How do you handle and learn from process safety incidents and near misses during startup and shutdown?

1 Report and investigate

The first step is to report and investigate any process safety incident or near miss that occurs during startup and shutdown. Reporting is essential to communicate the event to the relevant stakeholders, such as management, regulators, workers, and contractors. It also helps to document the facts, causes, and impacts of the event for future reference. Investigating is important to identify the root causes and contributing factors of the event, such as human error, equipment failure, design flaw, or procedural deviation. It also helps to determine the corrective and preventive actions (CAPA) that need to be taken to address the gaps and weaknesses in the PSM system.

2 Implement and track

The second step is to implement and track the CAPA that are derived from the investigation. Implementing means to execute the actions in a timely and effective manner, such as repairing or replacing equipment, revising or updating procedures, training or retraining personnel, or modifying or enhancing controls. Tracking means to monitor and verify the progress and completion of the actions, as well as their effectiveness and sustainability. It also means to document and communicate the results and feedback of the implementation to the relevant stakeholders.

3 Learn and share

The third step is to learn and share the lessons and best practices from the process safety incident or near miss. Learning means to analyze and understand the event and its implications for the PSM system, such as the hazards, risks, controls, performance indicators, and improvement opportunities. It also means to apply and integrate the learning into the PSM policies, standards, and culture. Sharing means to disseminate and exchange the learning and best practices with other units, sites, or organizations that have similar or related processes. It also means to foster a culture of openness, collaboration, and continuous improvement in PSM.

4 Review and improve

The fourth step is to review and improve the PSM system based on the learning and feedback from the process safety incident or near miss. Reviewing means to evaluate and assess the effectiveness and efficiency of the PSM system, such as the management commitment, employee involvement, process knowledge, hazard analysis, operating procedures, training, mechanical integrity, management of change, emergency response, incident investigation, auditing, and compliance. It also means to identify and prioritize the areas and aspects that need improvement or enhancement. Improving means to plan and execute the improvement or enhancement projects or initiatives, such as adopting new technologies, tools, or methods, benchmarking with best practices, or engaging with external experts or partners.

5 Prepare and test

The fifth step is to prepare and test the PSM system for the next startup and shutdown. Preparing means to ensure that the PSM system is ready and aligned with the startup and shutdown objectives, plans, and schedules. It also means to check and confirm that the equipment, procedures, personnel, and controls are in place and functioning properly. Testing means to simulate and verify the startup and shutdown scenarios and conditions, such as the process variables, transitions, interlocks, alarms, and emergency situations. It also means to evaluate and validate the performance and reliability of the PSM system under different circumstances.

6 Monitor and adjust

The sixth step is to monitor and adjust the PSM system during the startup and shutdown. Monitoring means to measure and record the process parameters, events, and outcomes during the startup and shutdown. It also means to compare and contrast them with the expected or desired values, targets, or standards. Adjusting means to modify or adapt the PSM system in response to the actual or potential deviations, anomalies, or issues that arise during the startup and shutdown. It also means to communicate and coordinate the changes with the relevant stakeholders.

7 Here’s what else to consider

This is a space to share examples, stories, or insights that don’t fit into any of the previous sections. What else would you like to add?