Capacity Development Programme in Industrial Disaster Risk Management

Capacity Development Programme in Industrial Disaster Risk Management Crisis Management:Avoiding and Mitigating Major Accidents Prof. Dr. Christian Jochum India, February 2009

Professional Profile Christian Jochum • Born 1943 in Frankfurt a.M./Germany • PhD in Chemistry, certified Safety Engineer • Honorary Professor at Frankfurt University • 28 years experience in large chemical/pharmaceutical company (Hoechst AG) • 1969 – 1979 Pharmaceutical research and pilot plant operations • 1979 – 1997 Safety department (Site and Corporate Safety Director and „Major Accident Officer“ since 1987) • EHS – and crisis management consulting for different types of businesses and administration since 1997 • Commission on Process Safety (formerly Major Hazard Commission) at the German Federal Minister for the Environment (Chairman since 1998) • European Process Safety Centre (Rugby/UK): Director of Centre since 2007

European Process Safety Centre (EPSC) www.epsc.org Network funded by 40+ mainly European based (petro)chemical multinationals to develop best practice in major accident/process safety Objectives: Information/know how exchange Legislation (esp. Seveso II & ATEX) participation & co-ordination of EU funded projects Outputs: Internal reports & books User groups & public conferences EU projects & working groups Major topics 2008/09: Process Safety Indicators/Learning from Accidents Safety Critical Equipment Fostering Senior Management Involvement in Process Safety (with EFCE) LOPA Experience & Development

Commission on Process Safety (Kommission fuer Anlagensicherheit [KAS]) • Mandated by the Federal Emission Control Act • Advises government as well as plant operators and state and local authorities on process safety • 32 members with different professional and educational background representing different stakeholders (“Round Table”) • Any group needs “allies” to win votes • Consensus intended, but majority decisions possible • About 55 guidelines issued on different topics, e.g. • Land Use Planning (Safety distances) • Risk evaluation and perception • Emergency Planning • Industrial parks • Provisions against terrorist attacks on chemical plants • All publications of the Commission are available (partly in English) at • www.kas-bmu.de

Outline Case Study: Hoechst Incidents 1992 1 2 Lessons Learnt 3 Improving Existing Plants 4 Conclusions

Case Study: Hoechst Incidents 1993 1 • In 1993 three major incidents occurred at 2 Hoechst sites near Frankfurt/Germany within 6 weeks • Feb. 22 Runaway reaction after an unnoticed stirrer failure. Emission of 10 tons methanol containing a possibly carcinogenic substance, contaminating a large residential area • March 15 Explosion of methanol – air – mixture during maintenance in a process plant. 1 worker killed, 1 seriously burnt • April 2 Major sulphur trioxide emission in a process plant • The series of incidents caused a lot of public concern and nationwide media coverage.

Hoechst Incidents: Severe Consequences 1 • Although the Feb. 22 emission did not cause serious injuries, it led to the most serious consequences for the company and the most “lessons learnt”: • Prevention would have been possible by a thorough risk analysis leading to a simple safety device (stirrer control acting on charging valve) • Confidence in the company´s competence in emergency response was torn down by • Gross underestimation of the affected area • Incomplete knowledge of the hazardous properties of the emitted substance • Inadequate wording in the first press conference • Aggravation of adverse reactions by neighbours, media and authorities by arrogant behaviour of site representatives long before the incident

Hoechst Incidents: Lessons Learnt 2 • Crisis management assessment should cover all parts of emergency- and crisis- management ... • identify hazards comprehensively • avoid or control risks • communicate remaining risks • mitigate consequences • remediate damages • restore trust ... pursuing the goal to define and train as much as possible in advance

Hazards 2 • Hazards have to be identified systematically ... Operation hazards • eg. „classical“ EHS-hazards, loss of production, ... Network hazards • eg. failure of utilities, supplies, transportation ... Environmental hazards • eg. natural hazards, adjacent plants and traffic ways, ... Environmental vulnerability • eg. densely populated areas/buildings, natural reserves, ... Terrorist threats • eg. plant vulnerability, neighbourhood/environment sensitivity, company image, ... ... and transposed into scenarios.

Prevention 2 • Avoid or control risks Assess procedures • Minimise hazards ( “Inherent Safety”) Define safety measures • Engineering/organisation/human factor/“Security” • update necessary? Assess safety measures • eg. Audit programs “Prevention is the best remedy”

Risk Communication 2 • Communicate remaining risks Internal • eg. training, drills External • Towards customers, neighbours, authorities – but careful regarding security risks! “who always claims `zero risk´, has no credibility in his ability to control risks!”

Mitigation 2 • Mitigate consequences • Internal emergency planning (above all organisation, equipment, drills) • Cooperation with external services (neighbouring plants, public services) Important: ability to react fast! The bigger a corporation, the higher the expectations even for small sites

Claim management 2 • Remediate damages • ... do not handle damages as insurance cases only • ... fears may not be justified, but are always real • ... be prepared for problems of competency and competition (internal and external) • ... identify “free-riders” “well treated wounds heal better”

Confidence Management 2 • Restore trust • ... prepare the fundament before the crisis • ... communicate open and clear (possible conflict regarding terrorist threats!) • ... do not downplay fears • ... give the company one face You may lose trust in hours. Restoring trust needs years

Crisis Management Systems: can the unpredictable be planned? 2 • Define as much as possible in advance, because ... • ... crisis always happen at the wrong time and place • ... your regular organisation is not sufficient to handle crisis • ... all resources of the whole company have to be available in due time • ... public, media and authorities expect professional handling of crisis, too • Will the crisis management system be adapted • to today´s frequent organisational changes?

