Gathering operating experience

Gathering lessons learned and experience data from internal and external sources is a key part of an OSH programme. Internal data can include records of incidents, performance indicators and worker health monitoring.

External sources can be similar information from other plants within an organization’s fleet, from other nuclear facilities (e.g. IAEA, WANO, INPO, owner group data and regulator reports), and from non-nuclear heavy industry (e.g. construction and petrochemicals). The follow subsections detail some recently published significant operating experience on nuclear and non-nuclear facilities.

8.2.3.1. OSART findings and trends

The IAEA routinely publishes results and lessons learned from OSART missions on its Operational Safety Services web site.²⁰ Known as OSART Mission Results (OSMIR), these reports highlight the most significant findings of OSART missions, while retaining as much of the vital background information as possible. Table 29 provides some recent OSMIR report findings on industrial safety, which indicate that the industry has further to go to meet excellent performance in this area. Industrial safety indicators in these reports (in management, organization and administration) were classified as ‘red’ (poor) for the first two time periods evaluated, and for the third time period the report did not use the same methodology but instead indicated that the number of industrial safety recommendations greatly exceeded the number of identified good practices.

8.2.3.2. Baker Report on process safety (non-nuclear example)

An explosion that resulted in 15 deaths and 170 injuries at a BP chemical refinery in 2005 in Texas focused attention on the issue of process safety and its relationship to industrial safety and safety culture. Process safety accidents such as fires, chemical leaks or explosions at petrochemical facilities have the potential to cause multiple injuries and fatalities, and negatively impact on the environment. Industrial safety accidents on the other hand primarily affect one worker or a small group of workers. The report of the safety review panel (Baker Report) that was convened to investigate the accident concluded that many of the characteristics discussed in this publication that are needed for strong industrial safety programmes, and indeed for strong nuclear safety programmes, were lacking at BP and thus contributed to a poor process safety programme [225]. Nuclear facilities with inherent hazards (e.g. radiation hazards and those inherent with chemical and fuel handling systems) can gain from such a perspective. The ten main recommendations are in Box 3.

20 See www-ns.iaea.org/reviews/op-safety-reviews.asp

TABLE 28. SELECTED CONSTRUCTION INDUSTRY INSTITUTE BEST PRACTICES AND THEIR ROLE IN ENHANCING OCCUPATIONAL SAFETY AND HEALTH

Best practice Description Example role in enhancing OSH

Zero accident techniques Site specific safety programmes and implementation, auditing, and incentive efforts to create a project environment and a level of training that embraces the mindset that all accidents are preventable and that zero accidents is an obtainable goal.

Enhances hazard recognition, near miss reporting, use of leading safety indicators, and the owner’s role in project safety.

Front end planning The essential process of developing sufficient strategic information with which owners can address risk and make decisions to commit resources in order to maximize the potential for a successful project.

Enhances predictability of job execution and consideration of industrial safety aspects early in the project when they can more effectively be addressed.

Constructability The effective and timely integration of construction

knowledge into the conceptual planning, design, construction and field operations of a project to achieve the overall project objectives in the best possible time and accuracy at the most cost effective levels.

Incorporates construction knowledge regarding work methods and hazards into the project design and execution plans (see Section 6.3.3.2).

Change management The process of incorporating a balanced change culture of recognition, planning and evaluation of project changes in an organization to effectively manage project changes.

Enhances the organization’s ability to recognize and address changes before they occur, including potential changes in OSH hazards and risks.

Benchmarking and

metrics The systematic process of measuring an organization’s performance against recognized leaders for the purpose of determining best practices that lead to superior performance when adapted and utilized.

OSH metrics would be included in an organization’s performance metrics.

Comparison to other organizations via benchmarking activities would be encouraged (see Section 8.2.2).

Lessons learned A critical element in the management of institutional knowledge, an effective lessons learned programme will facilitate the continuous improvement of processes and procedures and provide a direct advantage in an increasingly competitive industry.

Sharing of lessons learned regarding OSH issues would help continually to improve performance (see Section 8.2.3).

Planning for startup Startup is defined as the transitional phase between plant construction completion and commercial operations, that encompasses all activities that bridge these two phases, including systems turnover, check-out of systems, commissioning of systems, introduction of feedstocks and performance testing.

