Good morning and thank you for the invitation to give this keynote opening address, at the Mary Kay O’Connor Process Safety Center symposium. It is a great honour for me to be here and to be asked to deliver the Frank Lees Memorial lecture at your 16th symposium. I speak today as the Chair of Great Britain’s Health and Safety Executive (HSE) and President of the Institution of Chemical Engineers (IChemE). Both roles enable me to speak with passion about a subject I really care about – Process Safety. I never had the privilege of meeting Frank Lees although we were both alumni of Imperial College in London. Nonetheless, his outstanding work throughout his career on Process safety along with that of Trevor Kletz has had a major impact on my thinking – and indeed on my actions - particularly during the 20+ years that I worked directly in the major hazards industries. I feel particularly privileged today to be among so many people who share a common interest in the vitally important subject of Process Safety. But I believe that it is part of my role here today to provoke you into thinking afresh about the subject.
I left the UK almost four weeks ago and I have travelled here via Australia and Hawaii. I have not seen much UK press coverage for some time now, but one thing I can guarantee is that some newspaper somewhere in the UK will today be carrying a story which will be all about mocking health and safety. Misrepresenting those who care about saving people’s lives and preventing catastrophes, and presenting them as the ‘killjoys’ who stand in the way of people living their lives and enjoying themselves.
If your only source of information was the UK’s tabloid press you would see health and safety as a nuisance - banning children going on school trips, refusing to provide proper service to customers in restaurants, hardware stores, drive thrus and many other places. The list of trivia banned in the name of health and safety is endless, and is indeed a far cry from why all of us are here for this symposium.
You may wonder why I mention this at all given what we are all here to discuss. The reason is this; the press in the UK haven’t invented these myths about health and safety or decided for themselves that it is health and safety which stops these things happening. The stories arise because in each and every case someone in the company or organisation involved has told a customer, a client or even in some cases their own employees that these trivial matters are about health and safety.
Please don’t dismiss this notion as something that happens in other places, but not where you work. This isn’t just a quirky problem for us Brits. What I am describing here is one part of a complex puzzle and array of issues which fall under some people’s definition of the health and safety umbrella. I would like every one of you to stop and think about some of the rules that you might have in place in your workplace which relate to personnel safety and ask yourself how important they really are. Do you insist that people put lids on their coffee cups if they walk around? Are hot drinks banned on stairs and in elevators? Is everyone in your workplace issued with hi-viz gear and expected to wear it? If so, how do those who really need to, stand out from everyone else?
It is easy to see how some of these rules come about. Someone reports a near miss with a coffee spillage on the stairs. The investigation must come up with a recommendation, right? So lids on cups become mandatory and drinks are banned on stairs. It’s easier to have site wide rules about the wearing of protective equipment than to target action at those who are really most at risk, but in doing so – does this lead to unintended consequences or thwart the original intention – like making the key people stand out in their high viz?
I am very familiar with the arguments for some of these rules. It’s about creating the right safety culture throughout the organisation. But that will only be the case if the important stuff is given the right level of attention and the issues are addressed as well as dealing with the many low risk activities which are easy to make rules for.
Some hazards are easy to spot on site walkabouts. However, identifying some of the real concerns – the process safety concerns - requires knowledge and understanding of the process, of analytical techniques and methodologies and of human behaviour. It means knowing the right questions to ask, not just having an observant pair of eyes. The solutions to some of these less important issues are quick and simple – they don’t require plants to shutdown to fix, they are also cheap to fix. Process safety issues can involve plant downtime and high cost to put right. Not as much as the cost of failure of course, but more on that later.
I hope that some of you will recognise a few of these patterns of behaviour which I’ve just described which have been present in some organisations around the world where recent incidents have occurred in major hazard facilities. So, while I am delighted to see the agenda that you have for the next three days which will delve into many detailed aspects of process safety, it is also important that we take time to understand why this subject is not yet on the agenda of many of your senior managers. In some cases it may have been there once but it has been allowed to slip off and been replaced by the easier to do stuff.
Process safety, the need for it and the leadership of it must be properly understood at every level in the organisation – not just among a few dedicated process safety professionals. Whilst there is undoubtedly a great deal of debate taking place about process safety at the present time I need to be convinced that everyone who needs to, understands the part that they must play. The number of serious incidents which continue to occur around the world, often traced back to very similar causes of other incidents which have happened previously elsewhere, are a strong indicator that however much some of us may care about this important subject, we are still not getting it right.
