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Andy’s Almanac on Accidents, Part Four
Safety

Andy’s Almanac on Accidents, Part Four

By Sphera February 9, 2021

Originally slated to be a three-part series, Andy’s Almanac has been extended. Andy Bartlett, Sphera’s solution consultant for Operational Risk Management, details lessons learned from incidents he has seen during his 40-plus-year career. Listen to parts one, two and three.

 

James Tehrani:

Welcome to this SpheraNOW podcast, a program focused on Safety, Sustainability and Productivity issues. I’m James Tehrani Spark’s editor-in-chief. Today on the show I’ll be speaking with Andy Bartlett Sphera’s solution consultant for Operational Risk Management. In part three, we talked about how Process Safety manifests itself in the field. Today will be discuss… Here we go. Let me try it again. Welcome to this SpheraNOW podcast, a program focused on Safety, Sustainability and Productivity issues. I’m James Tehrani Spark’s editor-in-chief. Today on the show I’ll be speaking with Andy Bartlett Sphera’s solution consultant for Operational Risk Management. In part three, we discussed how Process Safety manifests itself in the field. And today we’ll be discussing some of the incidents. Andy has studied in the past decade or so. Thank you so much for joining me today, Andy, how you doing?

Andy Bartlett:

I’m doing well. James how about you?

James Tehrani:

I’m doing very good. And just so everybody knows, originally this was supposed to be a three-part series. We decided there’s just so much we want to talk about that we’re extending it. So this is like bonus time for all of us. This is great. Before we get into it, can you tell me a little bit about what’s going on with the COVID situation by you? Just so, I’m sure everybody is curious what’s going on in the UK?

Andy Bartlett:

Well, the lockdown this time is the same throughout the whole of the UK, so we only supposed to go out for exercise and for shopping. And we can’t meet up with the family, we can get takeaway meals and you can get delivered meals. I mean I’m doing a lot of cooking. I’ve learnt a bake banana bread after about 10 attempts. I’m getting this somewhere in the year. There’s always bananas left at the end of the week. The dogs in a bad way. He’s first really long and muttered and I keep trying to trim it, but he won’t let me so he’s going to the groom is tomorrow. That’s just opened again …

Andy Bartlett:

He is a Bichon.

James Tehrani:

Oh okay.

Andy Bartlett:

Yeah. White and fluffy with a temper.

James Tehrani:

Well, he’ll be nice and clean tomorrow. That’s great. So let’s pick up kind of where we left off. We were talking about your days in Saudi Arabia. At what point were you ready to retire and what did you think was going to happen in retirement and what actually did happen in your career and retire after retirement?

Andy Bartlett:

Well, I admit my plans retirement and I started my own business doing Risk Assessments for people. I did some for some retail facilities and some for office facilities and their construction sites. And I found that, I was not well-versed in planning and carrying out work myself. I got into a bit of a mess. I had a backlog and people pushing me for work. And I thought well, as a one-man business, I obviously took on too much work.

Andy Bartlett:

I’ll finish what I started and put my bills in. And then the following month I contacted a gentleman I’d met out in Saudi. And he was part of a pretty big business in the UK. And they said, “Yeah, we look for people like you, where would you come and join us?” So that’s what I did. And I started to work part time for this company in Scotland, which is about 250 miles away to five hour drive from where I live. But we didn’t have to go to the office. Everything could be done from home. And from then I haven’t looked back. It’s funny this morning, the people I worked for back in October 2012, contacted me today and said, “Have you got any time? We need some work done similar to what you did for us before.” I said, “I’m very sorry, but I’m busy.”

James Tehrani:

That’s great. Just in general, do you see that in the hazardous industries, are the incidents the same in the last couple of decades or with the evolution of software and technology? Are we seeing different incidents nowadays than you saw in the past?

Andy Bartlett:

Well, I’ve been looking at that and it’s still, loss of contentment, ignition, fire explosion, what is still the major thing that’s major Process Safety Incidents. That takes me back to, when I was working in the Middle East and we had five refineries in our department. And my boss would always say to me, before we had the morning call, “What do you think is going to happen today?” I said, “Oh, there’ll be a loss of contaminant incident.” And although there was always minor loss of containment incidents. Somebody had done something not right or some equipment had failed. But when you look at the big picture, some of these big incidents that happen, it’s… If you’re going to have a fire and explosion obviously you’ve had lots of contentment. And what I’ve been looking at is how could you model that and to look back and say right, if there had the technology that’s available there using the Swiss Cheese Model and the Barrier Model, what would it look like?

Andy Bartlett:

And it’s quite illuminating to see, you can see these things building if the people had the technology and the web or all, to start to look at it differently. And most of these reports when you read them and I’ve read quite a lot is, the focus on Process Safety is not always there. So that’s the main thing. And we know from our surveys that not a hundred percent of the responders say Process Safety is in build everywhere. It’s still not a hundred percent focus of managed whereas it should be [crosstalk 00:06:09].

