The Application Of Bow Ties For A Robust PSM Program
21st Annual International SymposiumOctober 23-25, 2018 College Station, TexasThe Application of Bow Ties for a Robust PSM ProgramMarisa Pierce and Tatiana NormanDNV GL USA, Inc.1400 Ravello Dr.Katy, Texas 77449, USAE-mails: Marisa.pierce@dnvgl.com, Tatiana.norman@dnvgl.comKeywords: Barrier-based risk management, Bow ties, PSM, OSHAAbstractThe fourteen elements of OSHA’s Process Safety Management (PSM) program underpin so muchof facility operations. PSM programs grow in complexity over time and can become increasinglydisembodied from the operational elements that form their robustness. Often new PSM programsare modeled from organically grown existing programs rather than tailored to the specific risks ofthe operation introducing more than necessary complexity from the beginning. Barrier-basedapproaches can revitalize an existing PSM program or serve as a platform to build a simplifiedPSM program.Bow ties reestablish direct connections to operations in a quickly visualized way transforming theperception of a PSM program from an operational albatross into an engagement tool to inspireownership at all levels of the organization. This paper walks through each of the fourteen PSMelements highlighting the application and value of applying a barrier-based approach to thedevelopment or implementation of a PSM program.Whether working with a robust PSM program that has become more complex over time or buildinga simple program based on the broad PSM concepts, bow ties can help a company focus theirefforts on efficiently addressing deficiencies in their management systems and managing theirmost important risks.
Acronyms and AbbreviationsAPI RPAmerican Petroleum Institute Recommended PracticeBSCATBarrier Systematic Causation Analysis TechniqueCCPSCenter for Chemical Process SafetyCFRCode of Federal RegulationsEIEnergy InstituteHAZOPHazard and OperabilityLOPALayers of Protection AnalysisMAEMajor Accident EventsOSHAOccupation Safety and Health AdministrationPHAProcess Hazards AnalysisPSIProcess Safety InformationPSMProcess Safety Management
IntroductionThe fourteen elements of OSHA’s Process Safety Management (PSM) program underpin so muchof facility operations. PSM programs grow in complexity over time and can become increasinglydisembodied from the operational elements that form their robustness. Often new PSM programsare modeled from organically grown existing programs rather than tailored to the specific risks ofthe operation introducing more than necessary complexity from the beginning. Barrier-basedapproaches can revitalize an existing PSM program or serve as a platform to build a simplifiedPSM program. Bow ties are commonly used to communicate the major accident hazards at anonshore or offshore facility.Development of bow ties often follows the completion of a Process Hazards Analyses. Bow tieworkshops use teams of experienced and knowledgeable people from various disciplines todevelop the bow ties and select the barriers, previously identified in the PHAs, that meet the criteriafor Major Accident Events (MAE) of being effective, independent, and auditable (Ref. /1/).The focus of this paper is to show how bow ties can be used in other ways to drive success in acompany’s management system, regardless of where that company or facility may be in its processsafety journey. This will be accomplished in the following ways: Lay out a process for developing or updating a relevant process safety management systemfor both OSHA PSM covered and non-covered facilities by engaging personnel in variouslevels of a company.Demonstrate how a bow tie can be used to develop or update a piece of the managementsystem program associated with one of the 14 PSM elements.Present examples of how to tap into the additional benefits of bow ties to engage employeesand improve a company’s management system program. Examples are shown for some ofthe PSM elements.The approach presented in this paper will include use of bow ties at the corporate level as well asat the manufacturing facility level. The principles discussed in the Center for Chemical ProcessSafety’s (CCPS) Guidelines for Risk Based Process Safety (RBPS) are used in the developmentof this topic.Using Bow Ties to Develop or Update a Management SystemBow ties can be used in developing a PSM program or updating an existing program for bothOSHA PSM covered and non-covered facilities. The following benefits for using bow ties for PSMprogram development include: Illustrating the barriers associated with MAEs.Showing the impact of compromised degradation controls to barriers.Engaging employees in barrier and degradation control qualityEncouraging employees’ appreciation for their role in identifying and maintaining barriersand degradation controls.Figure 1 shows how bow ties can be incorporated into the development or improvement of amanagement system program. This process is based on a company’s knowledge of the three factorsdiscussed in CCPS’s Guidelines for RBPS specific to their company’s business (Ref. /2/):
1. Identification of risks2. Level demand of process safety activity work compared to resources available.3. Existing process safety cultureThe steps are discussed further in this section.Figure 1 General Workflow for Bow Tie Application to PSM ProgramStep 1: Set the target.The target for a company’s PSM program will be determined by regulatory requirements. OSHAPSM requires that companies develop program management systems that address 14 elements. Acompany may further decide to use Guidelines for RBPS to determine what level of rigor is neededfor each element of its management system. Facilities that are not covered by OSHA PSM, stillchoose to have management systems as a best practice, and may use a risk-based approach to buildtheir management system program.
