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This book is one in a series of process safety guidelines and concept books published by the Center for Chemical Process Safety (CCPS). Please go to www.wiley.com/go/ccps for a full list of titles in this series.
It is sincerely hoped that the information presented in this document will lead to an even more impressive safety record for the entire industry. However, the American Institute of Chemical Engineers, its consultants, the CCPS Technical Steering Committee and Subcommittee members, their employers, their employers’ officers and directors, the Abnormal Situation Management® Consortium (ASMC) and its members, and Baker Engineering and Risk Consultants, Inc. (BakerRisk®), and its employees do not warrant or represent, expressly or by implication, the correctness or accuracy of the content of the information presented in this document. As between (1) American Institute of Chemical Engineers, its consultants, CCPS Technical Steering Committee and Subcommittee members, their employers, their employers’ officers and directors, the ASMC members, and BakerRisk, and its employees and (2) the user of this document, the user accepts any legal liability or responsibility whatsoever for the consequences of its use or misuse.
Guidelines for Managing Abnormal Situations
Center for Chemical Process Safety Of The
American Institute of Chemical Engineers
New York, NY
This edition first published 2023
2023
A Joint Publication of the American Institute of Chemical Engineers and John Wiley & Sons, Inc.
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Library of Congress Cataloging-in-Publication Data Applied for:
Hardback ISBN: 9781119862871
Cover Images: Dow Chemical Operations, Stade, Germany/ Courtesy of Dow Chemical Company manyx31/Getty Images; Creativ Studio Heinemann/Getty Images
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7.3
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7.3.7
Figure
LIST OF FIGURES
Figure 4.1
Figure 5.1
Figure 5.2
Figure 7.1.
Figure 7.2
Figure 7.3
Figure 7.6
Figure 7.7
Figure 7.8
Figure
LIST OF TABLES
LIST OF EXAMPLE INCIDENTS
ACRONYMS AND ABBREVIATIONS
ADIRU Air Data Inertial Reference Units (Ch. 7)
AIChE American Institute of Chemical Engineers (Preface)
AIM Asset Integrity Management (Ch. 3)
AOA Angle of Attack (Ch. 7)
AOPS Automatic Overfill Protection Systems (Ch. 3)
EHSS Environmental Health, Safety and Security (Ch. 4)
FCCU Fluidized Catalytic Cracker Unit (Ch. 7)
FCPC Flight Control Primary Computer [aka PRIM] (Ch. 7)
FCSC Flight Control Secondary Computer [aka SEC] (Ch. 7)
FDR Flight Data Recorder (Ch. 7)
FMEA Failure Modes and Effects Analysis (Ch. 5)
GCPS Global Congress on Process Safety (Ch. 5)
GEMS Generic Error-modelling System (Ch. 3)
GPWS Ground Proximity Warning System (Ch. 7)
HAZID Hazard Identification (Ch. 5)
HAZOP Hazard and Operability Study (Ch. 3)
HF Hydrogen Fluoride (Ch. 3)
HIRA Hazard Identification and Risk Analysis (Ch. 3)
HMA Highly Managed Alarm (Ch. 4)
HMI Human Machine Interface (Ch. 3)
HRA Human Reliability Analysis (Ch. 3)
IOGP International Association of Oil and Gas Producers (Ch. 5)
IOW Integrity Operating Window (Ch. 4)
ITCZ Inter-Tropical Convergence Zone (Ch. 7)
ITPM Inspection, Testing, and Preventive Maintenance (Ch. 6)
LCN Light Cycle Naphtha (Ch. 7)
LOPA Layer of Protection Analysis (Ch. 4)
LOPC Loss of Primary Containment (Ch. 6)
LPG Liquefied Petroleum Gas (Ch. 3)
MCAS Maneuvering Characteristics Augmentation System (Ch7)
MIC Methyl Isocyanate (Ch. 3)
MOC Management of Change (Ch. 3)
MOOC Management of Organizational Change (Ch. 5)
ND Navigation Display (Ch. 7)
OD Operational Discipline (Ch. 2)
PF Pilot (who is) Flying (Ch. 7)
PFD Primary Flight Display (Ch. 7)
PHA Process Hazards Analysis (Ch. 3)
PNF Pilot Not Flying (Ch. 7)
PORV Pilot Operated [Pressure] Relief Valve (Ch. 5)
PSID Process Safety Incident Database (Ch. 3)
PSM Process Safety Management (Ch. 7)
PSSR Pre-Startup Safety Review (Ch. 5)
PSV Pressure Safety Valve (Ch. 6)
RAGAGEP Recognized And Generally Accepted Good Engineering Practice (Ch. 3)
RBI Risk Based Inspection (Ch. 3)
RBPS Risk Based Process Safety (Ch. 1)
RCM Reliability Centered Maintenance (Ch. 3)
SA Situational Awareness (Ch. 3)
SIS Safety Instrumented System (Ch. 3)
SME Subject Matter Expert (Ch. 4)
SMS Safety Management Systems (Ch. 7)
SOP Standard Operating Procedure (Ch. 4)
TOH Transient Operation HAZOP (Ch. 5)
UCDS User Centered Design Services (Ch. 1)
VCE Vapor Cloud Explosion (Ch. 2)
VDU Vacuum Distillation Unit (Ch. 7)
Abnormal Situation
GLOSSARY
A disturbance in an industrial process with which the basic process control system of the process cannot cope.