The last time I gave a presentation to an international audience on the subject of process safety was in Kuala Lumpur in April of this year some of you in the audience today, I know were there. Only two days after I spoke the massive explosion occurred in West, here in Texas. While we must await the findings of the investigation to understand the detail of what happened in that incident, there is no doubt that the hazards of ammonium nitrate and its potential to cause major catastrophic incidents are well known – because they have happened before. Here in the US and elsewhere around the world.
So, if we know the hazards, and the potential consequences because it’s been seen somewhere else before, how is it that Process Safety can be overlooked and sidelined in favour of much smaller hazards in many organisations? It would be wrong to suggest that this is simply a case of people choosing to do the easy stuff.
Following most major incidents there is a strong desire to learn about what happened, but this is often coupled with an underlying need to find a particular quirk/practice which existed in that organisation which makes it different from your own – and therefore enables a quick and often fallacious conclusion that what happened there, “couldn’t happen here”.
Organisational culture often drives the need for problems to be solved or fixed. Ongoing challenges don’t translate well into objectives achieved and measured in performance terms. But process safety is not and never will be a quick fix – it is a state of mind and a continuous commitment. New systems, new procedures will only work for the long term if they are properly engineered, well communicated, understood by everyone, properly maintained - and monitored by senior management. Organisational culture is defined by the tone of the questions that are asked from the top. A leader who constantly seeks reassurance and doesn’t welcome bad news will get told everything is ok even when it isn’t. The leader who asks to understand what the process’s greatest vulnerabilities are and how they need to be addressed will create a very different climate in their organisation.
Changes which bring obvious benefits and improvements in some respects, can create other potential problems. Many of you will talk about new techniques and technologies which are helping to improve process safety. Noone would argue that remote operation of major hazard plant from control rooms via complex computer controlled systems is safer for operating staff and leads to smoother operating conditions – but how well do we understand the potential negative impacts of this remote operation? When we drive our cars we all use our eyes and ears to monitor much more than the dials on the dashboard in front of us. We listen to the sounds of the car and know when we hear a new noise that wasn’t there before; we see what’s going on outside of the car – traffic conditions, weather, other drivers to look out for, pedestrians, other hazards. But in a control room behind a computer screen – how much feel do operators maintain for the nature of the process they are running, how alert are they to the hazards they are monitoring and controlling, if you’ve grown up in a generation who play computer games – how much does it feel like being in another “virtual world”?
Activity and concern about process safety is always greatest in the immediate aftermath of an incident. But history clearly shows that memory fades with time. Even when lessons learned are passed on – and let’s be honest, that doesn’t always happen – the passage of time leads to memory fade because people change and move on, the real details of the causes and of important factors like design intentions and limitations get forgotten or lost.
So, how do we address the challenges of process safety and in particular the leadership challenge?
We have to move away from process safety being seen as a specialist subject – the preserve of the technical engineering community. We need to change the mindset at the very top of organisations, starting with the Boardrooms. Unless we do this, major incidents will continue to happen around the world which will cause substantial levels of casualties to employees and members of the public, major environmental damage, loss of assets and the ability to produce. Boards who do not focus on process safety have a very serious gap in their Corporate Risk register and are potentially taking a gamble with the survival of their business, possibly without even realising it.
It is also the case that damage is contagious and does not have to occur in your own business to have an impact. The reputation of whole industry sectors rest upon the performance of the weakest link. In some sectors at least there is already a recognition of this. Within the Chemicals sector Responsible Care which started in Canada in the 1980s has spread around the globe. At the heart of Responsible Care is a desire to raise the bar in safety and environmental performance across the whole sector and to build public trust and confidence in the industry as a whole. Sadly, in many countries, Responsible Care is not as strong on Process safety as it is on personnel safety and product stewardship – but this hasto change if Responsible Care is really going to build trust and confidence in the industry.
All high hazard industries have to make a commitment to leadership in process safety. Society is becoming less and less tolerant of mistakes. The public and in particular your neighbours wherever you operate tend to have a longer memory than your own corporate memory. Their intolerance is exacerbated when it falls to communities or Governments to pick up and carry the on-going costs of clean up, economic damage and caring for those who have been hurt and damaged by events which they know could have been prevented.