Drills 2 • Major incidents hopefully become less frequent. This makes drills even more important ... • ... to train seldom used procedures • ... to reduce mental stress during incidents • ... to optimise emergency- and crisis- management • ... to make sure that necessary resources are available The gap between resource consuming “full drills” should be filled with frequent “smaller” drills.

Plant & Process Safety: improvement of existing (“old”) plants 3 • Make best use of limited resources by a stepwise approach: • Have full knowledge about hazardous properties of all substances (e.g. Material Safety Data Sheets, data bases, etc.) • Identify and rank critical points (human- and eco – toxicity, hold-up of hazardous substances, reaction conditions, mechanical and physical hazards) • Document this in a safety study as a tool for use by the plant and by authorities • Focus improvements (manpower, money, additional safeguards etc.) and inspections on the most critical points • The higher the risk, the more independent safeguards (“barriers”) should be considered • Use the scenarios developed under (2) for emergency planning

“Swiss Cheese Model” (after J. Reason, modified by Mike Broadribb, BP) Lagging Indicator Leading Indicator

Plant & Process Safety: Use existing knowledge 3 • Most accidents and eco – incidents have a previous history ... • Preliminary events leading up to the accidents (failure of preliminary safeguards) have not been identified • Prior to most major accidents similar smaller incidents or near misses have happened, but not evaluated • ... which should be used for prevention • Raise the awareness of the workers • Use the experience of workers • Encourage reporting of deviations, near misses and even minor incidents as well as suggestions for improvements. Consider contests and awards for groups working together • Have a system for following up such reports/suggestions

Plant & Process Safety: The Human Factor 3 • Workers are risks and resources for safety • They have to know the risks to cope with • Detailed written procedures are a tool both for workers and for management. They should ... • describe the procedure as it is in the plant step by step • use a language and expressions which are understood by the workers (no scientific or technical paper) • highlight hazards, safety measures and critical process parameters (temperature, pressure, ...) • make independent double checks mandatory for critical parameters and procedures • include start-up, shut-down, maintenance and process-specific information for emergencies • Use other procedures (e.g. Quality) for safety purposes, too • Include normal and abnormal situations in training

Safety Operating Procedures 3 • Examples for visualization of safety information • Acetone Ladders

Emergency Preparedness 3 • Accidents may happen even in most modern plants. They cannot be planned, but they should be considered. • Use the scenarios identified for prevention of major incidents for emergency planning and training, too • Cover all relevant scenarios in the emergency plan • Assign responsibilities rather than regulating details • The emergency organisation is different from the normal organisation, but has to be empowered to use it • Adjust the emergency organisation to the dimension of the incident (e.g. “blue, yellow, red alert”) • Clearly document all available resources (site, company, neighbouring sites, authorities, ...) for the different scenarios. Ensure that they can be used in emergencies (e.g. co-operative agreements) • Before you rely on off-site resources, consider the time until availability • Industrial zones with many companies close together need special attention (“domino-effects”)

Emergency Response 3 • The basic principle: the faster and more effective the initial response, the smaller the consequences for men, environment and economy. • Provide the infrastructure for fast response (fire brigade, emergency control room, notification and availability of key personnel, etc.) • Encourage immediate reporting of incidents (not to wait until own efforts failed ...), do not blame for false alarms • Site fire brigades (or shared with adjacent sites) usually are faster and more efficient than municipal brigades, which rather serve as a back-up • If the fire brigade is (partly) staffed by operators be aware of the risks of understaffed production • Better start with a higher level of alarm (worst case assumption) and grade it down later than vice versa • Notify and involve public fire brigades and authorities as soon as possible • Analyse every incident and the response without blaming anyone to improve the emergency organisation

The Role of Authorities 3 • The cooperation between authorities and companies at an incident depends on their cooperation before the incident. • Open communication about risks and safety measures on a regular basis (e.g. in a local or regional committee) builds up trust which is urgently needed during emergency response • Authorities need to know about the possible scenarios for major accidents to do their own preparations • Authorities should have clear rules about their responsibilities in handling major incidents to avoid conflicts between the different agencies (e.g. labour safety, environment, civil protection, police etc.) • Mitigation of consequences should come first, legal prosecution of individuals responsible for the incident later

Neighbours, Journalists and Environmentalists 3 • The basic issue: Neighbours and the general public share the risks of industrial sites, but not necessarily the benefits. • Communication of relevant risks has to be done openly and in an adequate form (“not scientific”) prior to incidents (e.g. “neighbourhood councils”, brochures, ...) • to build up trust in the competence of the company to handle risks • to enable the neighbours to react adequately during an incident • The response of neighbours etc. to incidents is strongly influenced by the company´s response to requests and complaints prior to the incident • Fast and open information after an incident is crucial • Fears and worries of neighbours etc. have to be taken seriously even if they are based on emotions rather than science • On the long term, conflicts with neighbours etc. endangers the “licence to operate” • Committees with all stakeholders as the German Commission on Process Safety are an effective tool for cooperation and communication.

Conclusions 4 • Investing in safe and eco-efficient plants pays off at least on the long term • The (remaining) risks of industrial plants can be assessed and are the basis for scenarios for emergency planning • The knowledge and experience of the operators should be used by all means • Risks should be communicated as well as benefits to all stakeholders, esp. the neighbours • The resources for emergency response (manpower, equipment, communications, organisation etc) have to be planned in advance and readily available in case of an incident. People usually accept the risk of a chemical/pharmaceutical plant, but not incompetence in handling it • Authorities should involve themselves actively in emergency planning, balancing this out with their law enforcement duties • Combined efforts will definitely lead to safer and more accepted plants, as the figures from Germany may show

Development of Accidents in Germany since 1950 4 „Arbeitsunfälle“ = occupational accidents „Wegeunfälle“ = acc. on the way to work

Thank you for your attention!

Capacity Development Programme in Industrial Disaster Risk Management