PROCESS SAFETY PERFORMANCE INDICATORS A TOOL TO HELP SENIOR MANAGERS SHOW PROCESS SAFETY LEADERSHIP

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1 PROCESS SAFETY PERFORMANCE INDICATORS A TOOL TO HELP SENIOR MANAGERS SHOW PROCESS SAFETY LEADERSHIP Peter Webb Base Poyoefins UK Ltd, Carrington Site, Urmston, Manchester, M31 m31 4AJ E-mai: Peter.Webb@Base.com peter.webb@base.com As is the case with many major hazard companies, Base Poyoefins has achieved a significant reduction in work pace injuries over recent years. A key factor in achieving this has been the eadership and engagement of senior managers. They have been heped by having been abe to measure their successes and faiures by counting the number of injuries. Since 2003, Base has been deveoping a process safety performance indicator (PSPI) system which is intended to hep senior managers simiary engage in achieving improvements in process safety. Whie process safety incidents across the industry have not kied or injured as many peope as fas from height and moving vehice accidents, they often have far greater business consequences. This paper wi describe Base s eading and agging PSPI framework, and show how it is heping senior managers to get engaged in process safety. This is true not ony for managers of a technica but aso a non technica background. They now have a too which wi hep them show eadership in process safety. INTRODUCTION Lack of adequate process safety performance indicators (PSPIs) has been cited as a factor in a number of recent major accidents (Hopkins 2000, HSE 2003, US Chemica Safety and Hazard Investigation Board 2007). Against this background and interest from the reguators (HSE 2006), many companies invoved in major hazards are deveoping PSPI programmes. Base s PSPI corporate framework was pioted at the company s Carrington UK site over the period 2003 to 2006, and was adapted and impemented as a company wide initiative in Base makes poypropyene and poyethyene in 19 countries and has 6,800 empoyees. The framework comprises agging and eading indicators. A suite of agging indicators is anaogous to the different categories of injuries. These are standard across the whoe company, and are reported every month up through the ine. There was aready a mature incident reporting system in a sites in the company, and these incidents woud anyway have been recorded. But what is new is the headining of these narrowy defined incidents. This offers earning opportunities which have been derived from anaysing the information, to identify big picture concusions. The other part is eading indicators, and the decision was taken that it was not appropriate to try to seect a standards set for the whoe company. It was decided that it was 1

2 better for sites to choose their own. Whie this precudes the possibiity to benchmark, it aows the sites to focus on issues which are reevant to them, and aso increases buy in. Some successes have aso been achieved with eading indicators, athough somewhat ess tangibe. THE SWORD OF DAMOCLES Legend has it that Damoces was a young courtier in the court of Dionysius II of Syracuse. And he was a bit of a wag. One day he observed to Dionysius that the job of being king must be a pretty good one, with a the power and priviege. Dionysius responded that he coud give it a try if he iked. So Damoces was instaed in the throne, and Dionysius arranged for a sap up banquet with wine women and song. At the end of the evening, Dionysius asked Damoces what he had thought of his spe in charge, and Damoces tod him that he had had a great time. Dionysius then asked him what he had thought about the sword. He pointed to a arge sharp sword which was hanging above the throne by a singe thread of horse hair. Damoces swifty vacated the position. Dionysius expained that the sword was there as a reminder that the position carried responsibiities. Without it, it woud be too easy to get busy enjoying the trappings of power, and forget about the important stuff. Damoces had gained a better understanding of the roe, and was no onger envious of Dionysius. Injury statistics, PSPIs Senior Manager Junior Manager Figure 1. Managers engaged in a safety discussion (The Sword of Damoces, Richard Westa 1812, Ackand Art Museum) 2

