Capacity Development Programme
in
Industrial Disaster Risk Management
Crisis Management:
Avoiding and Mitigating Major Accidents
Prof. Dr. Christian Jochum
India, February 2009
©Prof. Jochum
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Professional Profile Christian Jochum
• Born 1943 in Frankfurt a.M./Germany
• PhD in Chemistry, certified Safety Engineer
• Honorary Professor at Frankfurt University
• 28 years experience in large chemical/pharmaceutical company (Hoechst
AG)
– 1969 – 1979 Pharmaceutical research and pilot plant operations
– 1979 – 1997 Safety department (Site and Corporate Safety Director and „Major
Accident Officer“ since 1987)
• EHS – and crisis management consulting for different types of
businesses and administration since 1997
• Commission on Process Safety (formerly Major Hazard Commission) at
the German Federal Minister for the Environment (Chairman since 1998)
• European Process Safety Centre (Rugby/UK): Director of Centre since
2007
©Prof. Jochum
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European Process Safety Centre (EPSC) www.epsc.org
Network funded by 40+ mainly European based (petro)chemical
multinationals to develop best practice in major accident/process safety
Objectives:
•
Information/know how exchange
•
Legislation (esp. Seveso II & ATEX)
•
participation & co-ordination of EU funded projects
Outputs:
•
Internal reports & books
•
User groups & public conferences
•
EU projects & working groups
Major topics 2008/09:
•
Process Safety Indicators/Learning from Accidents
•
Safety Critical Equipment
•
Fostering Senior Management Involvement in Process Safety (with EFCE)
•
LOPA Experience & Development
©Prof. Jochum
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Commission on Process Safety (Kommission fuer Anlagensicherheit [KAS])
Mandated by the Federal Emission Control Act
•
Advises government as well as plant operators and state and local authorities on
process safety
•
32 members with different professional and educational background representing
different stakeholders (“Round Table”)
•
Any group needs “allies” to win votes
•
Consensus intended, but majority decisions possible
About 55 guidelines issued on different topics, e.g.
•
Land Use Planning (Safety distances)
•
Risk evaluation and perception
•
Emergency Planning
•
Industrial parks
•
Provisions against terrorist attacks on chemical plants
All publications of the Commission are available (partly in English) at
www.kas-bmu.de
©Prof. Jochum
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Outline
1
Case Study: Hoechst Incidents 1992
2
Lessons Learnt
3
Improving Existing Plants
4
Conclusions
©Prof. Jochum
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Case Study: Hoechst Incidents 1993
1
In 1993 three major incidents occurred at 2 Hoechst sites near
Frankfurt/Germany within 6 weeks
• Feb. 22
Runaway reaction after an unnoticed stirrer failure. Emission of 10 tons
methanol containing a possibly carcinogenic substance,
contaminating a large residential area
• March 15
Explosion of methanol – air – mixture during maintenance in a process
plant. 1 worker killed, 1 seriously burnt
• April 2
Major sulphur trioxide emission in a process plant
The series of incidents caused a lot of public concern and nationwide
media coverage.
©Prof. Jochum
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Hoechst Incidents: Severe Consequences
1
Although the Feb. 22 emission did not cause serious injuries, it led to
the most serious consequences for the company and the most “lessons
learnt”:
• Prevention would have been possible by a thorough risk analysis leading
to a simple safety device (stirrer control acting on charging valve)
• Confidence in the company´s competence in emergency response was
torn down by
– Gross underestimation of the affected area
– Incomplete knowledge of the hazardous properties of the emitted
substance
– Inadequate wording in the first press conference
• Aggravation of adverse reactions by neighbours, media and authorities
by arrogant behaviour of site representatives long before the incident
©Prof. Jochum
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Outline
1
Case Study: Hoechst Incidents 1992
2
Lessons Learnt
3
Improving Existing Plants
4
Conclusions
©Prof. Jochum
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Hoechst Incidents: Lessons Learnt
2
Crisis management assessment should cover all parts of emergencyand crisis- management ...
• identify hazards comprehensively
• avoid or control risks
• communicate remaining risks
• mitigate consequences
• remediate damages
• restore trust
... pursuing the goal to define and train as much as possible in
advance
©Prof. Jochum
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Hazards
2
Hazards have to be identified systematically ...
Operation
hazards
•
eg. „classical“ EHS-hazards, loss of production, ...
Network
hazards
•
eg. failure of utilities, supplies, transportation ...
Environmental
hazards
•
eg. natural hazards, adjacent plants and traffic ways, ...
Environmental
vulnerability
•
eg. densely populated areas/buildings, natural reserves, ...
