentwithrecommendationsandfindingsGenerallyacceptedgoodengineeringpractices standardsDocumentationoffindingsandactionstaken 35 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers AssetIntegrityPrograms AssetIntegrityProgramsshouldaddress OperatingLimitsCorrectingDeficienciesBeforefurtheruseInasafeandtimelymannerwhenstepsaretakentoassuresafeoperationuntilpermanentcorrectionscanbemadeQualityAssuranceProgramFabrication Installation andspareparts suitableforservice 36 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers AssetIntegrityAsystemtoassureequipmentissuitableforit sintendedapplicationthroughoutit slifeMechanicalIntegrityAsystemtoassurethatequipmentusedtoprocess store orhandleHHCsisdesigned constructed installedandmaintainedtominimizetheriskofreleasesofsuchchemicalsReliabilityTheprobabilitythatanitemwillperformasexpected designed whenneededMechanicalIntegrityandReliabilityarenotthesamethingandarenotnecessarilyequalReliabilityisoftenmuchmorethanMechanicalIntegrity 37 AssetIntegrity MechanicalIntegrityandReliability Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers WrittenmechanicalintegrityproceduresInspectionandtestinginaccordancewithappropriatecodesandstandardsPHAandincidentinvestigationfindingsmayrequirechangesinmechanicalintegrityprocedures 38 ObligationsAndExpectations Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers DiscussionQuestions HaveyoudefinedyourMI processsafetycriticalequipment Howismaintenancetraininghandled Haveyoudefinedacceptableoperatinglimitsforequipment Doyouhaveaqualityprogramformaterialsreceived 39 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers DuPontBelleW Va 23Jan2010 BackgroundPhosgenesuppliedtofacilityin1toncylindersPhosgenebothstoredandconnectedtoprocessfromasemienclosedshedUsedasrawmaterialinmanufactureof5isocyanurateintermediates 40 PhosgeneShed 41 WhatHappened Phosgeneflextransferhoseconnectedtopartiallyfilled butnotinservice1toncylinderfailedcatastrophically1worker whohappenedtobenearthesiteofrelease wasexposedtothephosgeneandsubsequentlydied 42 WhyitHappened FlexhoseconstructedofPTFElined304SSwhichissusceptibletocorrosionKnowledgeofbetterhosematerialknownpreviouslyandcommunicatedbutnotacteduponChangeoutandreplacementofhosesrequiredonamonthlybasisbutnotfollowedNonroutineoperationsondayofincidentresultedinphosgeneleftisolatedinhosewhichresultedinthermalexpansion 43 PhosgeneFlexHoses 44 HoseChangeoutFrequency 45 AssetIntegrityContributingFactors MaintenancemodelofSAPusedtoissueworkordersformonthlyhosechangeoutsInlate2005datamanagingthechangeoutfrequencywasmodifiedandWOsnolongerissuedNoMOCappliedtothechangeNobackupprotectionsuchascriticalmaintenancechecklistsorinspectiontagsSupervisorsreliedonmaintenancecoordinatortorememberchangeout 46 OtherContributingFactors PHAsdeficient corrosionofhosesandliquidexpansioninhosesnotaddressedA1988riskanalysisidentifiedneedforenclosureofshedtominimizeprimarilyoffsiterisk Optionswereevaluatedbutnoactionstaken In2004aPHArecommendedenclosure noactiontakenInternalPhosgeneCommitteeauditobservedhoseshadmoderateexternalcorrosionbutdidnotprovidearecommendation HTMmanualguidanceonly notastandardOperatorsunawareofhazardsofthermalexpansionofliquidsNearmissonmorningshiftthedayofincidentnotaddressedDeficienciesinemergencyresponse 47 Critique HaveyouchangedyourMMSrecently Whatstepshaveyoutakentoensureallcriticaltestingisenteredsuccessfullyintothenewsystem HowrobustisyourMOCprocesswithrespecttoyourMMS Whatothersafeguardsdoyouemploywithrespecttoensuringcriticalsafetyequipmentismaintained testedandchangedoutonthedesignatedbasis 48 AssetIntegrityandReliability PrinciplesIdentifyequipmentandsystemsthatarewithinthescopeoftheassetintegrityprogramandassigninspection