Startup activities are high activity phases and occur at the end of each outage. Proper planning can help minimize unplanned changes and OSH risks (see Section 6.6.15).

Project risk assessment The process to identify, assess and manage risk. The project team evaluates risk exposure for potential project impact to provide focus for mitigation strategies.

OSH risks are part of this process.

Team building A project focused process that builds and develops shared goals, interdependence, trust and commitment and accountability among team members and that seeks to improve team members’ problem solving skills.

Well functioning teams are more likely to raise/identify OSH hazards and risks and work together on improvement strategies.

TABLE 29. OSMIR REPORT FINDINGS ON INDUSTRIAL SAFETY

Time frame Finding Ref.

2003–2006 “• Trend: There are some indications the local industrial safety policy is not sufficiently clear, or sufficiently well developed to ensure that hazards are minimized (7/21).

“This was manifested in a variety of ways, from lack of control of temporary storage areas (with associated hazards – notably fire) to unidentified/unrecognized hazards in the field.

“• Trend: There are many indications that employees fail to follow the requirements of their local safety rules and management fails to adequately enforce them (13/21).

“This was particularly evident in the failure to comply with the wearing of personal protective equipment and in the adherence to rules prohibiting smoking in inappropriate areas. Failure to require contractors to comply with safety rules was also identified during the missions (5/21).”

[222]

2007–2009 “• Trend: In some plants, there are indications that the industrial safety policies or programmes are established but they are not fully implemented in the field. (7/17).

“there are strong indications that behaviour in the field did not fully comply with the policies and programmes. It was found that communication and reinforcement of expectations, as well as supervision and co[a]ching, were not properly used by the management to achieve significant improvements in this area.

Managers do not always identify and correct inadequate industrial safety practices and eliminate hazardous behaviour of own staff or contractors.

“In particular cases, development, implementation and follow-up of corrective actions are not sufficiently considered.”

[223]

2010–2012 “• Trend: In many plants, there are indications that the industrial safety policies or programmes are established, but they are not fully implemented/followed in the field. (10/19).

“Examples show that;

— Plant personnel [do] not always wearing safety protective means (goggles, hard-hats, gloves, ear-protection tools etc.).

— Some plant equipment is missing or has disconnected grounding cables.

— Lighting defects are not always eliminated in timely manner.

— Electrical and other cabinets have no safety hazard warning labels.

— There are number of unlocked electric/I&C [instrumentation and control] cabinets.

— Escape routes are not appropriately marked.

“Though plants have established policies, standards and expectations on industrial safety that employees are required to meet, there are strong indications that behaviour in the field did not fully comply with these policies, standards and programmes. Management must put additional efforts to recover the situation and to ensure that expectations are communicated and reinforced repeatedly to make plant staff and contractors understand the industrial safety policies and strictly follow them in the field. This trend requires thorough analysis of the situation at the plants where the deficiencies were found and development of the respective corrective actions — training, posters, industrial safety days etc.”

[224]

BOX 3. RECOMMENDATIONS OF THE BP US REFINERIES INDEPENDENT SAFETY REVIEW PANEL [225]

RECOMMENDATION #1 — PROCESS SAFETY LEADERSHIP

The Board of Directors..., BP’s executive management..., and other members of BP’s corporate management must provide effective leadership on and establish appropriate goals for process safety. Those individuals must demonstrate their commitment to process safety by articulating a clear message on the importance of process safety and matching that message both with the policies they adopt and the actions they take.

...

RECOMMENDATION #2 — INTEGRATED AND COMPREHENSIVE PROCESS SAFETY MANAGEMENT SYSTEM BP should establish and implement an integrated and comprehensive management system that systematically and continuously identifies, reduces, and manages process safety risks at its U.S. refineries.

...

...a management system for process safety must be comprehensive; a weak or fragmented system will not address all of the numerous safety risks that exist in BP’s U.S. refineries.

...

RECOMMENDATION #3 — PROCESS SAFETY KNOWLEDGE AND EXPERTISE

BP should develop and implement a system to ensure that its executive management, its refining line management above the refinery level, and all U.S. refining personnel, including managers, supervisors, workers, and contractors, possess an appropriate level of process safety knowledge and expertise.

...

...BP should also seek input and advice from external groups with appropriate process safety expertise to help design, develop and implement this system.