Step 2: Identify and prioritize process safety risks.The next step is to sufficiently understand the risks, which is the first factor on which processsafety practices are founded (Ref. /2/). Many companies use various PHA methodologies toidentify and assess risks at their facilities with Hazard and Operability (HAZOP) studies being oneof the common types used. Bow ties and Layers of Protection Analyses (LOPA) are often used toidentify the effective, independent, reliable and auditable barriers. Bow tie workshops go one stepfurther in that the Bow tie workshop team members identify the degradation factors1 anddegradation controls2 needed for the barrier be available illustrated in Figure 2. Bow tie workshopsare convenient settings to engage the same people, who are assigned to the upkeep of barriers,through the activity of identifying specific degradation controls for each barrier.Figure 2 Bow tie Diagram Showing Barriers along with Degradation ControlsIt is equally important for companies to identify process safety risks all levels of its operationsincluding corporate and regional support levels. Bow tie diagrams can be useful for Corporate andRegional entities as well as manufacturing facilities.Step 3: Identify process safety activities using Bow ties.After identifying the risks and completing the bow tie workshops, the next factor to be addressedper RBPS Guidelines is the level of demand for process safety work activities needed comparedto resources available (Ref. /2/). To determine the process safety activities, it is important toconfirm that process safety practices associated with the degradation controls are in place. Allprocess safety activities identified should be listed and linked to a management system element.1Degradation controls are measures which help prevent the degradation factor impairing the barrier. They lie on thepathway connecting the degradation threat to the main pathway barrier. Degradation controls may not meet the fullrequirements for barrier validity (Ref. /1/).2Degradation factor is a situation, condition, defect, or error that compromises the function of a main pathway barrier,through either defeating it or reducing its effectiveness. If a barrier degrades then the risks from the pathway on whichit lies increase or escalate, hence the alternative name of escalation factor.
This activity can be completed as part of the bow tie workshop or separately. The outcomes wouldinclude the following: Short-term: A list of degradation control process safety activity gaps for existing barriers(e.g., missing PSI, out of date operating procedure, no maintenance procedure) andrecommendation plan to address the gapsLong-term: A list of process safety activities based on maintaining degradation controlsTime estimates for completing each process safety activityThe outcome from such a workshop may look like that shown in Table 1 (following page). Theinformation can then be used to calculate the process safety activity demand time associated withits respective management system element for all barrier degradation controls identified. Examplesare shown in Figure 3, Figure 4, Figure 5, and Figure 6 (on the page following Table 1).Figure 3 shows the process safety activity demand currently associated with each managementsystem element for the degradation controls. Figure 4 shows the additional process safety activitytime needed to ensure the barrier degradation controls are in place long-term. Figure 5 showsprojected long-term process safety activity demand time for the barrier degradation controls. Longterm process safety activity time is the summation of the additional process safety activity demandtime in addition to the existing process safety activity demand time. This will help a company seewhich management system elements need more resources long-term.Figure 6 is the time needed to implement the actions needed for the longer-term process safetyactivities. It helps prioritize resources short term.Step 4: Incorporate process safety culture findings.In addition to determining process safety activity and resource demand, is understanding theprocess safety culture (Ref. /2/), which may be accomplished through process safety cultureassessments and review of leading, near miss and lagging indicators such as those discussed inAPI RP 754 Process Safety Performance Indicators for the Refining and Petrochemical Industriesor CCPS’s Guidelines for Process Safety Metrics.Once process safety culture is understood across the organization, it is possible to determine howto prioritize which elements of the management system to focus on first.