James Tehrani:

So when we’re looking back on these historical incidents, there’s the cliche that hindsight is 2020. And it’s easy to say now, what could have been done to prevent such an incident in the past. But why is that so important to look back on these incidents now when there’s nothing you can do to change what happened then?

Andy Bartlett:

Well, it’s all about lessons learned and prevention. And I deal with CPS quite a bit. And one of the objectives was to try and get every engineer in facilities, process safety competent. If management have not gone through process safety competence, some members of management come from different business lines into a business land where you’re dealing with energy. And we should have some sort of [inaudible 00:07:13]. You need to do a process safety course, look at this incident, look how it formed using the Swiss cheese model or the Bow-Tie model. And you can see that these things are built and they didn’t all happen at once. There’s not many cases where there’s only one thing caused the incident. There’s always several buildup together to make it happen.

It’s the Swiss cheese model, which has been around for quite awhile Jim’s reasoned, and when you model them, it gives you an insight into what was happening. If management don’t apply control effectively and they don’t have audit and systems in place, they don’t have the preventative maintenance then these things can happen.

James Tehrani:

When you say, process safety competence are most organizations competent when it comes to the process safety?

Andy Bartlett:

Well, this is where you get your silos, where you have process safety engineers and they work with their team and they do the best they can. And how and when they bring things up a level to management, it doesn’t say, “Is the guideline?” I don’t know. Do facilities have their own ceilings when they say this has to be reported to management. And in a paper-based environment, everybody is sitting and they’re know what’s wrong with their part of the plant. The guy who’s in charge of inspection, he knows which piping systems are going to need money spent on them.

Andy Bartlett:

The guy that’s in charge of the rotating equipment, he knows where he’s bad actors are, the people who are in charge of fixed equipment, they know which ones have got metal thinning and the people in charge of the chemicals, they know where the usage is and how much they’re using, which gives you a feedback on what corrosion internally they’re trying to stop. There’s all these silos and being able to put them together into a one barrier model is when you start to see what’s happening. When does the guy who is in charge of rotating equipment and he has these bad actor problem, and he has a bad actor that you just can get a handle him, when does he go to management say you need to replace this.

Andy Bartlett:

of course, then it goes… It’s capital funds. So capital funds have to go to a committee and eventually somebody says yes or no, but if it’s put in the process safety model that this particular item is causing us high risk, and you start to see the red barriers come up in the areas of the plant that moved from green to orange and say, “Oh, that’s, we’ve got a risk building in this facility.” What do we need to do to reduce it? Where do we need to spend our money? And money is a limited resource. Where do I want to spend my money to bring my risk down? And when people start thinking like that, you then look at the process safety mentality is, I want to spend my money on the things that are going to reduce my risk of having a Process Safety Incident.

James Tehrani:

I see. When we’re talking competence, we’re talking about being able to share information, risk information easily throughout an organization. That’s a huge part of that.Right?

Andy Bartlett:

Yes. And with a paper-based system that’s difficult.

James Tehrani:

Definitely. All right. Well, I was hoping that we could talk about an incident that happened in 2005. It’s the… At the Buncefield oil storage depot in England. I was wondering if we could talk about that and you could kind of set up the scene of what took place that day in December of 2005.

Andy Bartlett:

Well, basically a tank was overfilled. It spread out. It was ignited. It had a massive fire and explosions and several tanks were damaged, billions of pounds of, sorry, millions of pounds of damage and a lot of damage to the environment from the overspill, from the Fireward sprayed under the facility and flowing away into the drains, et cetera. And because it was a big criminal case for the companies involved.

Andy Bartlett:

The UK Health and Safety at Work Act 1974, they find all of the people concerned, the companies involved and the contractors involved. When you got that cost, not only rebuilding, refurbishing the area round about and you’ve got fines to your company, it can take a company out of the business altogether. Spending some money on having a Process Safety Management System that is automated is cheap compared with what you’re going to pay if you don’t. So during this actual item, if you look at the Swiss cheese barrier model, the structural integrity was a little processed containment was obviously lit up, detection systems didn’t work properly, protection systems. The high level switches didn’t work properly. The shut down switches didn’t work properly. And all of these items had been reported at some time but not in a way that said, there is a risk coming, they will report it as a maintenance failure. As a-

James Tehrani:

So just I understand, all of this stuff was reported individually but there was no vision on how that could affect the depot holistically. Is that what you’re saying?

Andy Bartlett:

Yes. Such a… What you might think as a little thing is one of the, what is called a berm or a bund that the wall selecting, surrounding a tank where the pipes went through the wall hadn’t been sealed properly so when the tank spilled, the hydrocarbons were able to flow to the next tank. And of course when it ignited, there was a pool ready for that tank. So just a lit you know, it’s not a little thing, but suddenly somebody said, “Oh, it just needs, that pipe needs packing with some proper stuff.” They knew about it, but it wasn’t done properly. And it [crosstalk 00:14:06]-

James Tehrani:

Were hurt right?