3 THE HISTORY OF PROCESS SAFETY PERFORMANCE INDICATORS AT BASELL In the 1990s and eary 2000s the measuring and reporting of injury performance as a Tota Recordabe Rate (TRR) in our company had been an effective Sword of Damoces. It had heped to drive down injuries. Senior managers had payed a key roe in this. They were interested in safety, and TRR was a simpe, easiy understood too which they coud use to engage themseves. Senior managers had given site managers cear injury performance objectives, and site managers had found soutions appropriate to their own sites to achieve the desired objectives. TRR had a strong symboic vaue. What interests my boss fascinates me! Organisations need objectives. The greatest advantage of management by objectives is that it makes it possibe for a manager to contro his own performance (Drucker 1968). Defining what needs to be achieved rather than prescribing how it shoud be done, aows managers to appy a broader vision. This eads to stronger motivation and higher performance. In order for it to work, a manager needs to know not ony what his goas are. He aso needs to be abe to measure his performance and resuts against the goas. Managers need to be provided with cear measurements or metrics. According to Drucker, They do not need to be rigidy quantitative; nor do they need to be exact. But they have to be cear simpe and rationa. They have to be reevant and direct attention and efforts where they shoud go. They have to be reiabe at east to the point where their margin of error is acknowedged and understood. And they have to be, so to speak, sef announcing, understandabe without compicated interpretation or phiosophica discussion. Each manager shoud have the information he needs to measure his own performance and shoud receive it soon enough to make any changes necessary for the desired resuts. In other words, what gets measured gets done. Or as it has been said What interests my boss fascinates me. But the shortcomings of TRR started to become apparent. Despite a TRR trend which headed ever downwards, the company at sites around the word had nevertheess had fataities. Because of the profie which TRR was given, significant management time was spent on sometimes minor injuries. At the same time, senior managers seemed to be ess interested in osses of containment and fires. From the outset we reaised that it was essentia to think not ony about how and what to measure, but aso how the too coud be used by senior managers to drive improvements. Hopkins (2007) examined how BP at Texas City had been measuring but not managing process safety performance. In contrast, by tracking and headining the number of injuries, Texas City workpace safety had improved dramaticay. Managers remuneration, even though it was ony sma amounts of money, was affected by injury 3

4 performance in their area of contro. Injury statistics, ike Damoces Sword, had a powerfu symboic vaue which had strongy infuenced manager behaviour. So in 2003 at Carrington we set about designing a simpe too comprising eading and agging indicators, which we hoped woud achieve for process safety what TRR had done for workpace safety. We recognised that senior managers at the highest eve in our company were interested in safety, and we wanted to channe their interest towards process safety. We had in mind that if it worked at a site eve, it coud form the basis of a corporate impementation. There was nothing new about the concept of eading and agging indicators. OHSAS18001 (BSI 1999) for exampe taks about proactive and reactive indicators. We were trying to appy the concepts to process safety. SITE LAGGING INDICATORS We started by estabishing a suite of seven agging process safety indicators, which we defined in terms of consequence, Appendix 1. In arriving at our definitions we took account of those in RIDDOR for dangerous occurrences (HSE 1995), and a PSPI piot run in Scotand by the HSE and the SCIA (HSE/SCIA 2003). Additionay we adjusted and caibrated them to suit our own situation. We added a category for reeases of substances which coud have an impact on the environment. Note that we do not have a category for toxics, as this is not reevant for our business. To faciitate incident reporting and anaysis, the seven categories were set up in the site s computer based HSEQ management system QPuse. SITE LEADING INDICATORS In 2004 we moved on to deveop a system for eading indicators. We decided that we needed to define the framework in Tabe 1 for each indicator. Which risk contro systems to measure In panning our approach we strugged with items 1 and 2 in Tabe 1- how to decide which process safety issues to tacke. Of course we coud think of ots of things to measure, Tabe 1. Framework for eading PSPIs 1. Which risk contro system is weak and needs to be reinforced. 2. What specificay is the issue; what does the weakness reate to. 3. Definition of a metric. 4. How wi the data be coected, and who wi do it. 5. How wi the resuts be monitored, and corrective actions identified. 6. What target woud we aim for. 4

