safety in focus

April 2016

2 what is process safety?

3 removing barriers to
workplace incident reporting
4 effective risk communication
6 the hazards of portable
propane torches

A monthly publication of the Saudi Arabian Oil Company

safety in focus | April 2016

what is process safety?

By Jason Wan, Planning and Technical Services Division, Loss Prevention Department
Process safety is embedded within the
Saudi Aramco Safety Management
System and foundational to the
company's overall safety effort. This
year, our aim is to increase the focus
in the area of process safety. The
objective is to raise awareness of this
subject area, and facilitate
improvement in process safety at our
facilities.
When trying to define process safety,
perhaps the first question to ask is,
What is a process? A process (in
the context of process safety) typically
refers to any activity or combination
of activities including the use,
storage, manufacturing, or handling
of hazardous chemicals. Process
safety often describes interrelated
safety measures specific to industrial
operating facilities. For Saudi Aramco,
process safety mainly applies to
hydrocarbon facilities.
Typically, process safety is also
described according to the incidents
that this discipline is attempting to
prevent. Incidents like BP Texas City,
Buncefield in the U.K., Bhopal, India,
and even the Macondo blowout in
the Gulf of Mexico are some of the
more well-known incidents. The
common factors in these incidents
were:

A release of hazardous materials

in large quantities.

An impact on multiple persons

causing significant injuries, and
even fatalities.

An environmental impact.

Failure of many safety features or

safety layers.

In the BP Texas City incident, for

example, many things went wrong
and it resulted in 15 fatalities,

Figure 1. Blowdown drum and isomerization raffinate splitter after the incident

multiple injuries, significant damage

to the plant, and affected BPs public
image leading to public disgrace,
resulting in the resignation of the
CEO.

BP incident

The column overfilled and the

relief valves opened, allowing
liquid to flow to the blowdown
drum.

The blowdown drum is designed

to disperse vapor, but the sudden
surge in liquid meant that the
blowdown drum filled quickly
with boiling liquid.
An enormous cloud of flammable
vapor was formed, which found
an ignition source believed to be
a nearby truck, causing a fire and
explosion (Figure 2).

At BP Texas City, the following events

occurred:

The raffinate splitter (an

isomerization unit distillation
column used for splitting off
lighter hydrocarbons) was being
brought online (Figure 1).

The operator began start-up

operations on the column without
knowing the exact level in the
column because the level
indicator was providing an
incorrect reading. The level
indicator was showing a level of
2.41 m (7.9 ft), or 78% of its
design operating limit. In reality it
was 48.16 m (158 ft).

This is a simplification of the sequence

of events leading to the BP Texas City
incident to illustrate some of the
issues and complexity of process
safety. Key findings included:

The secondary high-level alarm

was not working and did not alert
the operator.

The plants design. Why did the

design allow the relief valve to
vent to atmosphere?

Maintenance issues with the

high-level alarm. Why was the
high-level alarm not working?
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Figure 2. BPs Texas City refinery after the incident

Poor placement of people onsite

putting them at risk. Why were so
many people so close to the unit
during start-up when they did not
need to be there?

Poorly written procedures that

did not reflect how the plant
should be started up.

Workers were working long hours

(12-hour shifts for 30 days). If
they were more alert could the
incident have been avoided?

Process safety is a discipline that

addresses factors such as those
mentioned above to effectively
manage operations in a manner to

Process safety

prevent incidents like BP Texas City. As

a discipline, it addresses fundamental
issues like the design of the plant, the
size and likelihood of potential
releases, placement of people and
buildings on site, operational
discipline (e.g., following operating
procedures), and many other issues to
prevent incidents.

removing barriers to workplace

incident reporting
By Alvaro Guzman, Planning and Technical Services Division, Loss Prevention Department
Reporting all safety-related incidents
is key to companies that have a
strong desire to learn from their
mistakes and a commitment to

continuous improvement. Getting this

right also reflects a mature safety
culture that benefits all employees.
When people take the time to report

all incidents including minor ones

such as first aid cases and major ones
resulting in lost-time events it is a
huge benefit to the organization.
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Incident reporting and investigation,

and the effectiveness of corrective
action implementation must be
encouraged to prevent recurrence as
well as more serious events.
Nonreporting can be hard to detect,
especially when there are no
mechanisms in place to validate
incident data. Underreporting gives
the illusion that an organization has
few safety incidents and allows
someone to assume this reflects a
strong, effective, and proactive safety
culture. Just because an incident isn't
reported doesn't mean it did not
happen, it just means it wasn't
reported properly.

