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Lessons from a Permit to Work Incident
Nigel Cann, ArupFIChemE, CEng, CEnv, RPEQNigel.cann@arup.com
2
What we will cover…
• Timing of incident• Plant process• Plant Layout• Incident Event• AcciMap of Incident• Actions that followed• What questions do you have?
Agenda
3
Incident Timing
Timing
25 Sep
98
24 Nov 9
8
12 M
ay 99
22 Jun 00
5 Oct 98 – I started
Production Process
STRIPPINGCOLUMN
DEG ASSER
AUTOCLAVES
STEAM
ADDITIVES
VCM TANKER
CHARGE WATER
VCM GASHOLDER
LIQUID VCM STORAGE
VCM RECOVERYPLANT
BAGGING ANDPAL LET IZ ING
BULK SUPPLY
SLURRYTANK
STORAGESILO
FLUID BED DRYER
CENT RIFUGE
PACKAGED SUPPLY
4 Process
Plant Layout
5 Layout
The Incident
6 Incident
7
LinkedIn – discussion groups
Longford - AcciMaps
8 AcciMap
9
AcciMap – Permit to Work Incident
AcciMap of Permit to Work Incident
Accident Sequence
Organisational
Governance
Regulatory
Outcomes
VCM released to environment
Ritag valve opened,
pathway to atmosphere
Working on Wrong
autoclave
Spool opening to remove
build up
Disperses in atmosphere
Sister autoclave on hold
Human Factors Turned wrong way
2. No checking b4 manual valve
operation
4. Poor signage
1. Poor PTW Management Control
2. Poor shift handover control
2. No Fatigue Control
3. Inadequate training in PTW
system
5. Poor Regulatory Oversight
Fatigue
Desire to finish job
6. Build up problem unsolved
Assistant on first day on site
3. Inadequate Training System
10
AcciMap – Permit to Work Incident
AcciMap of Permit to Work Incident
Accident Sequence
Organisational
Governance
Regulatory
Outcomes
VCM released to environment
Ritag valve opened,
pathway to atmosphere
Working on Wrong
autoclave
Spool opening to remove
build up
Disperses in atmosphere
Sister autoclave on hold
Human Factors Turned wrong way
2. No checking b4 manual valve
operation
4. Poor signage
1. Poor PTW Management Control
2. Poor shift handover control
2. No Fatigue Control
3. Inadequate training in PTW
system
5. Poor Regulatory Oversight
Fatigue
Desire to finish job
6. Build up problem unsolved
Assistant on first day on site
3. Inadequate Training System
11
1. Redesign Permit to Work System
• Seven international standards and guidelines reviewed
• Parent companies, API, HSE, IChemE, Confined Space Regs
• PTWs signed in field
• JSA to be prepared by work teams
• Monitoring program revamped
• Response plans for standbys• Rescue equipment in place before start• Induction improvements
PTW System
1. Poor PTW Management Control
12
AcciMap – Permit to Work Incident
AcciMap of Permit to Work Incident
Accident Sequence
Organisational
Governance
Regulatory
Outcomes
VCM released to environment
Ritag valve opened,
pathway to atmosphere
Working on Wrong
autoclave
Spool opening to remove
build up
Disperses in atmosphere
Sister autoclave on hold
Human Factors Turned wrong way
2. No checking b4 manual valve
operation
4. Poor signage
1. Poor PTW Management Control
2. Poor shift handover control
2. No Fatigue Control
3. Inadequate training in PTW
system
5. Poor Regulatory Oversight
Fatigue
Desire to finish job
6. Build up problem unsolved
Assistant on first day on site
3. Inadequate Training System
13
2. PTW Authoriser Changes
• PTW signed in field
• PTW authorization ended at shift change
• Enforced a rest period
• New shift aware
• Changing conditions to be considered:
• Weather• Temperature• Fatigue
Authorisers
2. No checking b4 manual valve
operation2. Poor shift
handover control
14
AcciMap – Permit to Work Incident
AcciMap of Permit to Work Incident
Accident Sequence
Organisational
Governance
Regulatory
Outcomes
VCM released to environment
Ritag valve opened,
pathway to atmosphere
Working on Wrong
autoclave
Spool opening to remove
build up
Disperses in atmosphere
Sister autoclave on hold
Human Factors Turned wrong way
2. No checking b4 manual valve
operation
4. Poor signage
1. Poor PTW Management Control
2. Poor shift handover control
2. No Fatigue Control
3. Inadequate training in PTW
system
5. Poor Regulatory Oversight
Fatigue
Desire to finish job