Terrorist threats
•
eg. plant vulnerability, neighbourhood/environment sensitivity,
company image, ...
... and transposed into scenarios.
©Prof. Jochum
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Prevention
2
Avoid or control risks
Assess
procedures
•
Minimise hazards ( “Inherent Safety”)
Define
safety measures
•
Engineering/organisation/human factor/“Security”
update necessary?
Assess
safety measures
•
eg. Audit programs
“Prevention is the best remedy”
©Prof. Jochum
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Risk Communication
2
Communicate remaining risks
•
Internal
External
•
eg. training, drills
Towards customers, neighbours, authorities – but careful
regarding security risks!
“who always claims `zero risk´, has no credibility in his ability
to control risks!”
©Prof. Jochum
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Mitigation
2
Mitigate consequences
•
Internal emergency planning (above all organisation, equipment, drills)
• Cooperation with external services (neighbouring plants, public
services)
Important: ability to react fast!
The bigger a corporation,
the higher the expectations even for small sites
©Prof. Jochum
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Claim management
2
Remediate damages
• ... do not handle damages as insurance cases only
• ... fears may not be justified, but are always real
• ... be prepared for problems of competency and competition (internal
and external)
• ... identify “free-riders”
“well treated wounds heal better”
©Prof. Jochum
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Confidence Management
2
Restore trust
• ... prepare the fundament before the crisis
• ... communicate open and clear (possible conflict regarding terrorist
threats!)
• ... do not downplay fears
• ... give the company one face
You may lose trust in hours. Restoring trust needs years
©Prof. Jochum
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Crisis Management Systems: can the unpredictable be planned?
2
Define as much as possible in advance, because ...
• ... crisis always happen at the wrong time and place
• ... your regular organisation is not sufficient to handle crisis
• ... all resources of the whole company have to be available in due time
• ... public, media and authorities expect professional handling of crisis,
too
Will the crisis management system be adapted
to today´s frequent organisational changes?
©Prof. Jochum
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Drills
2
Major incidents hopefully become less frequent. This makes drills even
more important ...
• ... to train seldom used procedures
• ... to reduce mental stress during incidents
• ... to optimise emergency- and crisis- management
• ... to make sure that necessary resources are available
The gap between resource consuming “full drills” should be filled
with frequent “smaller” drills.
©Prof. Jochum
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Outline
1
Case Study: Hoechst Incidents 1992
2
Lessons Learnt
3
Improving Existing Plants
4
Conclusions
©Prof. Jochum
Seite 18
Plant & Process Safety: improvement of existing (“old”) plants
3
Make best use of limited resources by a stepwise approach:
1. Have full knowledge about hazardous properties of all substances (e.g.
Material Safety Data Sheets, data bases, etc.)
2. Identify and rank critical points (human- and eco – toxicity, hold-up of
hazardous substances, reaction conditions, mechanical and physical
hazards)
3. Document this in a safety study as a tool for use by the plant and by
authorities
4. Focus improvements (manpower, money, additional safeguards etc.) and
inspections on the most critical points
5. The higher the risk, the more independent safeguards (“barriers”) should
be considered
6. Use the scenarios developed under (2) for emergency planning
©Prof. Jochum
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“Swiss Cheese Model” (after J. Reason, modified by Mike Broadribb, BP)
Lagging Indicator
Leading Indicator
©Prof. Jochum
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Plant & Process Safety: Use existing knowledge
3
Most accidents and eco – incidents have a previous history ...
• Preliminary events leading up to the accidents (failure of preliminary
safeguards) have not been identified
• Prior to most major accidents similar smaller incidents or near misses
have happened, but not evaluated
... which should be used for prevention
• Raise the awareness of the workers
• Use the experience of workers
– Encourage reporting of deviations, near misses and even minor
incidents as well as suggestions for improvements. Consider
contests and awards for groups working together
– Have a system for following up such reports/suggestions
©Prof. Jochum
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Plant & Process Safety: The Human Factor
3
Workers are risks and resources for safety
• They have to know the risks to cope with
• Detailed written procedures are a tool both for workers and for
management. They should ...
– describe the procedure as it is in the plant step by step
– use a language and expressions which are understood by the
workers (no scientific or technical paper)
– highlight hazards, safety measures and critical process parameters
(temperature, pressure, ...)
– make independent double checks mandatory for critical parameters
and procedures
– include start-up, shut-down, maintenance and process-specific
information for emergencies
• Use other procedures (e.g. Quality) for safety purposes, too
• Include normal and abnormal situations in training
©Prof. Jochum
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Safety Operating Procedures
3
Examples for visualization of safety information
Acetone
Ladders
©Prof. Jochum
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Emergency Preparedness
3
Accidents may happen even in most modern plants. They cannot be
planned, but they should be considered.