Note: In the context of a hazard evaluation, synonymous with deviation.
Abnormal Situation Management
Advanced Process Control
Abnormal Situation Management, or Managing Abnormal Situations, refers to a comprehensive process for improving performance which addresses the entire plant population. It promotes effective utilization of all available resources—i.e., hardware, software, and people, including the proactive or reactive intervention activities of members of the operations team, to achieve safe and efficient operations. Abnormal Situation Management is achieved through prevention, early detection, and mitigation of abnormal situations.
Advanced process control refers to techniques including multi-variable control, inferential control, feedforward, and decoupling. Multiple single-loop controllers are adjusted in unison, to satisfy constraints and attain optimization objectives while adhering to safe operating limits. Advanced process control techniques often use model-based software to direct the process operation. These applications require that the process model created accurately represents the process dynamics.
Asset Integrity Management
A process safety management system for ensuring the integrity of assets throughout their life cycle.
Boiling Liquid Expanding
Vapor Explosion (BLEVE)
Bow Tie Model
A type of rapid phase transition in which a liquid contained above its atmospheric boiling point is rapidly depressurized, causing a nearly instantaneous transition from liquid to vapor with a corresponding energy release. A BLEVE of flammable material is often accompanied by a large aerosol fireball, since an external fire impinging on the vapor space of a pressure vessel is a common cause. However, it is not necessary for the liquid to be flammable to have a BLEVE occur.
A risk diagram showing how various threats can lead to a loss of control of a hazard and allow this unsafe condition to develop into a number of undesired consequences. The diagram can also show all the barriers and degradation controls deployed.
Conduct of Operations
The embodiment of an organization's values and principles in management systems that are developed, implemented, and maintained to (1) structure operational tasks in a manner consistent with the organization's risk tolerance, (2) ensure that every task is performed deliberately and correctly, and (3) minimize variations in performance.
Distributed Control System
A system which divides process control functions into specific areas interconnected by communications (normally data highways), to form a single entity. It is characterized by digital controllers and typically by central operation interfaces. Distributed control systems consist of subsystems that are functionally integrated but may be physically separated and remotely located from one another. Distributed control systems generally have at least one shared function within the system. This may be the controller, the communication link or the display device. All three of these functions maybe shared. A system of dividing plant or process control into several areas of responsibility, each managed by its own CPU, with the whole interconnected to form a single entity usually by communication buses of various kinds.
Failure Modes and Effects Analysis
Hazard and Operability Study
A systematic method of evaluating an item or process to identify the ways in which it might potentially fail, and the effects of the mode of failure upon the performance of the item or process and on the surrounding environment and personnel.
A systematic qualitative technique to identify process hazards and potential operating problems using a series of guide words to study process deviations. A HAZOP is used to question every part of a process to discover what deviations from the intention of the design can occur and what their causes and consequences may be. This is done systematically by applying suitable guide words. This is a systematic detailed review technique, for both batch and continuous plants, which can be applied to new or existing processes to identify hazards.
Hazard Identification
Hazard Identification and Risk Analysis
Part of the Hazard Identification and Risk Analysis (HIRA) method in which the material and energy hazards of the process, along with the siting and layout of the facility, are identified so that a risk analysis can be performed on potential incident scenarios.
Hazard Identification and Risk Analysis (HIRA): A collective term that encompasses all activities involved in identifying hazards and evaluating risk at facilities, throughout their life cycle, to make certain that risks to employees, the public, and/or the environment are consistently controlled within the organization's risk tolerance.
Highly Managed Alarm
Human Machine Interface
Human Reliability Analysis
Inspection, Testing and Preventive Maintenance
An alarm belonging to a class with additional requirements (e.g., regulatory requirements) above general alarms.
The means by which human interaction with the control system is accomplished
A method used to evaluate whether systemrequired human actions, tasks, or jobs will be completed successfully within a required time period. Also used to determine the probability that no extraneous human actions detrimental to the system will be performed.
Scheduled proactive maintenance activities intended to (1) assess the current condition and/or rate of degradation of equipment, (2) test the operation/functionality of equipment, and/or (3) prevent equipment failure by restoring equipment condition.