testing andpreventativemaintenance ITPM taskDevelopandmaintainknowledge skillsprocedures andtoolsEnsurecontinuedfitnessforpurposeAnalyzeequipmentfailuresanddeficienciesAnalyzedata 49 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers DiscussionQuestion Yourplanthasaturnaroundevery3yearsProcessreliefvalvesaretestedManagementwantstoextendthetimeforturnaroundbyanadditional18monthsThiswillresultinadeviationfromtheestablishedprocedureWhatdoyoudonowwhenthissituationdevelops Whatcouldbedonetoassuretheriskisnotunacceptabletomanagement 50 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers 51 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers OperationsContractorSafetyManagement Contractor Safety Management SystemofcontrolstoensureContractedservicessupportbothfacilityoperationsandthecompany sprocesssafetyandpersonalsafetyperformancegoalsDoesnotaddressTheprocurementofgoodsandsuppliesoroffsiteequipmentfabricationfunctionsthatarecoveredbytheassetintegrityqualityassurancefunctionInvolvesworkerslocatedclosesttoprocesshazardsandmoreroutinetaskssuchasjanitorialandgroundkeepingservices 52 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers WhyIsItImportant Companycanachievegoals AccessspecializeexpertisethatisnotcontinuouslyorroutinelyrequiredSupplementlimitedcompanyresourcesduringperiodsofunusualdemandProvidestaffincreaseswithouttheoverheadcostofdirecthireemployees 53 Companiesandcontractorsshouldworktogethertoprovideasafeworkplacethatprotectstheworkforce thecommunity andtheenvironment aswellasthewelfareandinterestofthecompany Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers PiperAlpha 54 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers HostEmployerResponsibilities Hostemployershould ConsiderSafetyRecordsinSelectingContractorsInformContractorsofPotentialProcessHazardsExplaintheFacility sEmergencyActionPlanControlEntrance PresenceandExitinCoveredProcessAreasEvaluateContractorSafetyPerformanceMaintainInjury IllnessLogforContractorsWorkinginProcessAreas 55 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers ContractorResponsibilities Contractoremployershould TraintheiremployeesinsafeworkpracticesanddocumenttrainingAssurethatemployeesknowaboutpotentialprocesshazardsandemergencyactionplanAssurethatemployeesfollowsafetyrulesoffacilityAdviseemployerofhazardscausedbycontractworkorhazardsfoundbycontractor 56 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers DiscussionQuestions Youhavecontractoperatorsandmechanicsservicingoneof4processunitsonsiteTowhatextentshouldthecontractorsbetrainedincompanyproceduresversustrainingtheyhavereceivedfromtheircontractcompany Why 57 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers 58 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers OperationsConductofOperations ConductofOperations TheexecutionofoperationalandmanagementtasksinadeliberateandstructuredmannerInstitutionalizesthepursuitofexcellenceintheperformanceofeverytaskandminimizesvariationsinperformanceSomecompaniescallthisOperatingDiscipline walkthetalk 59 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers WhyIsItimportant AconsistentlyhighlevelofhumanperformanceisacriticalaspectofanyprocesssafetymanagementprogramAsoperationalactivitiesbecomemorecomplex anincreaseintheformalityofoperationsmustalsooccurtoensuresafe andconsistentperformanceofcriticaltasks 60 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers Martinez CA 1997 61 Copyright 2011CenterforChemicalProcessSafetyoftheAmericanInstituteofChemicalEngineers WhatHappened RuptureofpipingonhydrocrackerduetohightemperatureIgnitionandsubsequentexplosionandfireIfatality 46injured somecon