Andy Bartlett:

Well, let’s see 40 people injured but no fatalities. A lot of commercial and residential properties in the area had to be evacuated. And cause it was one of the biggest explosions of, I think it is the biggest explosion in the UK since the Second World War. And it was heard over a massive area of the UK.

James Tehrani:

Where you in the UK at that time?

Andy Bartlett:

No, I wasn’t. No.

James Tehrani:

Okay. Well, that’s…

Andy Bartlett:

Well I do have a friend who worked on the committee that put together new rules and regulations afterwards to try and stop what happened again. So-

James Tehrani:

Do you want to share a couple of those recommendations that came after about after that?

Andy Bartlett:

Well the type of Independent High-Level Switch, which was when I read the report, I thought that’s quite archaic to what I’m used to. Was to change it to a more modern type, this relied on a padlock being in the right place to work properly. And the test lever been in the right place. And the test lever didn’t have a spring, just something like that. It was left in the test position from the last test. So it didn’t work, is my understanding of it.

James Tehrani:

I see.

Andy Bartlett:

Yeah.

James Tehrani:

And okay. We talked a little bit about 2020 vision. What… I mean, we’re in 2021 now, obviously they didn’t have the technology available that we do now in 2005, but what with software would they be able to see now in terms of a risk pathway developing that they wouldn’t be able to back then?

Andy Bartlett:

I worked in a job where this type of software was installed. And one of the things that was in that was, a high level switch which we call it shut down switch. When it activated would highlight automatically on the computer system showing the barriers so that, not only did you have the alarm coming to the alarm system through the distributed control system, it would also come in and say, “You’ve got a high level switch going off there. Your protection system, your shut down system, barriers have been lit up.” And that would, if anything else was going on in the same area, then he would also have the risk pathway starting to form. So breach to a barrier as we call it, can be done automatically.

Andy Bartlett:

And then on the other side, you’ve got your systems in place, your inspection systems, your liability systems, reports put in about bad actors, about metal fitting, et cetera. Would be entered into this manually. And that would also start, you’d have to see where is the risk forming on your plant? So the system that we have installed has manual input and automated input and the person who’s watching the plant and across the manager can see all of this, can see what’s happening in the plant. And what …

James Tehrani:

This is all in real time. I mean, you’d be able to see everything that’s going on at that very moment.

Andy Bartlett:

The automated is in real time, of course the manual entry would be, I don’t know whether they do it weekly or daily or whatever, but it’s gotta be a better than the monthly report, which is put up on a PowerPoint and people sit and discuss it in the safety meetings and so, we need to do something about that. If it’s in here and you come in as a manager and grab a cup of coffee in the morning, switch the computer, “Oh, I’ve got a red barrier up in area one. I better go in [inaudible 00:18:10] what’s going on, what they’re doing about it.” That’s what’s set, your priorities is fixing the things that are lighting up your barriers.

James Tehrani:

When a barrier lights up, what does it say on the screen? Is it just a red box that explains there’s an incident that could potentially take place or something like that?

Andy Bartlett:

The model that we use has eight barriers and once a barrier is, say for example, a process contaminant barrier, down below, it would tell you which item is actually effecting that barrier. If you save the example, you issued a hot work permit, which means you brought an ignition source into a running unit, that would light up the ignition barriers and yes, I’ve now got an ignition source in my unit. And if the fire and gas detection alarm went off in that unit, well as the second part of your fire triangle, you could, if there were needed we either have a fire or explosion. So it’s a way of monitoring what’s going on as an overall risk view to see, to try and prevent fires and explosions, that’s the whole point of it.

James Tehrani:

What would the proper process be if there is an elevated risk, in part of the plan. What is it that the operator should be doing?

Andy Bartlett:

Well, you look at what is causing the risk and remove one of those from the equation. So in this particular case, I just, the hot work permit would be closed. The work would be closed down until the fire and gusty technique was fixed. That’s the easiest one for most people to understand is that you’ve got heat and you’ve got fuel and you also you’ve got the air and then you’ve already rated the goal for the fire explosion. So you would stop the one that you can, which is the hot work. And then you would go and find out why the gas detector wasn’t working and get it repaired.

James Tehrani:

Got it. Is there anything else about the Buncefield oil storage depot incident that people should know about?

Andy Bartlett:

Well, one of the items is poor communication at shift handover, which again, the software available at the manager shift handover. It’s documented and it can be seen, lack of engineering expertise on these switches and management of change process when the switches were changed, there wasn’t really a proper management of change from the old type switch to the new types switch, the process safety controls were not maintained. Senior managers didn’t have effective control, audit and systems weren’t working properly. There’s a whole list of things that went wrong and all of those could be managed in the same software showing what is the risk at any particular time, you know?

James Tehrani:

That’s all very interesting. Thank you so much for sharing that Andy. And I think we will end it there. And the next time we will talk about a different incident, a historical incident and kind of put it in that perspective that you just gave. And I really appreciate your time today. Thank you so much.

Andy Bartlett:

Okay. Thank you James. I’ll see you again.

James Tehrani:

Perfect. And this concludes today’s podcast. Thank you for listening.

 

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