February 2021

Environment and Safety

Implement effective operational discipline programs to improve process safety performance—Part 1

Operational discipline (OD) describes human behavior in complying with required systems, every time, to consistently achieve organizational goals and overall operational excellence.^1,2

Operational discipline (OD) describes human behavior in complying with required systems, every time, to consistently achieve organizational goals and overall operational excellence.^1,2 While a focus on OD is not a panacea, OD is a fundamental part of effective programs for achieving excellent performance in process safety, environmental, health and safety programs, quality, reliability and productivity.^2,3,4 Well-designed management systems are only the first step; the disciplined efforts of involved personnel in effectively implementing and following system requirements continuously are also needed. Failing to follow a system requirement—even just once—due to a human performance issue, inattention, complacency or other reason, can result in significant consequences, such as personal injury, environmental harm and business loss.

For example, an incident investigation by the U.S. Chemical Safety Board (CSB)⁵ concluded that an operator opened the bottom valve of an operating polymerization reactor, apparently bypassing an active pressure interlock, instead of the intended action of opening the bottom valve of a nearby reactor that was being cleaned. The resulting large release of hot, flammable material from the operating reactor ignited, leading to five fatalities and major damage to the facility. While the U.S. CSB investigation identified several other design and operating issues, human errors like this must be anticipated and appropriate safeguards provided to help prevent serious injuries and other significant consequences. Focusing on OD—doing the right thing, every time—is an essential component of maintaining effective safety programs and achieving excellent safety performance. Steps for getting started in implementing an OD program, or improving an existing effort, are discussed here.

Precursors to implementing OD

Precursors to implementing OD programs include:

• Recognizing and assessing hazards
• Implementing risk management programs.

It is necessary to know what hazards may be present to develop appropriate risk management requirements, so initial and continuing efforts to identify and assess hazards in the workplace define the type and level of risk management program needed.^2,6 If the hazards are not identified and assessed properly, how can appropriate safeguards and systems be implemented and maintained to manage the risks associated with those hazards? If process hazards, such as toxicity or flammability, are present, then a process safety program is needed. Depending on the actual level of risk, the quantity of hazardous materials present, intrinsic hazards, processing conditions, reactions and other factors, the requirements of a process safety program may vary and may or may not require regulatory compliance, such as with the Occupational Safety and Health Administration’s (OSHA’s) process safety management standard or other regulations. Occupational safety, industrial hygiene, environmental protection and other programs may also be required to help ensure all hazards are appropriately identified and managed.

As shown in FIG. 1, effective safety programs consist of three interrelated foundations² comprising:

1. Safety culture and leadership—Safety culture and leadership help define how an organization approaches and prioritizes problems and issues related to managing safety.^2,7 Is safety a core value with high priority in all cases, or is it more of an afterthought, subject to potentially conflicting organizational priorities such as cost or productivity? Safety culture influences the daily behaviors of leadership and workers, who either reinforce and improve the culture over time or allow it to degrade. Safety culture and leadership are part of the overall organizational culture that encompasses all the ways work is or should be done, as well as how it is impacted by safety considerations and requirements. In a weak safety culture, or with unaligned leadership, implementation of effective safety programs is often constrained, and achievement of excellent safety performance is difficult.
2. Safety systems—Comprehensive management systems provide a framework to help ensure hazards and associated risks are identified, evaluated and controlled.^2,7 In many cases, regulatory requirements provide a good starting point for defining the needed systems and requirements; however, in all cases, proper evaluation of potential risks is required to help ensure they are controlled and managed appropriately. This may necessitate going beyond the minimum essential practice defined by regulations, or may lead to complying with regulatory requirements when not required. Regulations [e.g., OSHA, U.S. Environmental Protection Agency (EPA)], consensus industry standards [e.g., National Fire Protection Association (NFPA), American Petroleum Institute (API)], industry guidance [e.g., Center for Chemical Process Safety (CCPS), American Society for Safety Professionals (ASSP)] and extensive literature provide detailed guidance for implementing appropriate safety management systems.
3. Operational discipline—OD, as defined previously, relates to how well safety and other systems are followed.^2,8,9,10 OD is influenced by many factors, including safety culture and leadership, quality of safety systems, and other human behavior and human factors programs.

