Beware of Blind Risk – What You Don’t Know Can Hurt You

Years ago, I was part of a team investigating an incident at a plant shortly after commissioning. An emergency lubrication system on a steam-turbine-generator of 50MW failed. Fortunately, no one was hurt, but the whole unit had to be shut down. Unfortunately, the “blame game” started between the owner, lead-contractor and equipment provider resulting in a legal battle related to insurance claims.

As part of our investigation, we looked for commissioning, operating and inspection records to review the history. Although the inspection records were in place and signed off, the tag detail and specifications of the commissioning test were missing or insufficiently detailed in the inspection systems.

Some time later at another plant, a process pipe carrying hot fluid had burst. There was no injury or loss of life but the whole unit had to be shut down. As part of our investigation, we looked for maintenance and inspection records to review the maintenance history. Not only were there no maintenance or inspection records for the segment, the tag itself was not present in the maintenance and inspection systems.

While the tag was on a P&ID, it was not on the line list that the plant used to manage its lines. As far as maintenance and inspection were concerned, it was as if this pipe didn’t exist. It only became visible to us after it had failed.

More recently in another incident, loss-of-containment occurred when valves started leaking because the wrong seal was installed. Why? Because OEM equipment was replaced with a lower cost substitute of lower quality.

These are examples of blind risk that costs time, money, and potentially lives.

The experience came back to me when I was reading Human Error, by James Reason. In the book, he expands on “Latent error and systems disasters”. These errors aren’t violations of rules; they’re decisions we accept. Choices we make at a given point in time.

Unfortunately, these choices create gaps in our “layers for protection”. The systems and processes we trust to stop incidents before they happen.

Since the gaps introduced by latent errors aren’t obvious or visible, they’re a blind risk. They lie dormant, like a beartrap in the undergrowth of a forest until someone inadvertently steps on it. Disasters like Piper Alpha, Longford, Texas City, Macondo, and Bhopal are burned into our collective conscience. In each case, latent errors were a contributing factor. Things we accept as part of project closeout or when we make physical changes to the plant may be introducing latent errors at our facilities. Do you have a complete and validated asset registry? Are your critical drawings such as P&IDs and single line diagrams up-to-date? Have you done a criticality assessment of your assets? Can you find the information when you need it? Can you trust it? Availability, completeness, accuracy and consistency of process safety information seems to be a major challenge for most companies. I was recently struck by the number of citations that OSHA issues for non-compliance. Consistently, the top 4 areas are:

• Equipment Integrity
• Process Safety Information
• Management of Change
• Actions and Recommendations coming out of Process Hazard Analysis

As we go about designing, maintaining, and operating our plants, we are constantly faced with decisions. What information should we capture and when should we capture it? How should we make it available and who needs access to it? How can we be sure it’s up to date, consistent, and complete?

As an industry and as individuals, we have a moral responsibility to protect human life and wellbeing and to be good stewards of our environment. Next time you’re faced with a decision, ask yourself – Are you introducing a latent error, or are you exposing a blind risk and managing it properly? 

Mitigating Blind Risk

I know overcoming these challenges isn’t easy. It takes a concerted effort involving standards, processes, technology, information management, and governance. But here are a few things to consider:

• Ensure that there is a documented asset and process safety information management strategy in place
• Adopt industry standards such as ISO 55000 and CFIHOS to reduce personal and company bias.
• Ensure there is governance and ownership in place for managing asset and process safety information
• Ensure the completeness and validity of your asset register
• Establish as minimum baseline requirement for data quality and measure it against adopted standards
• Execute frequent data quality audits or gap assessments to discover latent errors
• Track and execute corrective actions coming from audits

Contact us for more information on how we can help you mitigate the risk of latent errors in asset data and process safety information.