Reporting of Process Safety Incident and Near Miss

A process incident indicates that prevention was ineffective i.e. controls are either not adequate and/or not effective, prompt changes need to be made. Therefore, every process incident and Near Miss must be reported, recorded, and thoroughly investigated to prevent recurrence.

Process Safety Incident

Reporting of Process Safety Incident and Near Miss

Process Safety Incident

An incident is reported as a process safety incident if it meets the following four criteria:

1. Chemical implication or chemical process.
2. Above the minimum reporting threshold.
3. Location
4. Acute release

 1. Chemical or Chemical Process Involvement:

• A chemical process those are directly involved in the damage caused.
• An incident without chemical or direct process involvement. E.g.: an office building fire, even if the office building is on a plant site, is not reportable.
• The purpose of this criterion is to identify incidents related to the safety of the process. E.g.: a fall from a ladder resulting in a lost workday injury is not reportable process incident. However, if the fall is due to a chemical release, the incident must be reported.

 2. Reporting Threshold:

A release of matter or energy from a chemical process, which results in one of the following three situations:

• An employee or contractor Lost Time Injury and/or Fatality, or hospital admission and/or fatality of a third party (non-employees/contractor);
• Fires or explosions resulting in greater than or equal to $25,000 of direct cost to the company; or
• Acute release of flammable or toxic chemicals from the main container (i.e., a container or pipe) greater than the chemical release thresholds.

 3.Location:

• An incident meets the location criteria if it occurs in the production, distribution, storage, utility services or pilot plants of a facility that indicates measures in accordance with these definitions.
• This includes tank farms, ancillary support areas and distribution piping under control of the site.

This applies both to incidents that may occur in the contractor's work areas and to other incidents.

4. Acute Release:

•  A "one hour" rule is applied to report under this measure, which means that the release of material reaches or exceeds the reporting threshold within 1 hour or less.
• If a release does not exceed the TQ level over any 1- hour period, it would not be treated as a Process Safety Incident.

Note: If the duration of the release cannot be determined, the duration should be assumed to be 1 hour.

Process Near Miss

Examples of Process Safety Near Misses:

Process Safety Near Miss

1. Near Misses involving Safety Relief Devices or Safety Instrumented System:

• Opening of a rupture disk, a torch pressure control valve or atmospheric discharge or a pressure relief valve when the predetermined trigger point is reached.
• Failure to open of a Rupture Disk, a Pressure Control Valve to flare or atmospheric release, or a Pressure Safety Valve when the system conditions reach or exceed the prescribed trigger point.
• Activation of a Safety Instrumented System when "out of acceptable range" process variable is detected. For Example: (1) activation of high-pressure interlock on polyethylene reactor to kill reaction/shut off feed; (2) compressor shutdown from a high-level interlock on the suction knockout drum.
• Any time a safety instrumented system fails to operate as designed when a demand is placed on the system (1.e. unavailability on demand).

2. Near misses involving a process deviation or excursion include:

• Excursion of parameters such as pressure, temperature, flow outside the work window but within the design limits.
• Excursion of the process parameters beyond the pre-established critical control points or those for which an emergency stop or intervention has been indicated.
• Use outside the device design parameters.
• Unusual or unexpected uncontrolled response, regardless of whether it meets the design parameters.

3. Near misses associated with Management System failures/issues:

• These types of observations should be captured to understand where there are opportunities for improving a facility's Process Safety Management Systems.

 4. Discovery of a failed safety system upon testing:

• Backup devices that do not pass bank tests at established points.
• Interlock test failures.
• Uninterruptible power supply system malfunctions.
• It has been discovered that fire, gas and toxic gas detectors are defective during routine inspections / tests.
• During inspection of an emergency vent line header, the header was found to be completely blocked with iron scale because moisture from the emergency scrubber had migrated back into the header.
• During testing of an Emergency Shutdown System, a Teflon-lined Emergency Shutdown Valve was stuck open because the Teflon had cold flowed and jammed the valve.
• During inspection of a conservation vent, it was found that the vent was blocked by process material that had condensed and frozen.

5. Discovery of a defeated safety system:

• Process upset with interlock in bypass condition,
• Critical reports of instruments / devices do not agree with the defeat procedure.
• Bypasses left ON after leaving Main Block Valve in normal position.
• You cannot delete line break on critical lines.
• During replacement of a Rupture Disk, the disk was found with the shipping cover still in place
• The process control engineer accidentally downloaded the incorrect configuration to a DCS process unit.

6. Unexpected/Unplanned Equipment Condition:

• Equipment discovered in an "unexpected" state due to damage or premature / unexpected deterioration.
• Incorrect accessories used in the steam system.
• Equipment failure such as heat exchanger tubes that cause contamination of liquids.

7. Physical Damage to Containment Envelope:

• Falling of loads / falling objects within reach of the treatment equipment.
• Truck backed into wellhead
• Snowplow grazed gas line

Conclusion

Process incident or near miss indicates the failure of management system. All these incidents and near misses must be investigated to find out the root causes and accordingly corrective actions should be taken to prevent recurrences.

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