Misunderstanding the purpose

In many organizations, the purpose of
reporting can be unknown, vague,
ambiguous, or completely
inconsistent with the organizations
vision and goals. A clear purpose
changes the way incident reporting is
viewed in terms of learning and
making work practices safer. The
purpose of incident reporting should
be compatible with the vision and
purpose of the work itself.

Fear of blame or punishment

One important reason for
nonreporting is pressure to meet
safety targets. Blaming or punishing
employees for openly reporting

incidents, especially when they are

not the result of a willful disregard for
safety rules, means that others will be
reluctant to report. This is a difficult
barrier that can only be removed with
a strong commitment to provide a
positive incentive for reporting from
management and effective
communication with all employees.

Not understanding how to

report incidents
It is important to ensure that
everyone in an organization knows
how to correctly report incidents.
Complicated forms can be hard to
understand and electronic reporting
systems that require excessive input
or have complicated interfaces
discourage employees from making
the effort to report incidents. Systems
and forms that are easy to use are key
to engaging employees and using the
reporting tools appropriately.

Incidents are not properly

investigated
Once an incident is reported, a group
of competent people should conduct
a proper investigation. In many cases,
the investigation is not conducted or
is of questionable quality. Establishing
clear criteria for conducting
investigations and ensuring that
proper methodologies are followed is
the best way to remove this barrier.

Lack of communication
In any organization, most
opportunities for improvement and
corrective actions are applied to
systems rather than people. If incident
reporting does not lead to positive
changes, then reporting is pointless. It
is important to communicate what
actions the company has taken to
address the issues, so that employees
are aware of these improvements.
This feedback provides additional
motivation to report incidents.

Local culture of reporting

When coworkers and supervisors
discourage reporting, employees feel
uncomfortable and will have to
balance their responsibility to their
work against a need to get along with
colleagues. Having a strong safety
culture with consistent and positive
feedback for the right behaviors
nurtures an environment of open
reporting of incidents.

Conclusion
Identifying incident reporting barriers
is the first step in preventing future
incidents. Having a plan to address
those issues and monitoring their
progress provides benefits in the short
and long term, resulting in a stronger
safety culture.

effective risk communication

By Chukwuemeka U. Ihesiulo, Riyadh Area Loss Prevention Division
Risk assessment is an important tool
in the loss prevention toolbox. A
proper risk assessment allows an

organization to identify and evaluate

its risks, and then to develop and
implement credible safeguards that

will prevent losses. Risk assessment

could therefore be referred to as the
fulcrum of any loss prevention system.
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For a risk assessment to meet its

intended objective, the process must
be fully implemented. Unfortunately,
some assume that the risk assessment
process is complete once risk
reduction and control measures are
developed and the risk assessment
report is written. The Saudi Aramco
Safety Management System (SMS)
clearly emphasizes the importance of
risk communication by indicating that
a risk assessment has a limited value
if communication to employees has
not taken place. The SMS therefore
requires organizations to establish a
formal process, not only for
communicating major risks associated
with the facilities among all staff, but
also for sustaining the
communication.
Hazard identification. This step is
the process of identifying anything
that has the potential to cause harm
to people, the environment, company
assets, or reputation.
Risk assessment and evaluation.
This step involves identifying the
likelihood or frequency of an incident
occurring due to hazards. It also
involves estimating the magnitude of
any loss or consequence arising from
the incident in order to evaluate the
level of risk. The estimated risk is then
compared to established tolerability
criteria to determine if the risk is
acceptable, or if it must be reduced
to acceptable levels and managed.
Risk reduction and control. This
step includes the development of
measures to reduce and/or control the
risks.

Risk communication
Risk communication has been
described by Covello (1992) as, the
process of exchange of information
among interested parties about the
nature, magnitude, significance, and
controls of a risk. Communication is
an important part of the risk
assessment process to ensure that all
employees know and understand the
risks in their facilities, and the risk

reduction and control measures or

safeguards to implement.
Risk communication also ensures that
employees are aware of their
responsibilities in maintaining
safeguards, thereby preventing losses
in the organization.
Risk communication can occur via
written, verbal, or visual means.
Written communication involves
providing risk information in reports,
instructions, or procedures, while
visual risk communication presents
information in a graphic format. In
both cases, the risk information is
made available in flyers, booklets,
bulletins, or handbooks, either as
hard or electronic copies. Conversely,
verbal risk communication involves
discussions with employees.
Although the three risk
communication methods complement
each other, verbal communication
provides the opportunity for
employees to ask questions and seek
clarification. It is therefore advisable
to present risk information verbally
and then complement it using written
or visual methods, or a combination
of the two. This has a greater impact
on employees and they retain more of
the information.
Considering the importance of risk
communication to risk assessment
and its role in an organizations risk
management and loss prevention
system, companies should make
concerted efforts to ensure that risk
communication is effective.
The question then is: How can
effective risk communication be
achieved?