Table 1 Process Safety Activity Identification Outcome WorksheetHazard andTop EventThreatBarrierDegradation controlPSMElementIn placeoractiveLoss ofContainment– HighPressureNatural GasOverpressureInspection procedure,FAC-01-MNT-01MechanicalIntegrityYesLoss ofContainment– HighPressureNatural GasOverpressureMaintenanceprocedure, FAC-01MNT-02MechanicalIntegrityYesLoss ofContainment– HighPressureNatural GasOverpressurePSV-01A –PressureSafety Valveon NaturalGas stem onNatural GasInlet LineHIPPS-01HighintegrityPressureProtectionSystem onNatural GasInlet LineTrainingrequirements, HIPPStesting training e(per year)2 hoursActionTime toimplementactionNoneN/ANo2 hoursNoneN/AYes; 2 out of 4I&E techniciansare trained4Providetraining to J.Smith and A.Rogers(instrumenttechnicians)hired in Q12018.16 hoursTotal8 hours16 hours
Current PS Demand Time(hours per year)Additional PS Demand Time(hours per year)OperatingProcedures - SOPs5.34%0.43%0.21%TrainingOperatingProcedures SOPs16.67%Mechanical rocedures - SafeWork PracticesFigure 3 Current Process Safety Demand Time forBarrier Degradation ControlsLong-term Projected PS ActivityTime(hours per year)OperatingProcedures - SOPs0.41%7.76%TrainingShort-term Time For ActionImplemention(hours per year)3.45%OperatingProcedures - SOPs0.72%MechanicalIntegrity91.10%Figure 4 Additional Process Safety DemandTime for Barrier Degradation ControlsTraining27.59%68.97%OperatingProcedures - SafeWork PracticesFigure 5 Long-Term Process Safety Demand Timefor Barrier Degradation ControlsMechanicalIntegrityFigure 6 Short-Term Time for ActionImplementation TimeThe roles of the responsible resources can be assigned to each degradation control andcorresponding management system. It can also be possible to see how the emphasis of a person’srole can change with respect to management system elements.How much time a person’s role will change with respect to process safety activities vs. dailyroutine activities (if the breakdown of a resource’s role in there is known). This may help acompany determine if additional resources are needed or how to better prioritize the resources theyhave.
Step 5: Prioritize PS activitiesOnce the process safety activity demand and resource has been determined, the process safetyculture rating can be used to help a company determine which process safety activities to focus onfirst with respect to their management system.Step 6: Develop Management systemThe findings from the facility level and corporate level assessments can be combined to an overallperspective of a company’s management system to see company-wide, systemic patterns withcurrent and long-term process safe activities.Evergreen activitiesBow ties, barriers and degradation controls should be reviewed periodically to determine whereprocess safety activities should be modified and to change the resourcing as needed. Continuouslymonitor barrier degradation control integrity, ensuring procedures are up-to-date, inspections onbarriers or degradation controls are not overdue and maintenance activities are being performed atdesignated intervals. If deficiencies are noted with lagging or even leading indicators, the processsafety activity demands and resourcing availability should be reviewed. When changes are madeto equipment and associated barriers, bowties should be modified. If bowties are modified, thiscould impact the process safety activity demands associated with the barrier’s degradation controlsas well as the resources need to keep up the degradation controls.Consider periodically reviewing the management system using the review of bowties, barriers anddegradation controls periodically to assure that the management system is addressing the currentrisks with optimal resources.Bow Ties to Design, Maintain and improve Management System EffectivenessBow ties can be used at a high level to develop or update a piece of the management systemprogram associated with one of the 14 PSM elements especially at the Corporate level asmentioned in Step 2 in the previous section.Once a company has determined the contents to be included or areas of improvement needed forthe Employee Participation element of their management system, they can create a bow tie thatcan be reviewed periodically to determine areas of strengths and weaknesses. Figure 7 shows abow ties that was developed using the contents of CCPS Guidelines for RBPS for WorkforceInvolvement (Ref. /2/). The Hazard is based on the attitude of the employees (i.e., their perceptionthat their feedback does not matter and will not change safe work practices or safety culture). Thetop event is the result of the attitude which is “Lack of employee participation”, which is theopposite effect