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Real-world sample PHA using What-If Methodology provides valuable insight for newcomers to the process

Item Equipment Tag / Activity Question Scenario Consequence / Hazards Engineering / Admin Controls C F R Recommendations
4.025 All equipment found on all drawings. Facility Siting: Emergency Situation There is insufficient staffing to maintain (PSM) critical equipment and document activities as required by 29 CFR 1910.119 (j) to meet minimum standards and provide for safe process operation Insufficient maintenance coverage due to company downsizing Loss of VPP Recognition/Status Potential Violations/Fines Exposure to litigation Fire/Explosion Potential Release None 4 4 A Conduct study to determine the minimium staffing required to maintain critical equipment and staff accordingly.
4.018 All equipment found on all drawings. Facility Siting: Emergency Situation Control software is changed and modification is not communicated to affected employees Maintenance employee changes software and creates process upset Business Interruption
Potential for Spill
Potential for Fire
Training
System Backup
4 3 A Document all software changes via a written log. Require initials for review or changes. Investigate software for version control. Consider remote access for Control Engineer (i.e., Cytrix, PC Anywhere)
4.017 All equipment found on all drawings. Facility Siting: Emergency Situation Unauthorized tampering with an interlock Safety setpoints on load cells are
changed and the tank overflows.
CAMT high level setpoint is
adjusted outside of range and
overflow occurs.
Spill
Environmental Impact
Fire Potential
Process Interruption
Employee Training
Procedures
3 4 A Emphasize through training the requirements for interlock changes. Identify who is authorized. Strict and consistent enforcement or disciplinary polich.
4.016 All equipment found on all drawings. Facility Siting: Emergency Situation What if the emergency plan, the evacuation routes, and assembly point is not sited with consideration of possible incident locations? Evacuation points in relation to blowout panels Employee at Risk None 3 4 A Review evacuation assembly points to minimize risk to employees from blast in mixing.
4.015 All equipment found on all drawings. Facility Siting: Emergency Situation What if there is a potential for an incident with one piece of equipment to affect other equipment? Fire ignites in one mixing tank and spreads to other tanks(s). Process Interruption
Fire / Explosion
Quality Issue
Personnel Injury
Interlocks
Alarms
Human Intervention
4 1 C No recommendations
4.011 All equipment found on all drawings. Facility Siting: Control Room What if the control room is not designed and/or sited with consideration of possible process incidents? Blast occurs in mixing and shatters observation windows in control room Employee Injury Window covers with fusable links 2 4 B Confirm glass in window is blast resistant.
4.009 All equipment found on all drawings. Facility Siting: Security System What if there is no site security system? Unauthorized entry onto site by unauthorized personnel / contractors. Sabbotage
Fire / Explosion
Process Interruption
Risk to Onsite Employees
Controlled Acces
Perimiter Fencing
Camera Surveillance
Onsite Security Service
4 2 B Ensure security remains in place for life of facility.
4.003 All equipment found on all drawings. Facility Siting: HVAC Equipment What if a release is drawn back into the facility by HVAC equipment? A release is drawn back into the facility by HVAC equipment. This increases the exposure of employees to hazardous consequences. Employee Exposure
Fire / Explosion Potential
Low odor threshold allows for early detection 3 2 B No recommendations
4.002 All equipment found on all drawings. Facility Siting: External Events What if external events have not been accounted for in the system design? External events (e.g., natural disasters-tornado/hurricane, trucking or airplane crashes, etc.) have not been accounted for in the system design. The external event causes a leak / rupture, resulting in a release (i.e., SLA system is impacted by tornado / vehicle). Major Business Interruption
Property Damage
Potential Injuries
Emergency Disaster Plan 4 2 B Review integrity of supporting structure and accessibility to truck traffic. Install barriers where required or modify traffic patterns.
3.016 All equipment found on all drawings. Human Factors: Written Procedures What if a procedure is not periodically reviewed and updated? Changes are made in the process and existing procedures are not revised to reflect changes. Equipment Damage
Quality Issues
Employee Injury
Document Control
Required Annuual Procedure Review
2 4 B No recommendations
3.014 All equipment found on all drawings. Human Factors: Written Procedures What if there are no procedures for some or all of the operations or maintenance activities? Critical equipment maintenance is performed on equipment without documented PSM required maintenance procedures. Injury / Fatality
Equipment Damage
Process Interruption
Training
Job Knowledge
3 4 A Ensure all identified critical equipment has documented maintenance procedures and those procedures are followed.
3.013 All equipment found on all drawings. Human Factors: Training / Education What if employee training is not documented? Employee is not trained in safe work practices (Lockout Tagout / Operating Procedures). Injury / Fatality
Process Interruption
Documented Training 2 2 C Consider improving / enhancing software to notify area employees when refresher training is required.