Effective risk communication

Although risk communication has
been described as a difficult task to
perform satisfactorily, there are many
ways to ensure that a company can
be effective (Ng, 1997; University of
Leicester, 2004). The following are
some of the ways to achieve effective
risk communication.

Recognize the need for risk

communication. The Saudi Aramco
Safety Management System (SMS)
stresses the need for risk
communication and requires that all
members of an organization
communicate risk information to their
employees. This focus on the
communication process encourages
action.
According to Element 3 of the SMS,
Employees must be informed about
risks in their areas, so they can work
to prevent them by understanding
their own roles in managing them
and developing methods for reducing
or eliminating them.
Make the communication
interactive. The risk communicator
should make the process interactive.
This creates an enabling environment
for the healthy exchange of ideas or
constructive dialogue with other
employees. The communicator should
listen to and acknowledge employees
questions and concerns regarding the
risks, mitigation measures, and their
roles, then offer credible answers and
explanations. This enhances
understanding, creates trust, and
motivates the workforce to take
responsibility for their assigned risk
mitigation roles.
Make the message clear and
understandable. When discussing
risks and mitigation measures, it is
important to make the message clear,
simple, and not overly technical. Bring
the message home by referencing
incidents that the audience can relate
to and lessons learned from the
incidents. That way, employees can
better appreciate the risks,
safeguards, and their roles.
According to Element 2 of the SMS,
Effective risk communication ensures
all staff understand the major risks in
their facilities, the critical safeguards,
and their role in maintaining ongoing
safe operations.
Do not create fear in the
employees. Risk communication
involves telling employees that there
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are risks associated with their

activities. Some may misunderstand
this to mean that the organization is
exposing them to risks (University of
Leicester, 2004). It is, therefore,
important to present the risk
information to employees in a
reassuring way.
While employees need to be made
aware of the risks, it is important to
stress that adequate risk reduction
and control measures have been
developed and are implemented. That
way, employees will be assured that
their safety, company assets,
reputation, and the environment will
be protected.
Be convinced and confident. The
risk communicator should be
confident in the results of any risk
assessment, including the chosen risk
mitigation measures. This involves
getting the risk estimation numbers
right, explaining what they mean, and
the processes behind the decisions

made by the risk assessment team.

This will create employee confidence
in the chosen risk controls and in the
overall SMS.
Understand employees existing
risk perception. It is important to
understand that people respond to a
risk or hazard in ways consistent with
their perception of that risk (Adams,
2005). Also, the mental models
approach to risk communication
indicates that an individuals
perception of risk is determined by
their culture, beliefs, and ideas. The
risk communicator should therefore
try to understand the existing risk
perceptions among the employees, as
well as the culture, beliefs, and ideas
that underpin them. This will enable
the speaker to tailor the information
they present to the audience in a way
that either reinforces the right risk
perceptions or corrects wrong ones.
Saudi Aramco has a low tolerance for
risk and employee communication
and collaboration is important to

ensure similar low risk tolerance

among all members of the workforce.
Summarize and reinforce the key
points. Employees may not
remember all the information
presented, especially during a verbal
risk communication session.
Therefore, summarizing and
reinforcing key points at the end of
the session will help them recall the
information when needed.

Conclusion
Effective risk communication is a
valuable vehicle for risk management
and loss prevention. It ensures that
employees know and understand the
risks in their facilities, the risk control
or mitigation measures, and their
roles in implementing these measures.
This will engender employee
confidence in, and commitment to,
the organizations loss prevention
efforts and the overall SMS.

the hazards of portable

propane torches
By Muhammad A. Khan, Abqaiq Area Loss Prevention Division
In process industries, propane
torches are used in activities such as
igniting process equipment like
furnaces and heaters, soldering, and
for heat. Propane torches (Figure 1)
are intended for outdoor or wellventilated use only. Using them

indoors or with poor ventilation

creates hazards and can lead to
incidents.

Figure 1. Propane torch and accessories

Propane torches consist of a torch

assembly, propane cylinder, rated
hose, orifice valve, regulator/flame
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safety in focus | April 2016

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adjustment valve, and a safety key.

Most torches use propane gas as
fuel, although some are designed to
use liquid propane. Burners designed
for propane cannot be used with
natural gas and vice versa. Torches
attached directly to gas cylinders are
specifically prohibited because they
pose risks to users.
Unsafe use of propane torches and
poorly maintained equipment can
lead to injuries and, more seriously,
fatalities. Hundreds of propanerelated fires, injuries, and incidents
are reported by government agencies
worldwide every year.