Is there a role for regulation in process safety? The simple answer is yes, of course, there is. Regulation does lead to behaviour change. It is an effective way of setting minimum standards of what is required. Many countries already do have specific regulation for major hazard sites on and off shore. In the UK, as many of you will be aware, our approach is built upon the safety case approach – which places responsibility for identification and management of the hazards with the dutyholder; and requires that the dutyholder makes the case to the regulator to demonstrate that the hazards can be properly and effectively managed. We believe that this approach has significant advantages versus an approach where the regulator sets the rules and operators then measure themselves on compliance. But that said, it is still important for regulators to talk and share ideas even if their approaches are different.
One of the problems with any regulatory approach is that it can be a blunt instrument. Everyone in the sector will be impacted by the requirements even if they are already doing the right thing. It is difficult to take account of the many differences which exist between different processes without being overly prescriptive. More importantly, regulation can lead to industry especially at senior management levels, seeing process safety management as an externally imposed cost rather than a very necessary and integral activity which is fundamental to operating in the major hazards sector.
After the break this morning, one of the tracks will hear more from one of my UK colleague’s, Lawrence Cusco, about lessons learned from Buncefield. But I want to use Buncefield to show how and alternative approach to regulation can work. Following the explosion in the UK in 2005, the Board of Inquiry pressed for stronger regulation to address the failings which needed to be applied across the whole fuel storage sector. But, as an alternative to regulation, HSE worked with the industry to increase ownership and understanding of process safety risks at senior manager level. We embarked on a Process safety Leadership Programme aimed at Board and Senior executive level. This led to the enthusiastic adoption of a set of Principles of Process safety leadership by industry in the UK. This was seen as a strong starting point to an alternative approach to the introduction of tougher legislation. But I emphasise that it is a start and not yet fully sufficient.
A number of companies in the UK are now training senior executives and Board members in Process safety Management – helping them to understand the nature of the risks and the right questions to ask. We still have a long way to go however. Although we are pleased to see progress, it is too slow and it has taken too many incidents and far too little sharing of learning and good practice to get to where we are today.
We are not yet at the point where process safety is part of the DNA of running major hazards businesses in the way that, in many, personal safety is.
I am very grateful to Steve Arendt for letting me use my version of his slide which he presented in the UK some two years ago to illustrate the difference between the approach to Process safety and personal safety.
Consider the effort which has gone into developing a structure pyramid of measures for personal safety. It will be clear to you all that most people have moved away from relying on the actual occurrence of injuries and fatalities to indicate where we have personal safety issues. For more that 20 years now the UK trade body for the chemical industry has been collecting and reporting personal safety performance data from all of its members on personal safety.
But we need to see a similar approach being taken in relation to process safety performance. What gets reported to the regulator should be the tip of the iceberg. Below the waterline there should be active monitoring and reporting within every organisation and between companies. That monitoring and reporting needs to be structured and comprehensive. It needs leading indicators of performance, the signs that tell us that things are not as they should be, not just lagging indicators that tell us how many failures have actually occurred. Sharing and learning on process safety also needs to be truly global.
I would like to see much greater levels of cooperation between industry organisations, professional bodies such as AIChemE and IChemE and their respective Process Safety Centres, along with the good work which already goes on here at Mary Kay O’Connor Process Safety Centre. To me it is unfortunate that some of these organisations sometimes choose to compete rather than collaborate on a subject which is so important to us all.
I mentioned earlier some of the challenges of getting senior managers to see Process Safety as an investment in production assurance and business survival. So for those of you here today who are Process Safety specialists, a couple of the key questions are:
Beware of the dangers of offering reassurance when it is sought or even of providing that reassurance unintentionally.
If the answer to “Tell me that couldn’t happen here” is, “I can’t really do that”, then have the courage to say it. Short-term unpopularity is infinitely preferable to long-term guilt when it all goes wrong and you know you didn’t speak up. The next key hurdle is about how you say what you have to say. If you understand QRA, then telling someone that the risk of an event happening is 1 in 10 to the minus 6 or 8 means something to you, but what does it mean to them? To some this means “it will never happen”. They truly don’t understand that you’ve just told them that if the right set of circumstances were to coincide a catastrophe could happen tomorrow.
Some management system reports can also be misleading and falsely reassuring – small percentages on non-compliance may fail to convey the seriousness of some of those non-compliances. Examples of what has been found and fixed, need to describe what really might have happened if it had not been found.
