Process Safety in the Fertilizer Industry,

a New Focus
Technical process safety came to prominence as a discipline in the 1960s and 1970s and has continued
to develop since then. However, major process incidents continue to occur and it is by no means certain
that the process industries’ performance is improving. The investigations into the explosion and fires at
BP’s Texas City Refinery in 2005 have presented a new challenge to the process industries as a whole
to re-emphasis and improve process safety management, and this has also been embraced by many
regulatory agencies. This will set the tone for the years to come, particularly in terms of the role of
leadership and the development of strong process safety cultures. Models are emerging to describe
leadership behaviours and the characteristics of process safety cultures and more work is likely to
follow. This paper describes the evolution of technical process safety, the new challenges that it faces to
re-focus, the development of the concepts of process safety leadership and culture and the practical
steps some organisations are taking to increase the profile of process safety

Phil Eames
ABB Global Consulting

John Brightling
Johnson Matthey Catalysts

been tremendous sharing of incidents and safety

T echnical process safety came to

prominence as a discipline in the 1960s
and 1970s and has continued to develop
since then. However, major process incidents
matters, however incidents continue to occur.

Fertiliser production and process

continue to occur and it is by no means certain risks
that the process industries’ performance is
improving. Manufactured fertilizers are essential for the
production of adequate quantities of food, feed,
There is particular reference to the ammonia fibre and bio-energy. However, the production of
industry as at the same time process safety was fertilizer products present challenges with
being developed as a discipline in the 1960’s and respect to process safety due to the hazards
1970’s new production technologies were also inherent in the manufacturing processes.
being developed. Through the years there has

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 The most common fertilizers in large scale ammonia plants developed in the 1960’s remains
manufacture are urea and ammonium nitrate, economic for many operators, meaning many of
both containing ammonia synthesised using a the early plants are still operating.
process based on the Haber Bosch method
discovered in 1909. It remains the only chemical The equipment and machinery used in modern
breakthrough recognized by two Nobel prizes for large fertilizer plants can achieve high
chemistry, awarded to Fritz Haber in 1918 and reliabilities with on-stream factors in excess of
Carl Bosch in 1931. 90%. However, due to complex demands in
terms of the compositions, pressures and
In the process, ammonia is produced from water, temperatures present there remains an underlying
air, and energy; the energy source is usually significant process safety challenge, as
natural gas. Steam reforming of natural gas is the demonstrated by numerous serious incidents that
most efficient route and is used in the majority of continue to occur and are reported in the news
ammonia plants. These normally follow a globally (Pattabathula, 2010).
conventional steam reforming single stream
process, although production based on coal In the most common large fertilizer production
gasification is on the increase, especially in units the following hazards are identified as risks
China. Economies of scale have led to for which effective preventive measures need to
increasingly larger plants being built; however be installed and maintained in a highly reliability
the core technology of the single stream state.

Industry incidents reported in recent media news (Sept 2009 to Sept 2010)

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 Ammonia Production Natural Gas Explosions in Furnaces
• Fire/explosion hazard due to: Case 1 - A primary reformer radiant box
explosion occurred in January 1984 at the
- leaks from the hydrocarbon feed
Western Cooperative Fertilizers Ltd Plant,
system;
Calgary, Canada (Sparrow, 1985) as the reformer
- leaks of synthesis gas in the was being lit for the third time. Severe damage to
CO/removal/synthesis gas the furnace roof occurred, but there were no
compression areas (75% injuries to personnel.
hydrogen);
- the formation of an flammable gas Case 2 – A primary reformer explosion occurred
mixture inside equipment, for in August 1985 on the auxiliary boiler at Triad
example in the reformer or Chemical Co, Donaldsonville, Louisana (Davis,
process air line. 1986). The explosion occurred during starting
up; again no-one was injured but the primary
• Toxic hazards from: reformer and adjacent equipment were heavily
- the release of liquid ammonia damaged. The investigation concluded that gas
from the synthesis loop; had entered through 16 small leaks on some of
the block valves used on the tunnel burners, arch
- accidental release during storage burners and superheater. After other auxiliary
and handling; boiler fire box explosions in the USA, double-
block-and-bleed systems have been
Urea Production implemented.
• Equipment/piping failure due to
corrosion; Case 3 – After a scheduled shutdown in October
1997 at Mossgas Ltd, Mossel Bay, South Africa,
• Explosion hazard due to the formation of a powerful explosion occurred in the firebox of
a flammable atmosphere; the primary reformer (Wet, 1998). Extensive
• Toxic hazard due to ammonia release; damage due to the failure required the total
rebuilding of the primary reformer. Two
Nitric Acid/Ammonium Nitrate Production operators who were on top of the reformer
escaped serious injury and suffered only minor
• Equipment piping failure due to
cuts and bruises.
corrosion,
• Explosion of the air ammonia mixture, Case 4 – An explosion occurred at Petrokemija
• Explosion of nitrite/nitrate salts. Kutina Fertilizer Co, Croatia (Babic, 2003) as the
ammonia plant was being started up in May 2002
after a short shutdown. The walls of the reformer
Process safety incidents in convection section and auxiliary boiler were
fertiliser production damaged; nobody was injured. The investigation
found that although some gas isolation valves
Historical reports of events show that the major were found to be leaking, the leak size was
incidents and accidents in ammonia plants are considered too small to create an explosive
explosions and fires. The following review of mixture so it was concluded that manual valves
published incidents demonstrates how process had not been sufficient closed. The lack of
safety lessons continue to be re-learned. detailed instructions for lighting the boiler and

