Process Safety Fundamentals

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 What are Process Safety Fundamentals (PSF)?

◼ PSF is one of the top priorities for safe, reliable and profitable
operations for Global Mfg. It is a set of 9 fundamental expectations
when it comes to Process Safety, much like the life-saving rules for
Personal Safety. It provides a clear expectation what is required for
Global M to upkeep our license to Operate

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 Case for Action

◼ Despite periods of excellent performance, we experience a

number of significant safety (and reliability) “events” which
hurt people, impact the communities in which we operate
and make us uncompetitive. This incurs reputational
damage and costs us in the order of $0.5b/a.

◼ Though key performance indicators (API Tier 1 & 2 PSIs,

LOPCs) show a significant improvement over the last several
years, the frequency of major PS incidents remains flat. The
rate of API Tier 1 & 2 PSIs has also flat lined in M since
2012/2013.

◼ In Downstream Manufacturing, operational discipline

remains a common theme of both operational and
technical integrity issues

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 Why must we have 9 PSF?

◼ Outcome: Elimination of significant process safety incidents in our

business with the potential to harm us, our colleagues, our
communities, our business and our reputation
◼ Through: Always following process safety fundamentals, which
learning from incidents tells us make a big difference. We need
sharp focus and tough implementation
◼ Because: We care deeply about our safety and the safety of those
we work with. We know why the fundamentals matter and we
understand how they keep us safe.

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 Current Reality

◼ The 9 PSF will be a corner stone to a sustainable reliable business

and future.

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 Current Reality in the East
LPG Release from threaded end cap when isolation API Tier 1 and Tier 2
valve handle was struck by scaffolder. incidents in the East
Kerosene smell was noticed at CPI3 and OT200A during Field Operator SOSO round. between 2014 and
Upon investigation, V2702(Merox 3) drain valve for spent caustic was found to be 2015
partially open.
Notice CD1 Tops rundown sampling block
Valve left open releasing 13.3MT of crude. 0.5" valve left valve was found open and high amount of
50% cracked open over a period of 18hrs Tops overflowing from sampling hatch

Fuel Oil tank sampling point was found open resulting

the CD4 Field PT noticed that there was vapor coming to LOPC estimated at 1380 kg
from the open drain pit that is located near the CD4
crude furnaces. At the time, the PT thought that it Caustic overflowed from
P150B vent left partially
could have been steam that he was seeing. After the V2511 to COC pit via vent line
open. Crude released
conclusion of the Shift Team meeting, the PT due to topping up valve left
returned for closer investigation, at which time he open
found the vent line from E-7507 C/D open to the pit
A group of contractors were doing a hotwork on an elevated platform
when the fire occured. This fire resulted with varying degree of burn
The hose was connected from the vent point & injuries to the workers.
routed to the drip tray which was located below
the exchanger. The spillage from the drip tray
subsequently landed on the below exchanger TGU residue pump fire. Suspected HC to have leaked from drain
E1503AB where it was auto ignited & caused a fire. of pump discharge NRV bonnet cover. Drain valve suspected to
have vibrated open and drain is missing end blank.

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 How were they developed?

◼ Identified from learnings from significant process safety

incidents – M and the industry
◼ Refined following challenge – data and causal learnings
from our API Tier 1 incidents
◼ Multi-discipline team included site input
◼ Review of our YTD 2015 API Tier 1 incidents indicates that
50%+ involved one or more of these nine process safety
fundamentals