6. Build up problem unsolved
Assistant on first day on site
3. Inadequate Training System
15
3. Training in Permit to Work
• PTW training for different user types
• Validators for all high risk work
• Hot Work in Zone 1• Working at Heights• Confined Space Entry• Building Cavity• Roof• Near Radiation Sources
• Authorisers and Validators went through same training/testing
• Verbal test (had to have working knowledge)• Demonstration of PTW issue
PTW Training
3. Inadequate training in PTW
system
3. Inadequate Training System
16
AcciMap – Permit to Work Incident
AcciMap of Permit to Work Incident
Accident Sequence
Organisational
Governance
Regulatory
Outcomes
VCM released to environment
Ritag valve opened,
pathway to atmosphere
Working on Wrong
autoclave
Spool opening to remove
build up
Disperses in atmosphere
Sister autoclave on hold
Human Factors Turned wrong way
2. No checking b4 manual valve
operation
4. Poor signage
1. Poor PTW Management Control
2. Poor shift handover control
2. No Fatigue Control
3. Inadequate training in PTW
system
5. Poor Regulatory Oversight
Fatigue
Desire to finish job
6. Build up problem unsolved
Assistant on first day on site
3. Inadequate Training System
17
4. Signage
Signs
4. Poor signage
18
AcciMap – Permit to Work Incident
AcciMap of Permit to Work Incident
Accident Sequence
Organisational
Governance
Regulatory
Outcomes
VCM released to environment
Ritag valve opened,
pathway to atmosphere
Working on Wrong
autoclave
Spool opening to remove
build up
Disperses in atmosphere
Sister autoclave on hold
Human Factors Turned wrong way
2. No checking b4 manual valve
operation
4. Poor signage
1. Poor PTW Management Control
2. Poor shift handover control
2. No Fatigue Control
3. Inadequate training in PTW
system
5. Poor Regulatory Oversight
Fatigue
Desire to finish job
6. Build up problem unsolved
Assistant on first day on site
3. Inadequate Training System
19
5. Stakeholder Group
Stakeholder 1/2
5. Poor Regulatory Oversight
• Trust development• Engagement• Involvement• Reporting – Progress and Issues
• Someone to tell the good things to• Formal Environmental Improvement Plan
20
5. Stakeholder Group
Stakeholder 2/2
Do:• Be Honest• Listen• Explain technical issues using
simple language and analogies• Trust and be prepared to
expose issues• Get members involved
- Investigations- Exercises
Don’t!• Try to hide bad news• Dismiss concerns because
they are unscientific• Hide behind technicalities
and jargon• Hide behind lawyers• Avoid getting members
involved• Use a PR person
21
AcciMap – Permit to Work Incident
AcciMap of Permit to Work Incident
Accident Sequence
Organisational
Governance
Regulatory
Outcomes
VCM released to environment
Ritag valve opened,
pathway to atmosphere
Working on Wrong
autoclave
Spool opening to remove
build up
Disperses in atmosphere
Sister autoclave on hold
Human Factors Turned wrong way
2. No checking b4 manual valve
operation
4. Poor signage
1. Poor PTW Management Control
2. Poor shift handover control
2. No Fatigue Control
3. Inadequate training in PTW
system
5. Poor Regulatory Oversight
Fatigue
Desire to finish job
6. Build up problem unsolved
Assistant on first day on site
3. Inadequate Training System
22
6. Build Up Problem
Buildup 1/2
6. Build up problem unsolved
S2 A/C CLEANING FREQUENCY
0
50
100
150
200
250
300
350
400
450
500
A/C E weld agi capsbaffle modsA/C F
50%
200%
150%
100%
23
6. Build Up Problem
Buildup – 2/2
6. Build up problem unsolved
24
SUMMARY – Permit to Work Incident
• Permit to Work Controls are essential in High Hazard Industry- (Featured in 50% bow ties)
• Lessons from this Incident are:- Shift handover control- Fatigue and Rest- Signs and communication- Maintenance and operations sharing responsibility- Training and testing
• What I don’t see others doing…- Field sign on- Clear responsibility at worksite- Escape and emergency plans- Emergency preparedness
Summary
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What QUESTIONS do you have?
Questions
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