5 but we wanted to work with ony a handfu of indicators, five or six. We coud have ocked the management team in a smoke fied room unti they came up with the five. But we decided to use a team of peope who represented horizonta and vertica cross sections of the work force. We asked the team to brain storm around the question As you go about your work, what are the things which make you fee uncomfortabe about process safety. The team used a diagrammatic representation of our HSE management system as a guideword ist of risk contro systems, to prompt thought about which systems were weak. The ony constraint we put on the brainstorming was that, for a weakness to be added to the ist, the proposer had to give an exampe of how it had in his experience given rise to a risk. We got a ist of 14 items, and used a risk ranking too to prioritise them. Defining the metrics and measurement system We then ooked at trying to define a metric for each of the top five issues, and how we woud coect the data. From our investigations, we had decided that the metrics shoud have the attributes isted in Tabe 2. We were not abe to find a metric which met these criteria for every one of the top five issues. For exampe, the team had identified shift handover as a potentiay weak area, but we were not abe to find a suitabe metric. So we concuded that athough shift handover deserved attention, it woud have to be via a means other than as a eading PSPI. We picked another weakness to make up the ist of five. As an aside, in the meantime we have given further thought to how we coud measure shift handover. We have found some criteria which we coud use as the basis for periodic audits, but have some concerns about whether this wi be cost effective in terms of data coection; uness we can get the teams to audit themseves, somebody probaby from the HSEQ Department wi have to work unsociabe hours to do the audits! Monitoring In panning how we woud monitor the data we were mosty abe to use existing arrangements, e.g. the site HSE Committee, or the periodic inspection review meeting. But we Tabe 2. Desirabe attributes of eading PSPI metrics Support continua improvement Drive appropriate behaviour Emphasise achievements rather than faiures Be precise and accurate Be difficut to manipuate Be owned and accepted by the peope invoved in reated work activities and those using the metrics Be easiy understood Be cost-effective in terms of data coection 5

6 recognised it was important that peope with the power to make decisions were part of the monitoring process. The eading metrics we setted on and their associated framework are given in Appendix 2. CONCERNS PEOPLE RAISED Oh no! Not another report for management! A vaid concern, but we sought to impress on peope that it is not just about reporting, it is about creating a simpe too which managers can use to focus on and improve process safety. But a incidents aready get reported This is true, but the process safety incidents get buried, and we do not see the process safety big picture. We do see the big picture, because a process safety incidents get a fu investigation We caibrated the agging incident definitions so that we get about twenty incidents a year, on a site of about 150 peope and three pants. We have to be somewhat seective on which incidents to carry out a fu in depth root cause anaysis, and do not consider it a good use of resources to do twenty of those a year. We shoud take account of risk in deciding which incidents to count As mentioned in Tabe 2, good indicators are precise and accurate, difficut to manipuate, and easiy understood. Risk is none of these. We based our definitions on pure consequence, which means that a 49 kg reease of a fammabe materia in the open air woud not count as a PSPI, whie a 50 kg woud. This does not mean the 49 kg reease is unimportant, but you have to draw the ine somewhere. And if the 49 kg reease was of particuar interest, we woud anyway investigate it to get root causes and earnings. Perhaps a more fundamenta objection to using risk criteria is that recent work appears to indicate that high risk near misses are a poor predictor of actua incidents. The things which we perceive as high risk are apparenty not the things which cause the actua incidents. The Institute of Petroeum (2005) anaysed the causes of some 600 potentia and 800 actua major hazard incidents. The anaysis considered 31 causes. There were substantia differences in the frequency of causes of actua and potentia incidents. For exampe Leak from fanged joint or couping was the second most frequenty occurring potentia incident cause, but ony ranked seventh in the actua incidents. A PSPI programme which identified this cause for attention based on counting potentia incidents, might divert resources away from work which coud reduce the number of actua incidents. The iceberg theory tes us that our existing near miss reporting and behavioura programmes wi prevent major accidents 6