• Use the scenarios identified for prevention of major incidents for
emergency planning and training, too
• Cover all relevant scenarios in the emergency plan
• Assign responsibilities rather than regulating details
• The emergency organisation is different from the normal organisation,
but has to be empowered to use it
• Adjust the emergency organisation to the dimension of the incident (e.g.
“blue, yellow, red alert”)
• Clearly document all available resources (site, company, neighbouring
sites, authorities, ...) for the different scenarios. Ensure that they can be
used in emergencies (e.g. co-operative agreements)
• Before you rely on off-site resources, consider the time until availability
• Industrial zones with many companies close together need special
attention (“domino-effects”)
©Prof. Jochum
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Emergency Response
3
The basic principle: the faster and more effective the initial response,
the smaller the consequences for men, environment and economy.
• Provide the infrastructure for fast response (fire brigade, emergency
control room, notification and availability of key personnel, etc.)
• Encourage immediate reporting of incidents (not to wait until own efforts
failed ...), do not blame for false alarms
• Site fire brigades (or shared with adjacent sites) usually are faster and
more efficient than municipal brigades, which rather serve as a back-up
• If the fire brigade is (partly) staffed by operators be aware of the risks of
understaffed production
• Better start with a higher level of alarm (worst case assumption) and
grade it down later than vice versa
• Notify and involve public fire brigades and authorities as soon as
possible
• Analyse every incident and the response without blaming anyone to
improve the emergency organisation
©Prof. Jochum
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The Role of Authorities
3
The cooperation between authorities and companies at an incident
depends on their cooperation before the incident.
• Open communication about risks and safety measures on a regular basis
(e.g. in a local or regional committee) builds up trust which is urgently
needed during emergency response
• Authorities need to know about the possible scenarios for major
accidents to do their own preparations
• Authorities should have clear rules about their responsibilities in
handling major incidents to avoid conflicts between the different
agencies (e.g. labour safety, environment, civil protection, police etc.)
• Mitigation of consequences should come first, legal prosecution of
individuals responsible for the incident later
©Prof. Jochum
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Neighbours, Journalists and Environmentalists
3
The basic issue: Neighbours and the general public share the risks of
industrial sites, but not necessarily the benefits.
• Communication of relevant risks has to be done openly and in an
adequate form (“not scientific”) prior to incidents (e.g. “neighbourhood
councils”, brochures, ...)
– to build up trust in the competence of the company to handle risks
– to enable the neighbours to react adequately during an incident
• The response of neighbours etc. to incidents is strongly influenced by
the company´s response to requests and complaints prior to the incident
• Fast and open information after an incident is crucial
• Fears and worries of neighbours etc. have to be taken seriously even if
they are based on emotions rather than science
• On the long term, conflicts with neighbours etc. endangers the “licence
to operate”
• Committees with all stakeholders as the German Commission on Process
Safety are an effective tool for cooperation and communication.
©Prof. Jochum
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Outline
1
Case Study: Hoechst Incidents 1992
2
Lessons Learnt
3
Improving Existing Plants
4
Conclusions
©Prof. Jochum
Seite 28
Conclusions
4
• Investing in safe and eco-efficient plants pays off at least on the long
term
• The (remaining) risks of industrial plants can be assessed and are the
basis for scenarios for emergency planning
• The knowledge and experience of the operators should be used by all
means
• Risks should be communicated as well as benefits to all stakeholders,
esp. the neighbours
• The resources for emergency response (manpower, equipment,
communications, organisation etc) have to be planned in advance and
readily available in case of an incident. People usually accept the risk of a
chemical/pharmaceutical plant, but not incompetence in handling it
• Authorities should involve themselves actively in emergency planning,
balancing this out with their law enforcement duties
• Combined efforts will definitely lead to safer and more accepted plants,
as the figures from Germany may show
©Prof. Jochum
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Development of Accidents in Germany since 1950
4
120
109,18
100
80
98,65
83,12
Arbeitsunfälle
60
Wegeunfälle
54,51
„Arbeitsunfälle“ =
occupational accidents
40
34,9
20
21,13
18,08
20,45
13,92
8,96
8,16
5,85
5,42
„Wegeunfälle“ = acc. on
the way to work
5,37
16,79
15,78
14,93
5,31
5,01
4,96
0
1950
1960
1970
1980
1990
2000
2001
©Prof. Jochum
2003
2004
2005
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Thank you for your attention!
©Prof. Jochum
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Plant & Process Safety and Emergency Preparedness