Be clear that your role is to create unease, not to provide false (re)assurance. It is essential that we all focus on this need for a culture on constant unease.
So what will it look like when we achieve the right process safety culture?
We will have created a sense of chronic unease which replaces complacency. Leaders will ask the right questions. They will be keen to know what process safety vulnerabilities there are. Process safety specialists will respond in clear terms, which anyone can understand and relate to. Operators will be asked to speak about their real safety concerns not be pulled up for failing to hold the hand rails. Leaders will actively seek information which tells them where attention needs to be paid to address vulnerabilities. In this new world there will also be a positive desire to learn from others and to share knowledge and experience so that lessons do not have to be re-learned time and time again in different organisations. Collaboration and information sharing on process safety will replace unhelpful turf protection. Corporate lawyers must also be challenged to help us communicate and share, not to stand in the way of sharing and learning. Process Safety knowledge and competence will be recognised as fundamental to anyone who takes on a position of responsibility within the major hazards industries.
Last year the OECD produced guidance for senior leaders in high hazards industries on what corporate governance for process safety should look like. This important publication needs to be brought to the attention of senior managers. The thinking and the route to improving Corporate Process Safety Governance has already been done by an international panel of experts. Here is a voluntary approach which offers a way forward – but only if Boards of companies take note and act upon it.
The introduction to the guidance makes the business case for process safety very well.
It states that:
“Safer operation and sustainable success in business cannot be separated. Failure to manage process safety can never deliver good performance in the long term and the consequences of failure are extremely costly”
The guidance highlights eight key self-check questions which need to be answered by Board members and senior managers – NOT by technical experts or operations personnel.
These are pretty searching questions to be posed at Board level – and for Boards to answer for themselves. They should be, they are designed to generate unease, to get board members and senior managers out of their comfortable complacency – to own up to what they don’t know – but should.
The guidance then goes on to provide more questions which delve more deeply into the areas where real improvement needs to be made. But at this point it is likely that senior managers will be ready to send for you – their process safety management professionals - to help answer the next set of questions because they will have realised just how important your knowledge and your expertise are.
I am particularly pleased that IChemE is taking a firm leadership position with regard to the competence of process safety professionals. For far too long there has been a lack of any form of professional recognition for those who constantly apply process safety professionalism day-in day-out and who, like many of you here today, are continuing to explore new techniques and ideas to further develop process safety. This lack of formal recognition has hindered the understanding of others of the vital contributions a process safety professional makes to safe design and operation of process plant. Here again, we have seen a rapidly increasing number of people achieving professional recognition for their occupational safety knowledge at global level but not the same for process safety.
IChemE’s new standard for Professional Engineering Competence in Process Safety details the competences expected of a professional safety engineer and explains how applications for PEng registration can be made. Since the intention to offer such recognition was first announced almost a year ago the response from around the world has been tremendous. Interest has come not only from the UK, but from Australia, Malaysia, Kazakhstan, China and, of course, here in the USA and the first applications for registration are currently being processed.
Despite the importance of Process Safety competence the key to changing the culture, to making a major shift in performance on process safety and to learning all of those many lessons of the past which we seem to forget all too easily, remains one thing – Leadership.
Operating a major hazards facility anywhere in the world requires the risks to be properly managed. Taking a gamble is not an option and focussing on the really important things rather than the trivial and easy to do is a must. That requires leaders who understand how important this approach is and who create the right culture for everyone else in the organisation to behave in the right way.
We need leaders who know what they don’t know and are willing to learn.
We need leaders who can live with a chronic sense of unease and who can spot the warning signs of complacency creeping in.
We need leaders to give the same priority to process safety wherever they are in the world because the threat of process related incidents occurring is the same worldwide.
We need leaders who are prepared to sit down with their peers and share the hard lessons they have learned and own up to mistakes they would not want to see others make again.
As you learn from colleagues at this conference over the next few days keep asking yourself:
Make this conference from the point from which you go back into your organisation and create unease.
Ladies and gentlemen. Thank you for listening. I hope I have done justice to the memory of Frank Lees and I hope that I have offered you a different perspective on some of the issues and topics you will participate in over the next few days.
Thanks again also to the Mary Kay O’Connor Process Safety Centre for its collaboration with IChemE, long may this continue and grow to include others.