7 Groeneweg (2006) anaysed the Oi & Gas Producers Association safety performance indicators over the years 1997 to This represented 12.3 biion hours of data. He ooked for correations between companies for the different severities of injuries. He wanted to find out if the companies which had the highest fata accident rate (FAR) aso had the highest ost time injury frequency (LTIF). He found no correation. He aso ooked for correations between other indicators: tota recordabe injury frequency, and near misses. He found no (or hardy any) correation. His concusion is that the iceberg theory does not hod. He suggests that injuries which affect one or a few peope are reated to behaviour, but the injuries which resut in arge numbers of fataities are due to faiures in the primary processes. Put another way, if you want to prevent fataities, you need to target your safety programme on the things which cause fataities. Likewise for major accidents. Ketz (1993) previousy suggested that injury statistics have been over vaued by industry, and that we shoud measure the things we want to contro. THINGS WE HAVE LEARNED FROM THE SITE IMPLEMENTATION The need for a champion Somebody needs to be given the job of overseeing the programme. This is not compicated stuff, and many of the eements of it use existing systems. But it does need to be tended. Senior Management Invovement The Site Manager has found it easy to monitor the programme through the site s QPuse HSE MS software, and he has used this to raised the profie of process safety. Athough the HSEQ Department is the owner of the PSPI too, the Site Manager has picked it up and is using it. The Bottom Line. Does it work? Since we defined the agging indicators in 2003, we have recorded 80 process safety incidents. In the first year we noticed that we had had 10 fires. We had previousy been aware that we did have fires, but had not reaised just how many. These were a minor incidents, as were the other 70, but nevertheess it was mind focusing. Most of the fires were smoudering insuation, so we took some simpe steps to reduce the eaks, and to remove the insuation from around the eak points. In the second year we had amost eiminated the insuation fires. We have used the agging indicator data to focus on other areas. Leading Indicators are more difficut There is no question that this is the case. And some of the indicators we chose have not worked for us. The permit to work monitoring did not yied usefu information, because the audit too we were using was not sufficienty discerning. The process safety training 7

8 indicator faied because we had not got buy in from the peope required to coect the data. But we are now much better at communicating process safety information to shift technicians, are better at cosing out inspection findings, and have a better contro of our controed inspection programme. Whie the agging indicator programme is running exacty as it was set up in 2003, we have had to make more running adjustments to the eading indicators. GOING GLOBAL In 2006 it was decided to make the Carrington PSPI framework the basis for a corporate programme. We understood that for the programme to be a success, we needed to convince senior managers to pick up the too and start using it. This woud invove a change process. Prochaska s change mode identifies 6 stages: Pre-contempation, Contempation, Preparation, Action, Maintenance and Reapse. We assessed that the company was at the Preparation stage, so the emphasis of our change process was initiay on probem soving and estabishing support systems. In case some peope were sti at the Contempation stage, we promoted the expected positive outcomes. To hep with the marketing we branded the programme with a sateite navigation ogo, and the motto PSPIs. Navigating to HSE success. Figure 2. We made some adjustments to existing corporate guideines, and wrote a new guideine on PSPIs. For the agging indicators we used the Appendix 1 definitions. For the eading indicators, we had decided that there was no singe set which woud be appropriate across the company. Adopting a singe set woud have run the risk that sites be forced to coect data which was not usefu, diverting efforts from indicators which might be more usefu in their ocation. Aso we fet it important that sites buy into their own set of indicators. The PSPI guideine therefore concentrated on giving the sites a simpe methodoogy to foow to pick their own. The corporate PSPI programme was officiay impemented in Apri Each site was given two objectives: To coect and report to Corporate HSE the agging indicators every month; By the end of the year to have seected their own set of five eading indicators. Figure 2. PSPI ogo 8