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 the lack of procedural control, as well as human of factors such as (1) operators not following the
factors, were cited as reasons for the explosion. prescribed operating procedures, (2) hardware in
the form of a process air block valve and a
Case 5 – An explosion occurred at DSM, separate check (non-return) valve both failing to
Geleen, Netherlands (Duisters, 2005) in April stop the flow of process gas backwards and (3)
2003 during the lighting of a gas fired furnace of the set point in the control system for the purge
the melamine plant, resulting in three fatalities. having been set in error.
The accident happened because of the incorrect
application of a prescribed procedure for After much hard-won experience the author
restarting the furnace after a brief shutdown. The concluded his paper with “While nothing can be
investigation led to process hazards analysis made entirely failure proof, we have found that
studies on all DSM fertilisers gas fired sound engineering judgement and experience
equipment and many process safety can generally demonstrate room for
improvements. improvement and often this can be accomplished
without major expenditures if we look at what
Case 6 – An explosion occurred at Yara Tertre, can go wrong. We proved that if it can go wrong
Belgium (Flamme, 2010) during restart after an it usually will!”
unplanned plant trip in July 2009. The accident
resulted in two seriously injured operators and Case 2 – At the Petronas Fertilizers, Kedah,
significant damage to the primary reformer, Malaysia ammonia plant an explosion occurred
requiring a total rebuild. The incident September 1999 (Othman, 2002). The 12”
investigation concluded that the direct cause of process airline to the secondary reformer was
the accident was the introduction, by human ruptured for about 5-6 metres by the explosion,
error, of a large amount of fuel gas through unlit caused by back-flow of process gas containing
arch burner. hydrogen, methane and carbon monoxide into
the process air line.

Explosions in Process Air Feed line Contributory factors were stated as (1)
There have been a number of process air inadequate knowledge of the operating
incidents relating to inadequate isolation or procedures and (2) inadequate hardware
control when adding air into the process via the specification for leakage class of trip valves.
secondary reformer. This step is essential to add
nitrogen to the ammonia process; however air
contains oxygen which requires careful control. Explosions in Atmospheric Tanks
Atmospheric pressure tanks containing an
Case 1 - In a period of only seven months aqueous solution could be considered as less
between May to December 1980, Columbia hazardous than other parts of plant; however the
Nitrogen Corporation’s ammonia plant in following two incidents show how they are an
Augusta, Georgia (Clarke, 1981) experienced a ever present danger.
number of failures of the 14” process air piping
due backflow of process gas from the secondary Case 1 – An explosion of a weak aqueous
reformer, which ignited inside the piping when it ammonia solution tank occurred in January 1973
came into contact with the hot process air stream. at ICI Billingham, UK (Henderson, 1974). 1,000
tons of 10% ammonia solution escaped as the
The conclusions of the investigations were that bund wall was demolished in the incident. As it
the different failures resulted from a combination