Some precursors related to safety culture, leadership and safety systems that impact the effectiveness of an OD effort are listed below. Consideration should be given to implementing or strengthening safety and related programs in these areas if they are deficient.

Some precursors to effective OD programs include:

• Establishing safety as a core value vs. potential conflicting priorities, such as cost or productivity
• Committing to consistent and visible leadership of safety
• Promoting a sense of vulnerability to support safety awareness and engagement and avoid complacency
• Maintaining open communications
• Documenting operating procedures and safe work practices
• Developing effective and timely training practices
• Implementing fitness-for-duty programs to mitigate possible worker impairment due to stress, fatigue, alcohol, prescribed or over-the-counter medications, or illegal drugs
• Evaluating and managing process risks
• Monitoring and reviewing key performance indicators
• Providing management of change (MOC) programs to identify and manage new hazards that may be introduced
• Implementing equipment inspection, testing and preventive maintenance programs to help ensure tools and equipment are reliable and safe to use.

OD program characteristics

The characteristics and importance of effective OD programs have been discussed elsewhere^2,11,12,13 and have recently been reviewed in the context of achieving excellent process safety performance,^3,4 reducing loss of containment incidents¹⁴ and as a leading indicator of plant performance.¹⁵ OD programs comprise both organizational and personal OD efforts. The characteristics describing organizational OD^2,11 are intended to help company and/or facility leadership develop effective OD programs, based on:

• Leadership focus: Leaders emphasize and provide a positive work environment, managing processes and resources for effective programs and employee engagement. Leaders are personally involved and passionate about safety and reflect the behaviors
  they expect from their organization. A leader’s consistent behavior helps build trust and engagement in the organization.
• Employee engagement: Employees understand and value the importance of safe work activities and contribute to organizational programs and activities.
• Procedural principles: Correct ways of performing work are defined and completed as planned, following documented and authorized systems and procedures.
• Housekeeping and workplace standards: Standards are established for maintaining safe equipment, tools and facilities. Employees are proud of their work environment and consistently maintain high levels of housekeeping.

Organizational OD efforts are closely related to good safety culture and leadership practices. As shown in FIG. 1, effective safety management systems also help enable workers at all levels of an organization to do their work correctly and safely, every time.

The characteristics describing personal OD^2,11, as shown in FIG. 2, are intended to support the day-to-day focus on OD to help ensure all employees:

• Know how to perform their work correctly and safely (knowledge)
• Commit and plan to perform the work the correct way without deviations or shortcuts, based on training (commitment)
• Anticipate and are prepared for what could go wrong or look for and recognize what may be different in their current work environment and respond accordingly, based on training and experience (awareness).

The goal is to have knowledgeable, prepared, experienced workers at all levels of the organization who account for the existing work environment rather than have an unquestioning focus on strict adherence to procedure when circumstances vary or change. This requires developing appropriate operating procedures and effective on-the-job training for required work activities, including recognition and troubleshooting of possible deviations and the correct responses. This provides a foundation for thoughtful compliance. A summary of the OD program characteristics and their relationships is shown in FIG. 3.

IMPLEMENTING EFFECTIVE OD PROGRAMS

Implementing an effective OD program or improving an existing program depends on the starting point and intended goals. Key activities, which will be discussed in following sections, include:

1. Focusing on OD improvement
2. Raising awareness and value for OD
3. Evaluating OD performance
4. Identifying, prioritizing and pursuing improvement opportunities
5. Sustaining and renewing OD program activities.

Focusing on OD improvement

Management should consider improving OD for the following reasons:

• A required part of effective safety programs, as shown in FIG. 1
• Poor performance either creates the desire to improve or allows continued problems
• Good performance creates the desire to avoid complacency.

Benefits of an effective OD program include:^2,8

• Process (and other) hazards and risks are identified, evaluated and managed
• Equipment and facilities are properly designed, operated and maintained
• Management systems are well designed, implemented, executed and supported
• Operating problems, incidents and near misses are consistently investigated and addressed.