9 Senior management interest at the corporate eve The company Chief Financia Officer visited the site before a decision had been taken to ro it out gobay. We took the opportunity to se the concept to him. Athough we suspect he is not an expert in process safety, he understands risk very we. He pubishes a monthy etter on the company intranet, and we were very peased to see the foowing words of support in his March 2007 etter, just before the aunch in Apri: Our good start to 2007 continued in February, both in terms of safety and financia resuts.... But as good as we are in persona safety which is a shared vaue throughout Base we know that we must aso maintain wordcass process safety performance.... Base s HSE team wi soon introduce Process Safety Performance Indicators (PSPIs) as a way to further improve our abiity to contro the risks associated with the processes and hazards in our pants. PSPIs wi hep us measure how we we have been controing process risks and, more importanty, they wi provide critica information we can anayze to determine what we have to do to improve. He had moved easiy from Prochaska s Preparation stage to the Action stage. Avoiding management by drives, or initiative overoad In the absence of the PSPI too, managers had itte ese avaiabe to them but to react to the atest incident. Managers then get ony an incompete picture, and steer the organisation in a direction which might not be hepfu We need more process safety training, or Our sites are not managing changes adequatey. This management by crisis or by drives can be counter productive (Drucker 1968). Things aways coapse back into the status quo ante three weeks after the drive is over. It puts emphasis on one aspect of safety, to the detriment of everything ese. In the words of Peter Drucker: Peope either negect their job to get on with the current drive, or sienty organise for coective sabotage of the drive to get their work done. In either event they become deaf to the cry of wof. And when the rea crisis comes, when a hands shoud drop everything and pitch in, they treat it as just another case of management-created hysteria. Management by drive, ike management by beows and meat axe, is a sure sign of confusion. STATUS OF THE GLOBAL IMPLEMENTATION Lagging indicators It is eary days, but from impementation in Apri unti September 2007, there had been 357 process safety incidents recorded. Of these 55 were fires (a minor), of which 27 were associated with the same type of equipment. Each one of these has been investigated ocay, but we are confident that we wi be abe to extract usefu big picture earnings from this information, share it around the company, and reduce the number of fires. 9

10 Leading indicators Many sites by now have chosen their eading indicators. Indicators reated to integrity inspection seem to be a popuar choice. Lack of an incident database We do not currenty have a company wide corporate incident recording system or database. This means we have to work a itte harder at the data coection and monthy reporting at the corporate eve, to make sure that senior managers have the right information; they need to be abe to understand what is going on on their patch, the sites which they are responsibe for. The company does have a knowedge exchange system where discussion topics can be posted and questions raised. This has been effective in sharing information about the PSPI system, and aso sharing experiences and information about process safety incidents. THE HSE GUIDANCE AND THE BAKER PANEL REPORT In 2006, the HSE pubished guidance on PSPIs (HSE 2006). Unfortunatey we did not have the benefit of it when we were deveoping our programme. It is an exceent document, and we woud ike to offer some comments. As mentioned above, in some cases, having chosen the weak risk contro system, we found it difficut to define a metric. We ike the suggestion in the guidance to ask What does success ook ike. On how to choose which risk contro systems to measure, we think the guidance coud give more hep management team in smoke fied room or workforce invovement? A significant difference between our two approaches is the HSE s recommendation to chose inked pairs of eading and agging indicators. This is with the intention of giving dua assurance. This is a good idea, but we wonder if it wi make the process of finding suitabe eading indicators more difficut, possiby too difficut for some. A set of disconnected but nevertheess individuay reevant agging and eading indicators might be good enough. In our experience, a major benefit of the PSPI programme has been that it has moved process safety in genera onto the radar of senior managers; maybe it does not matter too much if the indicators are not exacty correct. Hopkins (2007) examined the meaning of eading and agging indicators in the HSE guidance and Baker (2007), and found that the terms were not used consistenty. He identified three types of process safety indicator: A. Measures of routine safety reated activity, e.g. proportion of safety critica instruments tested on schedue. B. Measures of faiures discovered during routine safety activity, e.g. proportion of safety critica instruments which fai during testing. C. Measures of faiures reveaed by an unexpected incident, e.g. numbers of safety critica instruments which fai in use. 10