3.012 All equipment found on all drawings. Human Factors: Task Design / Job Organization What if an employee is stressed due to shift work and overtime schedules? Due to staff shortages, employee is required to work extended hours (16). Fatigue increased risk for accidents
Morale Issues
Employee Health Issues
Overtime Policy 3 4 A Adhere / enforce overtime policy
Provide additional staff to provide coverage
3.009 All equipment found on all drawings. Human Factors: Organization / Policies What if human factors / issues are not systematically addressed by management? Employee reductions / staffing in hazardous areas requires employees to perform additional responsibilities and often work alone due to business conditions (cost reductions). Employee Injury / Fatality
Quality Issues
Potential for Fire / Explosion
Conflict Resolution Program
HR Hotline Ombudsman
3 3 B Educate levels of management with influence on decision making to the importance of staffing in critical areas.
3.007 All equipment found on all drawings. Human Factors: Workplace / Working Environment What if the work environment is too cold, hot, humid, noisy, or dark? Employee work environment is extremely hot and places employee at risk for heat stress / stroke due to insufficient cooling capability on first and second floor. Employee Injury / Fatality
Operator Error
P.M. - Facilities Maintenance 2 4 B Professional review of HVAC System by a competent expert with the necessary credentials and knowledge (i.e., ASHRAE P.E.)
3.005 All equipment found on all drawings. Human Factors: Operator / Process Interface What if set points are changed without authorization? Setpoints are changed without MOC resulting the equipment to operate outside the safe operating limits. Equipment Damage
Employee Injury / Fatality
Release
Process Interruption
Quality Issues
MOC Procedure Training 3 4 A Ensure operating limits established in operating procedures are communicated and adhered to.
3.004 All equipment found on all drawings. Human Factors: Operator / Process Interface What if the control / display layout does not follow the standard format? Controls are confusing and operator makes an error. Spill
Fire / Explosion Hazard
Interlocks / Alarms Training 3 1 C Standardize emergency push buttons through the Mixing Area.
3.003 All equipment found on all drawings. Human Factors: Operator / Process Interface What if an employee strikes equipment, piping, or valves with a hammer, wrench, etc? An employee strikes equipment / piping / valves with a hammer, wrench, etc. This causes a crack or rupture, resulting in a release. Fire / Explosion Potential
Employee Injury / Fatality
Spill
Training
Ventilation (reduced vapor concentration)
3 3 B Re-emphasize the importance through documented training.
3.002 All equipment found on all drawings. Human Factors: Operator / Process Interface What if the employee must perform maintenance on equipment while operating? Maintenance is performed on equipment while the equipment is operating. An upset occurs, exposing the maintenance personnel to a release. Employee Injury / Fatality Training
Job Knowledge
Manufacturer Recommendations
2 3 B Identify areas where this could occur and document the procedural requirements.
3.001 All equipment found on all drawings. Human Factors: Operator / Process Interface What if there is inadequate isolation prior to maintenance? Piping and / or equipment is inadequately isolated for maintenance. The piping / equipment is opened, resulting in a release. Spill
Employee Injury / Fatality
Equipment Damage
Fire / Explosion Potential
Lockout / Tagout Procedures 4 4 A Ensure that all equipment containing energy sources in the Mixing Area have a documented Lockout / Tagout Procedure in place.
2.003 All equipment found on all drawings. Emergency Situation: Location and Use of Emergency Equipment What if emergency equipment is incompatible between emergency response teams? Emergency equipment is incompatible between emergency response teams (e.g., fire department, hazardous response contractors, local emergency response teams, etc.). This results in an increased exposure to hazardous consequences. Delayed Response
Potential for Injuries / Fatalities
Coordinated Training w/ Fire Department
Radio exchange at Main Gate with Response Personnel
Roles and Responsibilities
3 1 C No recommendations
2.001 All equipment found on all drawings. Emergency Situation: Employee Emergency Notification System What if the employee emergency notification system is non existent, inadequate or inoperable during an emergency situation? The employee emergency notification system is non existent, inadequate or inoperable during emergency situation. This prevents proper initiation of emergency actions (e.g., evacuation, shelter in place), increasing the exposure to hazardous consequences Employee Injury / Fatality
Delay in Required Emergency Response
Separate Radio Frequencies
Dual Repeaters on Backup Power
Training
3 2 B Ensure / Verify repeaters are not on same circuit.
1.001 All equipment found on all drawings. Facility Siting: Equipment What if the instrumentation tubing is improperly protected? The instrumentation tubing is improperly protected. The tubing experiences an impact. This causes the tubing to leak, resulting in a release or this causes an incorrect reading resulting in a release. Potential for Unsafe Shutdown
Process Interruption
Spill / Release
Potentail Fire / Explosion
  2 3 B Conduct surveillance for tubing susceptible to impact.