of what the management system element is aiming to achieve. The threats on theleft-hand side are based on a breakdown or lack of key principles needed to implement anEmployee Participation Program. These key principles are discussed in CCPS’s Guideline forRBPS (Ref. /2/). The preventive barriers are based on the possible work activities described foreach of the key principles. To prevent breakdown of the preventive barriers, the degradationmechanisms for each barrier should be identified and controlled (Ref. /2/).Figure 8 shows the degradation factors (i.e., Inconsistent Implementation) and degradationcontrols (i.e., Owner of Employee Participation Element) associated the preventive barrier of“Consistent implementation” to prevent “Lack of dependable work practice” (Ref. /2/). It is worth
noting that a bow tie like this can be created to assess the effectiveness of any company’smanagement system elements using the information in Guidelines for RBPS. In a workshopsetting, senior management and workers validate the existence of the barriers, assess theeffectiveness of those barriers, review selected metrics, and develop recommendations to improvethe existing Employee Participation program.Figure 7 Bow Ties for Employee Participation Management System Element (Ref. /2/)
Figure 8 Bow Tie for Employee Participation Management System Element (with focus onDependable Work Practice) (Ref. /2/)Various Applications of Bow Ties to Support OSHA PSM ElementsBowties can be used in other ways to engage employees in implementing the elements of amanagement system. This section shares some examples of how this can be accomplished.Employee ParticipationBow ties can be used to monitor the success of an existing program in engaging the workforce ata high level as well as monitor the success of workforce involvement within each ManagementSystem Element. An example of an element-specific bow tie for Process Hazards with focus onemployee participation is shown in Figure 10 (on the following page). Figure 10 shows thedegradation factors and degradation controls associated with the preventive barrier of “PHAactivities” and “Involvement of competent personnel” to prevent “Lack of dependable workpractice” (Ref. /2/).
Figure 9 Bow Tie for Employee Participation within Process Hazards Analysis Management System Element (Ref. /2/)
Figure 10 Bow Tie for Employee Participation within Process Hazards Analysis Management System Element (with focus onDependable Work Practice) (Ref. /2/)
Process Safety InformationEstablished Process Safety (PSI) and relevant standards employed are required for coveredprocesses in accordance with OSHA PSM 1910.119 (d). A bow tie can be an accountability toolfor PSI and compliance with relevant standards associated with barriers. This type of informationis referred to as barrier metadata in the joint publication by CCPS & Energy Institute on Bow Tiesin Risk Management: A Concept Book. If PSI for a barrier or degradation control is missing, abarrier can be considered as not in place during the bow tie workshop. Therefore, the bow tie couldbe considered incomplete until the PSI is verified or acquired. It should be noted that the bow tiewould be used as a mapping tool, not a repository for documents.Operating and Safe Work ProceduresThe employer must develop and implement written operating procedures, consistent with theprocess safety information, that provide clear instructions for safely conducting activitiesinvolved in each covered process in sections in accordance with OSHA PSM 1910.119 (f).OSHA PSM 1910.119 (k)) specifically focuses on the requirements for hot work. Proceduresmust be established to assure that there are no deficiencies in the barriers. The existing standardoperating procedures and safe work procedures and relevant sections of the procedures can bedocumented in the bowtie. This shows the connection of the procedural steps to the bow tie toenforce the criticality of the procedure and specific sections or steps in preventing or reducingthe likelihood of a major accident event. Procedures are shown as a degradation control. A pooror missing procedure can degrade a barrier. The use of bowtie for operating and safe workprocedure is illustrated in Figure 11. The degradation control “Neighbouring firefighting units inremote areas” references the “Bridging Document” as necessary for the barrier “Activefirefighting system” to be in place.Figure 11 Illustration of Bow Tie with Operating Barrier Degradation Controls
TrainingOSHA 1910.119 (g) states that the implementation of an effective training program is one of themost important steps that an employer ca
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