11 Indicators of type A are consistenty referred to as eading, and type C as agging, but categorisation of type B is inconsistent within both documents. However, he concuded that this was of itte consequence; it is more important to define indicators which are not ony reevant but which aso generate a statisticay usefu number of hits. WHERE NEXT? Do we want more or fewer incidents?! We think that for the agging indicators, at east initiay, we want to encourage the reporting. Of course we do not want to have more incidents, we ony want to have a better view on what incidents we are aready having! For that to happen, senior managers must hande the too with care; rather than a gun to the head of the site managers, it must be a vehice for an informed discussion about process safety. Benchmarking and setting targets An interesting question which is aready on the minds of senior managers is whether we shoud set corporate targets for the agging PSPIs anaogous to injury rates. For the time being, this woud seem unnecessary as we are getting the benefit just from the profie PSPIs have brought to process safety, and from the big picture earnings. But at some point we wi inevitaby need to define targets. An interesting question is what the denominator shoud be for the PSPI rate per pant, per ton of throughput, per ton of hazardous materia inventory, per man hour? For eading indicators we do not see a possibiity to benchmark, since every site has a different set. The ony objective is to have the system in pace and working. Nevertheess, this objective and the expectation that sites demonstrate how they are using eading indicators to drive improvements in process safety performance has a powerfu symboic vaue, ike the Sword of Damoces. Hopkins (2007) advocates reating senior manager remuneration to PSPIs, but comments that this works because it is symboic, affecting reputation and pride, rather than exercising any rea financia everage. Hopkins aso cautions against perverse outcomes, which are a consequence of the measure itsef being managed rather than safety. This author beieves this risk can be controed by ensuring that the PSPIs have the attributes isted in Tabe 2. Lagging indicator definitions We do not have a category for dust hazards, and these are reevant for our business. We are thinking about what woud be a suitabe definition. The Change Process The organisation is moving through the process of changing the safety focus towards process performance. We are moving through the Action stage of Prochaska s change mode; 11

12 strategies shoud therefore emphasise how this new too has put managers in a better position to contro process safety, what the benefits are for them, and that the norma short term fuctuations in persona safety performance wi not be bamed on efforts being diverted away. As we move through the maintenance stage we wi need to ensure that adequate support is given, and that interna rewards are reinforced. We shoud aso be prepared for reapses, for exampe a drop off in agging indicator reporting, and what we wi do about it. CONCLUSIONS There is no siver buet for HSE performance. PSPIs are just one of the required eements of a propery functioning management system. And we know that there are many areas where we have to improve. Before our PSPI programme was impemented, senior managers were aready interested in process safety. But it had not been as easy for them to engage themseves as it had been in persona safety, since they had no process safety Sword of Damoces. Now they have a too. Athough with hindsight we shoud not have been surprised, we have discovered that the PSPI programme is driving improvements not ony because of the usefu information it produces but aso, perhaps more importanty, because it is heping senior managers to demonstrate eadership. Consequenty we have concuded that whie choosing the right indicators is important, it is more important to design a programme which is easy for senior managers to use, produces reiabe data and which heps senior managers exercise their eadership accountabiities with regard to process safety. REFERENCES Baker J. (2007) The Report of the BP US Refineries Independent Safety Review Pane. Downoad from British Standards Institution (1999) BSI-OHSAS 18001Occupationa heath and safety management systems Specification. BSI, London. Drucker P.F. (1968) The Practice of Management, Pan Books, London. Groeneweg J. (2006), The future of behaviour management. Heath and Safety Cuture Management for the Oi and Gas Industry. Conference, Amsterdam, The Netherands. Heath and Safety Executive (1995) The Reporting of Injuries, Diseases and Dangerous Occurrences Reguations. HSE Books, Sudbury. Heath and Safety Executive (2003) BP Grangemouth Major Incident Investigation Report. Downoad from Heath and Safety Executive/Scottish Chemica Industries Association (HSE/SCIA) (2003). Piot project on vountary reporting of major hazard performance indicators: Process safety and compiance measures Guidance notes. Heath & Safety Executive (2006) Deveoping process safety performance indicators, A step by step guide for chemica and major hazard industries HSG254, HSE Books, Sudbury. 12