...

RECOMMENDATION #4 — PROCESS SAFETY CULTURE

BP should involve the relevant stakeholders to develop a positive, trusting, and open process safety culture within each U.S. refinery.

...

...BP should ensure that mechanisms exist that effectively promote and facilitate two-way communication between BP managers and all relevant stakeholders.

...

RECOMMENDATION #5 — CLEARLY DEFINED EXPECTATIONS AND ACCOUNTABILITY FOR PROCESS SAFETY BP should clearly define expectations and strengthen accountability for process safety performance at all levels in executive management and in the refining managerial and supervisory reporting line.

...

...Ultimate accountability and responsibility cannot be delegated and rests at the top of the organization. BP must strengthen accountability and responsibility for process safety performance in executive management...

...

RECOMMENDATION #6 — SUPPORT FOR LINE MANAGEMENT

BP should provide more effective and better coordinated process safety support for the U.S. refining line organization.

...

...BP should designate and establish a full-time leader for process safety who reports to a refining line manager above the refinery level.

...

RECOMMENDATION #7 — LEADING AND LAGGING PERFORMANCE INDICATORS FOR PROCESS SAFETY BP should develop, implement, maintain, and periodically update an integrated set of leading and lagging performance indicators for more effectively monitoring the process safety performance of the U.S. refineries...

...

...BP should develop and implement within six months from the date this report is issued a reasonable set of integrated performance indicators....

...

RECOMMENDATION #8 — PROCESS SAFETY AUDITING

BP should establish and implement an effective system to audit the process safety performance at its U.S. refineries.

...

RECOMMENDATION #9 — BOARD MONITORING

...The Board should, for a period of at least five calendar years, engage an independent monitor to report annually to the board on BP’s progress in implementing the Panel’s recommendations....

...

RECOMMENDATION #10 — INDUSTRY LEADER

BP should use the lessons learned from the Texas City tragedy and from the Panel’s report to transform the company into a recognized industry leader in process safety management.

8.2.3.3. Root cause report on Arkansas Nuclear One stator drop event

In 2013, during movement of the Unit 1 main turbine generator stator (ca. 475 t), a temporary lift assembly failed resulting in loss of life, loss of off-site power to Unit 1, structural damage to the turbine building and physical injuries. The root cause report into the accident identified that the design of the lift assembly could not support the loads anticipated, calculations to ensure that the assembly was designed to support the projected load had not been reviewed, and load testing of the modified temporary lift assembly had not been performed according to OSHA regulations [226]. World Nuclear News reported that the Nuclear Regulatory Commission found that Entergy “did not ensure adequate supervisory and management oversight of the contractors and other supplemental personnel involved with the stator lift, and this contributed to the event” [227]. The event emphasizes the need for careful oversight of contract work for industrial safety concerns.

8.2.3.4. Tokyo Electric Power Company 2015 press conference handout on safety measure improvements after accidents

The Tokyo Electric Power Company (TEPCO) released press conference handouts [228] on the causes of several accidents resulting in death and injury that occurred at its nuclear power plants, and on its measures to improve safety. The handout emphasizes the important role for supervisors and lessons learned programmes in preventing industrial safety accidents. The events were in 2015 during recovery efforts following the 2011 earthquake and accident and included the following:

(a) A worker installing a water tank at Fukushima Daiichi nuclear power plant fell 10 m from the top of the tank (empty at the time) into it and died.

(b) A worker inspecting equipment at a Fukushima Daini nuclear power plant waste treatment facility had his head caught between a piece of scaffolding and a 700 kg piece of moving equipment and died.

(c) A worker received an injury at Kashiwazaki Kariwa that needed three months to heal.

The main issues relating to these accidents were seen to be:

— Lack of efforts to eradicate human accidents due to strong schedule pressure;

— Weakness in using lessons learned from past troubles and accidents and rolling out information;

— Lack of management skill in accident prevention (e.g. supervisors spending too much time on desk work and not being sufficiently trained for on-site supervision, and operational procedures not being sufficiently detailed).

Corrective measures included increased training on accident prevention, increased emphasis on the priority of safety over schedules, and a commitment to have senior executives patrol the facilities to identify risks and personally convey the ‘safety first’ message [229].