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 spread over the surrounding area, 4 people were Case 1 - In July 1989 the casing of a high
affected by ammonia fumes. pressure ammonia pump on the Urea Plant
operated by ICI Billingham, UK failed
It was concluded that the tank failed because of catastrophically without warning (Nightingale,
the combustion of gases in the vapour space of 1990). The release of 10te liquid ammonia
the tank. However, a source of ignition could not resulted in the deaths of two employees who
be identified and therefore a new Code of were working close to the injector; other staff in
Practice was devised to cover all likely local control room used portable breathing sets to
possibilities, including use of mandatory escape as the control room proved to be
nitrogen gas blanket where hydrogen can inadequate as a toxic shelter.
accumulate, designing such tanks with the roof-
to-wall weld such that it fails first in the event of Recommendations from the investigation
over-pressuring and eliminating all possible included (1) formally registering machines (like
sources of ignition. In particular, the tank should vessels) so that inspection recording and design
be fully earthed, and any associated electrical review of all repairs is completed.; (2) other
equipment should not be capable of initiating an similar equipment being examined with a view to
explosion. The tank must be designed to how failure of the machine could lead to the
eliminate the likelihood of static discharges. possibility of loss of containment; (3) designing
ammonia isolation system so that releases can be
Case 2 – An explosion occurred in October 2009 minimised so far as is reasonably practicable in
at Yara Ferrara, Italy (Schlaug, 2010) on an the event of a loss of containment; (4) improving
atmospheric aqueous ammonia storage tank the integrity of the control room as a toxic refuge
collecting solution from purge scrubbers. The and (5) improving the site’s emergency
explosion was due to combustion of an procedures.
air/hydrogen mixture, with the most likely
scenario being that the explosive mixture ignited Case 2 – In May 2007 at Nagarjuna Fertilizers,
due to a lightning strike. Key learning from the India the seal of a high pressure ammonia pump
investigation was that hydrogen/air could failed after a cylinder locknut became undone
accumulate and reach explosive limits and this (Raghavan, 2010), resulting in the release a large
needs to be addressed through process design cloud of ammonia within the middle of an
either by removing risk of explosive ammonia/urea complex. Despite the large release
accumulation (e.g. nitrogen purge) or designing there were no reported injuries.
the systems so that all possible ignition sources
are eliminated with the applicable hazardous area Recommendations included improving the
classification code. design of the cylinder locknut and routine
inspection of it as a critical component.

Toxic hazard due to Ammonia Release It was concluded that (1) additional isolation
As well as fire and explosion hazards there is valves installed as a result of process hazards
also the potential for toxic hazard due to the analysis helped greatly in providing quick
handling and storage of liquid ammonia. positive isolation; (2) air respirator banks in all
Appropriate precautions to protect both the the main control rooms helped operators to
operators and the local population need to be continue and control the critical operations and
taken in the design and operation of the plants to (3) modifications should only be implemented
ensure that reliability is maximized with with original equipment manufacturers consent.
minimum risk.

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 Outside the ammonia and urea fertilizer operators. Initially the meetings were concerned
production facilities the downstream ammonia only with air separation plants, which were
storage facilities also continue to present a risk, susceptible to explosions and other incidents in
where a "small" release can cause multiple those days.
injuries to members of the public.
Over the years, thanks not least to the useful role
Recently after an incident in which following an of the sharing best practices, the reliability of air
ammonia release resulted in over 100 members separation plants improved steeply and the
of the public seeking medical attention, U.S. ammonia industry went through a phenomenal
Chemical Safety Board (CSB) Chairperson period of growth led by a revolution to modern
(Moure-Eraso, 2010) commented "We are seeing production technology. The modern ammonia
too many ammonia releases in our daily incident process was revolutionised in the mid- 1960’s
reviews. Though many are “small” releases, a allowing single stream plants of approximately
high consequence accident that causes multiple 1,000 tonnes per day capacity to be built based
injuries to members of the public is a serious one on steam technology since it has been developed
that warrants examination”. Based on the CSB's to allow ever larger plants up to 3,300 te/day.
monitoring of media reports there were four high However many of the older plants of 1960-
consequence incidents in the USA that involved 1980’s vintage remain running. At the time they
the release of anhydrous ammonia which led to a were built, plant designs complied with the
total of six fatalities in 2009. regulations of that time. However in recent
decades regulations have become stricter.
To ensure consistent company standards are
applied at a number of their terminals which are Beyond the fertilizer industry, technical process
of a different vintage, one company has recently safety came to prominence in the 1960s and 70s
described their approach using a process safety as incidents such as Feyzin (1966) and
management-based assessment (Bridges, 2010). Flixborough (1974) demonstrated the destructive
power of high hazard processes. Techniques such
as hazard and operability (HAZOP) study
The origins and development of emerged to improve the ability to identify and
process safety management control these process hazards; this technique was
made public following the Flixborough disaster.
Technical process safety is by no means a new
The Seveso incident (1976) prompted the
subject. Within the DuPont Company the tale is
development of a European regulatory
told of the company’s founder building his
framework focused on major process hazards
family home within range of his new explosives
which emerged in the 1980s. In the meantime, in
plant, on the banks of the Brandywine River in
the USA the explosion at Phillips’ Pasadena,
Delaware, as means to demonstrate his
Texas site (1988) triggered the emergence of the
confidence in the safety of his new explosives
first mandatory process safety management
process. That was in 1802.
(PSM) system required by the Occupational
Safety and Health Administration’s Process
In respect of the fertilizer industry a strong
Safety Management Standard (1992) and the
example of the long struggle for improvements
Environmental Protection Agency’s Risk
in process safety was the founding of "Safety in
Management Program (1996). Since then the
Ammonia Plants and Related Facilities"
requirements of the Seveso regime have been
meetings in 1956 by the American Institute of
tightened; technical developments have been
Chemical Engineers (AIChE) for the discussion
made in areas such as consequence modelling,
of safety-related issues for ammonia plant
quantified risk assessment and safety integrity