As a result, process safety, environment, health and safety (EHS) performance, productivity and cost, and product quality performance should improve. To achieve or improve these results, appropriate management focus on improving OD is required to get started due to the need to:²

• Demonstrate personal attention and commitment to the effort
• Provide appropriate resources to support program execution
• Develop effective processes to facilitate employee awareness, understanding and involvement
• Implement, improve, standardize and maintain needed systems and activities
• Support, evaluate and monitor performance, including frequent observation of work tasks.

OD-related requirements should be added to appropriate process safety, incident investigation, auditing, and other standards and guidelines to support consistent implementation of OD activities. For example, incident and near-miss investigation standards should be revised to include the identification of OD-related causal factors, which can be used to help reduce incident frequency and identify potential OD improvement opportunities. OD learning opportunities can be also identified from investigating EHS, quality, productivity and other operational problems, in addition to process safety.

Failure to implement or sustain effective OD programs can be catastrophic. For example, the 2005 Texas City refinery explosion investigated by the U.S. CSB¹⁶ resulted in 15 fatalities, 180 injuries and major facility damage, as shown in FIG. 4. While the CSB identified many causes, some of the OD issues identified in the CSB investigation of the incident are highlighted below. Subsequent investigations¹⁷ of several company refineries found “instances of a lack of OD, tolerance of serious deviations from safe operating practices, and apparent complacency toward serious process safety risks at each refinery.”

Examples of OD issues identified by the CSB refinery investigation include:¹⁶

• Management did not emphasize the importance of following procedures as evidenced by its (1) lack of enforcement of the MOC policy, (2) acceptance of procedural deviations during past startups, and (3) failure to ensure that procedures remained up to date and accurate, contributing to a work environment that encouraged operations personnel to deviate from procedures.
• Inadequate training for operations personnel contributed to causing the incident. The hazards of unit startup and for abnormal situations were not adequately covered in operator training.
• A “check-the-box” mentality was prevalent, where personnel completed paperwork and checked off on safety policy and procedural requirements even when those requirements had not been met, contributing to a culture of “casual compliance.”
• Managers did not effectively implement their pre-startup safety review policy to (1) ensure nonessential personnel were removed from areas in and around process units during startups, and (2) verify the adequacy of all safety systems and equipment, including procedures and training, process safety information, alarms and equipment functionality, and instrument testing and calibration.
• A lack of supervisory oversight and technically trained personnel during the startup, an especially hazardous period, was an omission contrary to refinery guidelines. No experienced supervisor or technical expert was assigned to the startup after the day supervisor left, although safety procedures required such oversight.
• An effective incident investigation management system to capture appropriate lessons learned and implement needed changes had not been employed.
• The mechanical integrity program did not ensure that deficiencies were identified and repaired prior to failure, resulting in the “run to failure” of process equipment.

An effective OD program emphasizes completing all tasks correctly and safely, every time, regardless of the role of individuals in the organization—it is important to recognize that OD is for everyone, not just operators. Kletz,¹⁸ for example, observed that:

Every accident is due to human error: someone, usually a manager, has to decide what to do; someone, usually
a designer, has to decide how to do it; someone, usually an operator, has to do it. All of them can make errors, but the operator is at the end of the chain and often gets all the blame. We should consider the people who have opportunities to prevent accidents by changing objectives and methods, as well as those who actually carry out operations.¹⁸

It is also important to recognize that OD improvement efforts must relate to specific local site or organizational issues, based on differing safety culture, leadership, work activities, hazards and/or geographic locations. These factors likely vary from one site or area to another, especially in larger companies or facilities. Common issues may be identified, but local differences may lead to different priorities for improvement. Frequent observation of specific work activities can assist in identifying potential OD improvements.

