Process Safety is about managing the integrity of systems and processes to prevent serious injuries and incidents resulting from toxic releases, fires, explosions, and uncontrolled reactions.

These potential high-severity events may result from many different activities and each incident results from a complex interaction between the actions of people working in different teams, different processes, and equipment.

Learning from Normal Work is not about imposing rules, but about revealing how the work is really done in practice. Therefore, the starting point for proactive learning is an activity, e.g. log out tag out, or isolation, and not a verification of compliance with a process.

Let me show you an example.

A large refinery had suffered several significant incidents in the years preceding 2017. The site and one of the production units decided to apply the Walk-Through / Talk-Through (WTTT), and learning teams to their log-out / tag-out (LOTO) process and isolation procedures.

First, a series of WTTTs were conducted with individual operators to examine a recent incident and how LOTOs are executed. The learnings from these provided materials for further engagement with the shift teams leads and unit management, and the development of a case for change.

Then, a 2-day long learning team was subsequently organized and focused on how the unit conducted its LOTOs.

The team was composed of two operators from each of the five shifts that work in the unit, two of the shift leaders, and representatives from the maintenance, planning, contractors, and HSE departments.

They dissected the task from how the job request is first raised, scoped, and planned, how it is executed in the field, through to the final return to service of the system.

The team found a range of improvement opportunities from lack of coordinated verifications, to multiple versions of procedures in place, inadequate line labeling, gaps in emergency response, and more.

It prompted the unit to immediately implement a pilot program.

The corrective actions included introducing coordinated verifications of critical steps, changing how the company assessed risk how they used field checks or a new practice of using marking-up processes and equipment drawings and bringing these on all field checks, and many others.