106: Analysis Issue

Node Analysis Issue

Definition/Typical Issues

Was the safety/hazard/risk review procedure inappropriate? Does it provide insufficient guidance for the scope of the review? Are the resources needed to perform the review not available? Are personnel inadequately trained in use of the procedure?

Did the analysis fail to consider all modes of operation/maintenance or other required hazard review issues? Did the review fail to address the requirements of all applicable orders, regulations, and guides?

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: This node addresses situations where the analysis identified the wrong hazards, causes, or consequences. Situations where the correct hazards, causes, and consequences were identified but incorrect or ineffective recommendations are specified are addressed by the Recommendation Identification Issue (#107) node.

Examples 

Example 1

  • An explosion occurred in a waste tank because incompatible materials were mixed. The process hazard review had been performed, but it failed to consider all the possible sources of material that could be added to the tank.

Example 2

  • A complex shutdown system failed to mitigate a process upset, resulting in a release of a hazardous material. The review procedure for the plant specified that a hazard and operability (HAZOP) analysis be performed for all new/modified systems; however, the HAZOP system was not well suited for analyzing this type of system (the failure modes and effects analysis technique would have been a better choice of technique).

Example 3

  • A major spill violating an environmental permit occurred at a process that had recently undergone a hazard review. This type of spill, which had no safety consequences, was not addressed in the study because the review procedure did not require evaluation of environmental hazards.

Example 4

  • A risk assessment was recently performed on a packaging operation. The risk assessment did not address supply problems because the review procedure did not require that issue to be considered. Later, a fire at a key supplier's facility led to a 4-week shutdown.

Example 5

  • The facility's control system was modified to allow wireless control of systems from throughout the facility. There was no existing standard by which the wireless control system might be assessed. Interactions with other radio signal devices in the facility caused spurious actuations of equipment.

Typical Recommendations

  • Ensure that the hazard review technique is appropriate for the complexity of the process.
  • Ensure that the hazard review technique is appropriate for the process being analyzed.
  • Ensure that hazard reviews comply with all applicable orders, regulations, and guides (e.g., some include specific checklists for the safety/hazard review).
  • Ensure that the review procedure addresses the scope of analyses and the training required for hazard analysis team leaders.
  • Determine the types and severity of consequences to be addressed in the program, for example:
    • Worker injuries exceeding a threshold
    • Public injuries exceeding a threshold
    • Environmental damage exceeding a threshold
    • Property damage exceeding a threshold
    • Business interruption losses exceeding a threshold
    • Company reputation damage exceeding a threshold
  • Provide detailed training to all employees and contractors who are assigned specific roles in performing proactive analyses.
  • Use checklists to prompt personnel to consider a broad spectrum of hazards.
  • List accident scenarios that represent the range of consequences identified in previous hazard identification and risk assessment work activities.
  • Expand the list of accident scenarios to those that are identified based on expert opinion.
  • For emergency response planning analyses, critically review the accident scenario list and (1) remove scenarios that are not credible or very unlikely to be severe enough to warrant emergency response, (2) consolidate scenarios that appear to be very similar in effects and tactics that might be used for response, and (3) ensure that it includes both worst credible case scenarios and more likely, less severe scenarios.
  • Assess the range of accident scenarios in terms of types of consequences (fire, explosion, toxic release, etc.) and the "footprint" of these consequences.
  • Model the expected impacts from the planning scenarios to determine the geographical area that might be affected by each scenario.

Cross-References

Version 10 Element(s)
Node ID Node Name
77 Review Procedure LTA

 

Maritime Element(s)
Node ID Node Name
88 Ineffective Review
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