www.csb.gov

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EvolvingSafetyThoughts

MaryBethMulcahy,PhDChemicalIncidentInves0gator

U.S.ChemicalSafety&HazardInves>ga>onBoard

SafetybyDesignApril2016

ChemicalSafetyBoard(CSB)•  Independent Federal Agency

•  Non-regulatory

Mission

To prevent chemical accidents

•  Conduc=ng root cause inves=ga=ons

•  Repor=ng findings publicly

• Making recommenda=ons to organiza=ons and agencies that can affect change •  Companies •  Government Agencies (local, state and federal) •  Standard seJng, i.e. American Petroleum Ins=tute (API)

TTU…

BarriersPreventorMiFgateMajorAccidents

Technical/Physical(equipment&

engineeredcontrols)

OrganizaFonal(policies&procedures)

OperaFonal(humanacFon)

ManagementFailures

SafetyCulture

APIRecommendedPrac>ce,754,1sted.,ProcessSafetyPerformanceIndicatorsfortheRefiningandPetrochemicalIndustries,April2010,pp8

ProcessSafetyIndicatorPyramid

MeasuringSafetyCulture

Accident

PoorCommitment GoodCommitment

GoodSafetyPoliciesandProcedures

PoorPoliciesandProcedures

SafetyCulture

GoodCommitment

GoodSafetyPoliciesandProcedures

SafetyCulture

Accident

TheHeartofSafetyCuture?

LossofControl

TheHeartofSafetyCulture

Top Event LossofControl

Hazard/TopEvent

Hazard •  Health Hazard

(carcinogen, toxin, etc.)

•  Physical Hazard (flammable, explosive, etc.)

Whendoyouhavetochangeyourresponse? •  Threshold amount

•  Loss of containment

•  Loss of u=li=es

Barriers

MajorAccident

Top Event LossofControl

Barriers

Alarms

PreventaFveMaintenance

Back-upSystems

PPE

EvacuaFon

AutomaFcShutdownSystem

PreventaFve MiFgaFve

MajorAccident

Top Event LossofControl

ManagementSystems

PreventaFveBarriers

MiFgaFveBarriers

•  Hazard Iden=fica=on

•  Procedures

•  Incident Inves=ga=ons

•  Indicators

Top Event LossofControl

TTUExample

LossofControl

BacktoCulture…