Integrity Operating Window
Lagging Metric
Layer of Protection Analysis (LOPA)
An Integrity Operating Window (IOW) is a set of limits used to determine the different variables that could affect the integrity and reliability of a process unit. An IOW is the set of limits under which a process, piece of equipment, or unit operation can operate safely. Working outside of IOWs may cause otherwise preventable damage or failure.
A retrospective set of metrics based on incidents that meet an established threshold of severity.
An approach that analyzes one incident scenario (cause-consequence pair) at a time, using predefined values for the initiating event frequency, independent protection layer failure probabilities, and consequence severity, in order to compare a scenario risk estimate to risk criteria for determining where additional risk reduction or more detailed analysis is needed. Scenarios are identified elsewhere, typically using a scenario-based hazard evaluation procedure such as a HAZOP Study.
Leading Metric
Loss of Primary Containment
A forward-looking set of metrics that indicate the performance of the key work processes, operating discipline, or layers of protection that prevent incidents.
An unplanned or uncontrolled release of material from primary containment, including non-toxic and non-flammable materials (e.g., steam, hot condensate, nitrogen, compressed CO2 or compressed air).
Management of Change
A management system to identify, review, and approve all modifications to equipment, procedures, raw materials, and processing conditions, other than replacement in kind, prior to implementation to help ensure that changes to processes are properly analyzed (for example, for potential adverse impacts), documented, and communicated to employees affected.
Management of Organizational Change
Normalization of Deviance
Pressure Safety Valve
Pre-Startup Safety Review
Management of organizational change (MOOC) is a framework for managing the effect of new business processes, changes in organizational structure or cultural changes within an enterprise. MOOC addresses the people side of change management.
A gradual erosion of standards of performance as a result of increased tolerance of nonconformance.
A pressure relief device which is designed to reclose and prevent the further flow of fluid after normal conditions have been restored.
A systematic and thorough check of a process prior to the introduction of a highly hazardous chemical to a process. The PSSR must confirm the following: Construction and equipment are in accordance with design specifications; Safety, operating, maintenance, and emergency procedures are in place and are adequate; A process hazard analysis has been performed for new facilities and recommendations have been resolved or implemented before startup, and modified facilities meet the management of change requirements; and training of each employee involved in operating a process has been completed.
Process Hazard Analysis
Process Safety Incident Database
An organized effort to identify and evaluate hazards associated with processes and operations to enable their control. This review normally involves the use of qualitative techniques to identify and assess the significance of hazards. Conclusions and appropriate recommendations are developed. Occasionally, quantitative methods are used to help prioritize risk reduction.
A database that is used to collect and record information from past process safety incidents.
Process Safety Management
RAGAGEP
Risk Based Process Safety
A management system that is focused on prevention of, preparedness for, mitigation of, response to, and restoration from catastrophic releases of chemicals or energy from a process associated with a facility.
"Recognized and generally accepted good engineering practice", a term originally used by OSHA, stems from the selection and application of appropriate engineering, operating, and maintenance knowledge when designing, operating and maintaining chemical facilities with the purpose of ensuring safety and preventing process safety incidents. It involves the application of engineering, operating or maintenance activities derived from engineering knowledge and industry experience based upon the evaluation and analyses of appropriate internal and external standards, applicable codes, technical reports, guidance, or recommended practices or documents of a similar nature. RAGAGEP can be derived from singular or multiple sources and will vary based upon individual facility processes, materials, service, and other engineering considerations.
The Center for Chemical Process Safety's process safety management system approach that uses riskbased strategies and implementation tactics that are commensurate with the risk-based need for process safety activities, availability of resources, and existing process safety culture to design, correct, and improve process safety management activities.
Reliability Centered Maintenance
Risk Based Inspection
Safe Operating Limits
A systematic analysis approach for evaluating equipment failure impacts on system performance and determining specific strategies for managing the identified equipment failures. The failure management strategies may include preventive maintenance, predictive maintenance, inspections, testing, and/or one-time changes (e.g., design improvements, operational changes).
A risk assessment and management process that is focused on loss of containment of pressurized equipment in processing facilities, due to material deterioration. These risks are managed primarily through equipment inspection.
Limits established for critical process parameters, such as temperature, pressure, level, flow, or concentration, based on a combination of equipment design limits and the dynamics of the process.
Safety Instrumented System
Safety Management System
Situational Awareness
A separate and independent combination of sensors, logic solvers, final elements, and support systems that are designed and managed to achieve a specified safety integrity level. A SIS may implement one or more Safety Instrumented Functions (SIFs).
Comprehensive sets of policies, procedures, and practices designed to ensure that barriers to episodic incidents are in place, in use, and effective.
The conscious dynamic reflection on the situation by an individual. It provides dynamic orientation to the situation, the opportunity to reflect not only the past, present and future, but the potential features of the situation. The dynamic reflection contains logical-conceptual, imaginative, conscious, and unconscious components which enables individuals to develop mental models of external events.
