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GUIDELINES FOR MANAGING ABNORMAL SITUATIONS

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.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/ go/permissions.

The right of CCPS to be identified as the author of the editorial material in this work has been asserted in accordance with law.

Registered Office

John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USA

For details of our global editorial offices, customer services, and more information about Wiley products visit us at www.wiley.com.

Wiley also publishes its books in a variety of electronic formats and by print-on-demand. Some content that appears in standard print versions of this book may not be available in other formats.

Trademarks: Wiley and the Wiley logo are trademarks or registered trademarks of John Wiley & Sons, Inc. and/or its affiliates in the United States and other countries and may not be used without written permission. All other trademarks are the property of their respective owners. John Wiley & Sons, Inc. is not associated with any product or vendor mentioned in this book.

Limit of Liability/Disclaimer of Warranty

In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of experimental reagents, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each chemical, piece of equipment, reagent, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. The fact that an organization, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may provide or recommendations it may make. This work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a specialist where appropriate. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages.

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

7.2.3

7.2.4

7.2.5

7.2.7

7.2.8

7.2.9

7.3

7.3.1

7.3.2

7.3.7

Figure 2.1

LIST OF FIGURES

Figure 2.4

Figure 2.5

Figure 3.1 BP Texas City Raffinate Splitter

Figure 4.1 NASA Control Room – Engine Research

Figure 5.1 Protection and Their Impact on the Process

Figure 5.2

Figure 7.1. The Three Pitot Tubes on the A330 Aircraft

Figure 7.2 Aircraft Pitch Commands and Pitch Attitude from 02:10:05 to 02:10:26

Figure 7.3 Airspeed Indication from 02:10:06 to 02:11:46*

Figure 7.4 FCCU Separation

Figure

Figure 7.6 Source of the Jet Fire with Destroyed Control and Office Block

Figure 7.7 Manway at the End of 60 Still Base - Source of the Jet Fire200

Figure 7.8 Schematic Drawing of the Separation Stages

Figure 7.9 Schematic Drawing of 60 Still Base 202

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)

APC Advanced Process Control (Ch. 3)

API American Petroleum Institute (Ch. 2)

ASM® Abnormal Situation Management® (Ch. 1)

ASMC Abnormal Situation Management® Consortium (Ch. 1)

BLEVE Boiling Liquid Expanding Vapor Explosion (Ch. 3)

CAS Computerized Air Speed (Ch. 7)

CCPS Center for Chemical Process Safety (Preface)

CDU Crude Distillation Unit (Ch. 7)

CIMAH Control of Industrial Major Accident Hazards (Ch. 7)

COMAH Control of Major Accident Hazards (Ch. 7)

COO Conduct of Operations (Ch. 2)

CPC Critical Process Controller (Ch. 7)

CSB Chemical Safety Board (Ch. 3)

DCS Distributed Control Systems (Ch. 2)

ECAM Electronic Centralized Aircraft Monitoring (Ch. 7)

EFCS Electronic Flight Control System (Ch. 7)

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.

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