104: Proactive Risk/Safety/Reliability/Quality/Security Analysis Issue

Node Proactive Risk/Safety/Reliability/Quality/Security Analysis Issue

Definition/Typical Issues

Was the problem caused by an inadequate hazard review of the system? Was there a failure to perform a risk assessment of the system? Was there a failure to identify the safety, reliability, quality, and security hazards?

Typical analyses addressed by this node include:

  • Process hazard analyses
  • Hazard and operability analyses
  • Reliability analyses
  • Security vulnerability analyses
  • Failure modes and effects analyses
  • Reliability-centered maintenance analyses
  • Enterprise risk management analyses
  • Project risk management analyses
  • Fault tree analyses
  • Event tree analyses
  • Probabilistic risk assessments
  • Job safety analyses

Note 1: Proactive analyses are performed before a failure occurs. Reactive analyses are performed after a failure occurs. Reactive analyses are addressed under nodes #110-115.

Note 2: This node addresses general proactive analyses. Analyses performed specifically as part of a change assessment are addressed under the Change Control Issue (#98) node.

Note 3: Normally, pre-job briefings are addressed under the Job Plan/Instructions to Workers Issue (#187) node. However, if the pre-job briefing includes the performance of a job safety analysis (JSA) and the causal factor occurred as a result of failure to properly perform the JSA, it is appropriate to code under this node.

Note 4: Issues associted with the design of the reliability program, such as mechanical integrity (MI); reliability-centered maintenance (RCM); risk-based maintenance (RBM); inspection, testing, and preventive maintenance (ITPM), should be coded under Node 29 - Equipment Reliability Program Design Issue.

Examples 

Example 1

  • During a process hazard analysis of a new system, the review team recommended the installation of a larger overflow line to handle the largest possible flow into the tank. The results of the review were not incorporated into the installation package. The system was started up without a larger overflow line installed. As a result, the wastewater tank was overpressurized and failed.

Example 2

  • A scenario for rapid overpressurization of an atmospheric decanter system was not considered prior to startup of a process because the hazard review did not address procedural deviations during an allowable startup mode. As a result, no safeguards were put in place to mitigate these errors.

Example 3

  • No job safety analysis was performed prior to disassembly of a pump involved in an incident. Acid had entered the pump during the incident, and the workers were exposed to it during the disassembly process. No job safety analysis had been performed because the disassembly used a standard procedure.

Example 4

  • Lineman were assigned the task of moving a 30-foot utility pole as part of a road widening project. The linemen performed a pre-job brief that included a job safety analysis (JSA) of this particular situation because the generic JSA needed to be tailored to the specific conditions of this job site. A cable television cable, that the personnel failed to identify during the JSA, was damaged during the work.

Typical Recommendations

  • Ensure that all newly installed and/or significantly modified equipment is included in a hazard review prior to startup.
  • Track and document the final resolution for all recommendations.
  • Ensure that personnel, equipment, and environmental losses are all addressed in the review.

Cross-References

Version 10 Element(s)
Node ID Node Name
72 Safety/Hazard/Risk Review

 

PSM Element(s)
14

 

RBPS Element(s)
Hazard Identification and Risk Analysis

 

Maritime Element(s)
Node ID Node Name
84 Safety/Hazard/Risk/Security Review Issue
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