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 9 Process Safety Fundamentals
Always use two barriers for hydrocarbon
& chemical drains & vents
Reasons this is important:
Relying on a single barrier, such as a closed valve,
to prevent releases from drains and vents has led
to significant LOPCs and process safety incidents.
Incident basis: Montreal LFI
We should:
•Close vent and drain valves and install caps or
plugs after each use
•Close both (two) valves at sample points after
taking samples
•Close both (two) vent or drain valves on systems
requiring quick opening to the atmosphere
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Do not leave an open drain
unattended
Reasons this is important:
Leaving a drain or vent valve open and
unattended has resulted in hazardous
material releases and process safety
incidents
Incident basis: SAPREF gasoline, multiple
incidents across all regions
We should:
•Drain or remove volatile hydrocarbon
liquids from equipment in closed systems
•Do a risk assessment where open
draining of volatile material can’t be
avoided and obtain proper approval for
open draining.
•Always be present when draining water
from equipment or tanks containing
hydrocarbons or hazardous materials, or
the potential to contain hydrocarbons or
hazardous materials, and immediately
close the drain valve when draining of
water is completed
•Never leave bleeders on block and
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bleed isolations in hydrocarbon and
hazardous material service unattended
Take interim mitigating measures in
case of failure of safety critical
equipment
Reasons this is important:
Safety critical equipment must work
correctly to keep you safe. SCE is a barrier
protecting you from significant process
safety incidents
Incident basis: Deer Park OP3 cracked gas
release
We should:
•Follow local site procedures on how to
manage failure of IPFs
•Follow local site procedures on how to
manage failure of relief valves and
pressure relief systems
•For other types of SCE, follow a written
mitigation plan if the equipment cannot
be repaired within the required timeframe
•Assure interim measures are in place and
effective
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 9 Process Safety Fundamentals
Perform MOC and install backflow
protection when connecting utilities to
process
Reasons this is important:
Reverse flow of hydrocarbons and chemicals
into utility systems has resulted in several
significant incidents.
Incident basis: Moerdijk caustic; Stanlow
firewater; SAPREF instrument air to HF
We should:
•Not connect utilities to process unless
absolutely necessary
•Use MOC for temporary connections
•Install backflow prevention when connecting
utilities to process or other utility systems
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Follow the SU/SD procedures and sign
off after each step
Reasons this is important:
Operator action following procedures is an
important barrier to prevent process safety
incidents. The likelihood of a process safety
incident is higher during startups and
shutdowns than during normal operation
Incident basis: Bukom CCU
We should:
•Understand and follow the startup and
shutdown procedures
•Sign off real time as the procedure is
executed (except for emergency shutdown
procedures)
•Sign off within 24 hours after the procedure is
executed for emergency shutdown
procedures
•Escalate to shift management if procedure
steps cannot be carried out as written
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Walk the line – verify and validate
any line-up change
Reasons this is important:
Verifying and validating that operational
line-ups are correct ensures process and
utilities streams are routed to the right
locations. Incorrect line-ups can bypass
process safety barriers leading to major
incidents
Incident basis: Deer Park C4 HiPo release,
Norco CDU Fire
We should:
•Verify upstream and downstream valves
are in the correct positions for all line-up
changes by physically walking the lines
•Validate, by use of levels, flows, pressures
and temperatures, that line-up changes
are as intended
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 9 Process Safety Fundamentals
Do not make a change without
proper MOC
Reasons this is important:
Unintended consequences of changes
can lead to significant incidents, including
releases, fires, explosions and fatalities.
Incident basis: Flixborough, Longford
We should:
•Know how to recognize a change
•Document the change using a proper
MOC
•Review and approve design or plan
including hazard screening and risk
analysis
•Execute the change and train the people
affected by the change
•Do a readiness review, handover and
acceptance
•Do a close out and capture learnings
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Verify for completeness of tightness
after maintenance work
Reasons this is important:
Equipment and piping tightness prevents
significant LOPCs from occurring when
hydrocarbons or hazardous chemicals are
introduced into the system.
Incident basis: Norco CDU; Bukom Flare Vessel;
PD crude pump LOPC (2014)
We should:
•Ensure that all vents and drains are isolated
before introducing hydrocarbon or hazardous
chemicals into the system
•End blank or cap all vents and drains before
introducing hydrocarbon or hazardous
chemicals into the system
•Remove all temporary connections before
introducing hydrocarbon or hazardous
chemicals into the system
•Perform a system leak test prior to introducing
hydrocarbon or hazardous chemicals into the
system
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Always check that equipment is
pressure free and provide safe
isolation before starting maintenance
work
Reasons this s important:
Effective process isolation and verification that
equipment/piping is pressure free ensures that
personnel will not get hurt due to release of
pressure while equipment is open for
maintenance.
Incident basis: Jurong steam condensate LTI
(2011); Rheinland Pipe rack Gasoil: Sarnia
boiler incident
We should:
•Ensure that an approved isolation plan is
available for every maintenance activity that
requires breaking into a pressure envelope
•Confirm the right level of isolation is in place
before allowing maintenance work to start
•Confirm that there is no pressure in the system
before allowing maintenance work to start
and verify through the use of a first flange
break only as a last resort
•Assume the isolated hazard
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during first break and prescribe and confirm
 What does success look like at 31 Dec 2016?

• Employees raise concerns & dilemmas without

fear of hierarchy/consequence.
• Commitment from management team to
resolve derogations.
• Consistent storyline across all levels on 9 PSFs
and what it means.
• Behavioral change – individuals comply with 9
PSF because they agree with it and not out of
fear of potential consequences.

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Copyright of Shell Eastern Petroleum (Pte) Ltd CONFIDENTIAL