13 Hopkins A. (2000) Lessons from Longford, The Esso Gas Pant Exposion. CCH Austraia Ltd., Sydney. Hopkins A. (2007) Thinking about process safety indicators Human & organisationa factors in the oi, gas & chemica industries. Conference, Manchester. Institute of Petroeum, (2005) A framework for the use of key performance indicators of major hazards in petroeum refining. Energy Institute, London. Ketz T. (1993) Accident data the need for a new ook at the sort of data that are coected and anaysed. Safety Science 16, US Chemica Safety and Hazard Investigation Board (2007) Investigation Report Refinery Exposion and Fire, BP Texas City. Downoad from 13

14 Appendix 1. Company Wide Lagging Process Safety Performance Indicators Eectrica Short Circuit Eectrica short circuit or overoad which was either attended by fire or exposion or which resuted in the stoppage of a piece of process equipment. Exposion or fire An exposion or fire occurring in any pant or pace, where such exposion or fire was due to the ignition of process materias (incuding ubricating or heat transfer ois), their by-products (incuding waste) or finished products. Reease of fammabe materia inside a buiding The sudden, uncontroed reease inside a buiding of 3 kg or more of a fammabe iquid, 1 kg or more a fammabe iquid at or above its norma boiing point, or 1 kg or more of a fammabe gas. Reease of fammabe materia in the open air The sudden, uncontroed reease in the open air of 50 kg or more of any of a fammabe iquid, a fammabe iquid at or above its norma boiing point, or a fammabe gas. Reease of a substance which coud have an impact on the environment The sudden, uncontroed reease of 50 kg or more of a substance which coud have an impact on the environment. Safety Reated Protective System caed into operation Emergency depressurisation/faring, operation of pressure reief devices, breaking of bursting discs, operation of fina eement instrumented protective functions, quenching of exothermic reactions, crash cooing etc. which are instigated either automaticay or by operator intervention. This category is restricted to systems beyond warning devices. Excuded are protective systems designed soey to ensure the integrity of the process or product quaity where there is no safety or environmenta protective duty. Excuded are activations of these systems simpy due to instrument mafunction, uness the mafunction caused process conditions to deviate away from safe operation. Safety Reated Unpanned Shutdowns Occasions where a process or activity has to be shut down or hated because it woud be otherwise unsafe to continue. This covers emergency stoppage of an individua pant, either automaticay or by operator intervention, to prevent a oss of containment or other dangerous situation irrespective of the time invoved, or stoppage or suspension of a panned pant or process start up due to a faiure or mafunction of part of the pant or equipment, if unchecked, it had the potentia to give rise to an emergency. 14

15 15 Appendix 2. Carrington Site Leading Process Safety Performance Indicators HSEMS eement Issue Definition of metric System of measurement System of monitoring Target Inspection Inspection Communication, Safe operation Permit to work Training Inspection findings are not being cosed out Inspections are overdue Technicians are not receiving a reevant process safety information Lack of ongoing information on how we it is working Peope are overdue with important refresher or process safety reated training % of inspection recommendations progressed. % of controed inspections which are due and compete at the end of the month. Reported by department and site overa. % of Key Communications which are signed off by a of the intended recipients in 2 months. % of PTWs inspected during weeky pant safety waks which are found to be a satisfactory according to the check ist in Appendix 1 of CHSES.2 % of peope who have attended defined safety training by due date. Inspection findings are recorded in an Access database. Report generated quartery by Maintenance. Site Inspector generates a report from SAP at the end of the month. Dept mgrs choose Key Communications, and report in standard format. Operations managers to fi in tabe of resuts. Training Dept extract data from Training Records system, and report quartery. Quartery Inspection Meeting, chaired by Site Mgr. Quartery Inspection Meeting. Site HSE Counci, chaired by Site Mgr. Monthy departmenta HSE meeting, and monthy Site HSE Counci. Data monitored at quartery Site Training Steering Committee Meeting. Symposium Series NO. 154