Propane
Propane is a common liquefied gas
used for multiple purposes such as
welding, cutting, burning, and gas
stoves. Commercial propane may
contain small amounts of propylene
and other hydrocarbons such as
butane. Propane is an odorless,
invisible gas and is heavier than air;
therefore, an identifying odor is
added for quick detection that smells
like boiled cabbage or rotten eggs.
Propane is supplied as a liquefied gas
in cylinders.

Safety precautions
Some of the more common sense
precautions them to avoid using
propane torches near combustible or
flammable materials, and not to use
them as a personal heat source.
Storage. Propane cylinders must be
stored on a level surface, in an
upright position, and secured to
prevent falling. When not in use,
their discharge valves must be
secured with a cap designed to
protect them. Cylinders should be
stored in a secured, well-ventilated
area away from any ignition sources
and direct sunlight.
Gas supply hose. The supply hose
must provide sufficient clean fuel to
the burner at the recommended
operating pressure, especially when
operating at full capacity.
Air supply pipe burners. These
require sufficient amounts of primary
and secondary air for safe and
efficient combustion. Insufficient
primary air results in a low flame
temperature and will eventually
cause carbon buildup in the burner.
Insufficient primary air is indicated by

candle-yellow flames. If the gas

orifice is too large, it may be
impossible to adjust the primary air.
The burner will only use enough
secondary air to complete efficient
combustion. The burner will act
erratically if the secondary air flow is
restricted and this can result in
carbon buildup. The lack of
secondary air is indicated by a bluish
flame, which will often be visible
away from the burner.
Working space. The distance
between the top of the burner and
the bottom of the surface being
heated should be about twice the
diameter of the burner. This allows
room to complete the flame
combustion, so the flame is visible
and well-defined. The inner cone of
the flame should not strike the
surface being heated because it may
result in incomplete combustion.
Insufficient space can lead to the
same hazard and release unburned
gas into the work environment.
Venting of hot gases and the
products of combustion must be
done with a natural flow upward and
outward.

safety in focus | April 2016

Resources

Resources available on Loss Prevention

Departments homepage: http://
lp.aramco.com.sa
1. Safety films available from the LPD
Film Library:

o SMG 02-002-2010,
Qualitative Risk Assessment

Saudi Aramco Safety Management

System
Saudi Aramco Construction Safety
Manual

Covello, V., Risk Communication,

Trust, and Credibility, Health and
Environmental Digest, 6:1, 1992, pp.
1-4.

Saudi Aramco General Instructions (GIs)

100.011, Compressed Gases Safe
Handling
100.020, Process Safety Protecting
Employees
100.152, Compressed Gas Cylinders

Adams, J., Risk, UCL Press, London,

2005.

o GI 6.001, Notification
Requirements for Incidents
(Including Fires)

Ng, K.L., and Hamby, D.M.,

Fundamentals for Establishing a
Risk Communication Program,
Journal of Health Physics, 73:3,
1997, pp. 473-82.

o GI 6.005, Reporting,
Investigation and Recording of
Injuries/Occupational Illnesses

100.198, Process Safety Management

100.222, Incident Reporting: You Can
Save a Life
100.258, Process Safety: Employee
Awareness
100.289, Working around Vehicles
Safely
2. Courses

o GI 6.007, Reporting of
Contractor On-Job Injuries/
Occupational Illnesses
o GI 7.026, Crane and Heavy
Equipment Incident Reporting
and Investigation Procedures

University of Leicester, General

Issues in Risk Assessment, Lecture
Notes, 2004, pp. 3-22.
4. Additional Resources

Safety Management Guides (SMGs)

o SMG 01-001-2015, Visible

Safety Leadership

Safety Handbook, e-Learning

3. References

o SMG 02-001-2009, Risk

Assessment and Management
Guide for Managers

Saudi Aramco Safety Handbook

The editorial staff welcomes readers comments and ideas. Please email your suggestions to
SafetyinFocus@aramco.com or mail them to Safety in Focus, Saudi Aramco Loss Prevention Department, A-117,
Building 3150, LIP, Dhahran 31311, Saudi Arabia or call 872-8669.
Safety in Focus (ISSN 1319-1802) is produced by the Support Services Unit of Saudi Aramcos Loss Prevention
Department and focuses on operational and on-job safety.

Copyright 2016, Saudi Aramco. All rights reserved.

Safety in Focus | July 2015

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