It is necessary to start where you are, recognize where you are going and determine where you actually want to go in terms of improving OD. The FLAME model² describes best practices for leadership efforts in getting started on improving OD:

• Focus: Develop a plan to provide and enable appropriate focus on OD and effectively communicate the plan and associated goals to develop awareness and engage site personnel, who are supported daily through leadership attention and priorities.
• Leadership: Leadership acts as visible role models, committed to continuous improvement and excellent OD performance through the use of effective, consistent leadership practices.
• Accountability: Organizational, team and individual goals include a focus on OD with clear expectations on performance, feedback and recognition, as appropriate.
• Measurement: Metrics, audits and other tools are defined to periodically assess site activities, performance and progress
  toward goals.
• Engagement: Leaders provide a work environment that provides engagement and support to site personnel, based on good communication processes, employee input and involvement, and interdependent behaviors.
  Site personnel know they are important to success and their contributions are valued.

Although OD improvement is ultimately the responsibility of everyone in an organization, it can be helpful to assign an OD champion and team to provide additional focus and accountability for implementing and sustaining effective OD programs. An important goal is to create an OD flywheel^19,20 or habit²¹, where initially small changes lead to larger improvements and momentum over time to achieve OD goals and improve performance.

Part 2, which will appear in the March issue, will discuss raising OD awareness, evaluating OD performance, pursuing improvement opportunities and sustaining OD programs. HP

LITERATURE CITED

1. Klein, J. A., “Operational discipline in the workplace,” Process Safety Progress, Vol. 24, 2005.
2. Klein, J. A. and B. K. Vaughen, Process safety: Key concepts and practical applications, CRC Press, 2017.
3. Klein, J. A., “Tune up process safety performance,” Chemical Processing, October 2019.
4. Klein, J. A., “Sustaining effective process safety programs in CPI facilities,” Chemical Engineering, February 2020.
5. U. S. Chemical Safety Board, “Vinyl chloride monomer explosion,” Report No. 2004-10-I-IL, 2007.
6. Center for Chemical Process Safety (CCPS), A practical approach to hazard identification for operations and maintenance workers, Wiley-AIChE, June 2010.
7. Center for Chemical Process Safety (CCPS), Guidelines for risk-based process safety, Wiley-AIChE, March 2007.
8. Center for Chemical Process Safety (CCPS), Conduct of operations and operational discipline, Wiley-AIChE, 2011.
9. Klein, J. A., W. M. Bradshaw, L. N. Vanden Heuval, D. K. Lorenzo and G. Keeports, “Implementing an effective conduct of operations and operational discipline program,” Journal of Loss Prevention in the Process Industries, Vol. 24, 2011.
10. Vaughen, B. K., J. A. Klein and J. C. Champion, “Our process safety journey continues: Operational discipline today,” Process Safety Progress, Vol. 37, 2018.
11. Klein, J. A. and B. K. Vaughen, “A revised model for operational discipline,” Process Safety Progress, Vol. 27, 2008.
12. Klein, J. A. and E. M. Francisco, “Focus on personal operational discipline to get work done right,” Process Safety Progress, Vol. 31, 2012.
13. Klein, J. A. and B. K. Vaughen, “Implement an operational discipline program to improve plant process safety,” Chemical Engineering Progress (CEP), Vol. 107, 2011.
14. Klein, J. A. and S. Dean, “Develop a loss-of-containment reduction program,” Chemical Engineering Progress (CEP), Vol. 116, 2020.
15. Bitar, F. K., D. Chadwick-Jones, M. Lawrie, M. Nazaruk and C. Boodhai, “Empirical validation of operating discipline as a leading indicator of safety outputs and plant performance,” Safety Science, Vol. 104, 2018.
16. U. S. Chemical Safety Board, “Refinery explosion and fire,” Report No. 2005-04-I-TX, 2007.
17. Baker, J. A., et al., “The report of BP U.S. refineries independent safety review panel,” 2007.
18. Kletz, T., An engineer’s view of human error, 3rd Ed., CRC Press, 2001.
19. Collins, J., Good to great: Why some companies make the leap and others don’t, HarperBusiness, 2001.
20. Collins, J., Turning the flywheel, HarperCollins, 2019.
21. Clear, J., Atomic Habits, Avery, 2018.

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