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 levels for instrumented protective systems; and The Baker Report challenge
the use of process safety management systems
has become widespread and is considered One fundamental finding within the Baker
industry best practice by International Fertilizer Report is that BP failed to sufficiently emphasise
Association (IFA) Safety Handbook (2009) process safety. This in itself constitutes a
significant challenge, but it also draws attention
to the critical factor, which is that managing
BP Texas City and the Baker Report process safety and personal safety are
fundamentally different activities (albeit
One might expect that, by now, there would be a overlapping). Indeed, the CSB investigation
degree of confidence in the management of report was heavily critical of BP’s failure to
process safety across the process industries, learn the lessons from three major process safety
together with clear indications of improvements incidents that occurred within a 10-day period at
in performance. its Grangemouth Refinery in Scotland in 2000;
an incident following which the UK Health and
However that appears to be far from the case. Safety Executive pointed out that “control of
This is shown in the history of incidents in major accident hazards requires a specific focus
ammonia production shown above, where similar on process safety above and beyond
process safety incidents continue to reoccur. conventional safety management” (UK Health
Also in the wider petrochemical industry, and Safety Executive (2003).
process incidents have continued at roughly
similar intervals to the past and one incident in A second important challenge offered by the
particular – the explosion at BP’s Texas City Baker Report relates to developing strong
Refinery on 23rd March 2005 – has presented a process safety leadership and process safety
major new challenge to the process industries in culture. Whilst the role of leadership and culture
terms of the focus on process safety are well understood in relation to personal safety
management. The reason for this is that in its the Baker Report coins the terms specifically in
investigation report (US Chemical Safety and relation to process safety, arguably for the first
Hazard Investigation Board, 2007) the US time. In doing so it again emphasises the
Chemical Safety and Hazard Investigation Board differences between process safety and personal
(CSB) recommended that BP commission an safety. This paper explores the linked concepts
independent review of process safety of process safety leadership and culture later.
management across all five of its US refineries.
The review (BP US Refineries Independent
Safety Review Panel, 2007), often referred to as Why the challenges have taken so
the Baker Report after its chairman ex-US
Secretary of State James Baker, made a set of long to emerge
far-reaching recommendations to BP In the meantime, it is useful to postulate why it
management that went well beyond the technical has taken so long for these challenges to emerge.
factors at which many major incident
investigations stop. Moreover, the Baker Report Two factors may be important. The first is that
suggested that these recommendations are likely process safety has evolved primarily as a
to apply to many companies across the process technical discipline, hence the term technical
industries. It is this challenge that has led to a process safety (or, in some companies, just
renewed focus on process safety, enthusiastically technical safety). Its proponents and practitioners
embraced by regulatory authorities. So what is were largely engineers and, over time, company
the nature of this challenge? senior management came to trust and leave it to

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 the experts without gaining personal the scenes” by the technical experts, and the
understanding or devoting prominent attention to primacy given to personal safety.
it. Although the emergence of process safety
management systems has brought the term
management alongside that of process safety, How other changes are making
these systems are based around the process safety management more
implementation of technical procedures such as difficult
change control and equipment integrity
management. The emergence of the discipline of In the meantime, the process industries have also
human factors has helped to bring focus on been changing rapidly; new business practices
people within the process safety arena but has have emerged that are making the successful
taken the Baker Panel to draw specific attention management of process safety even more
to process safety leadership and culture. challenging. These include (Moosemiller and
Antrobus (2009) :
The second factor that may have held back the
The consolidation of small companies
prominence of process safety is the revolution in into larger ones, reducing the ability of
personal safety management that has taken place central organisations to oversee
since the early 1990s. The process industries individual sites;
have invested, and continue to invest, enormous
The decentralisation of corporate
resources in the reduction of personal injuries. functions, forcing sites to set their own
The concepts of leadership and culture have long standards and resulting in a narrower
been associated with personal safety experience base and loss of corporate
management, drawing on the models of memory;
traditional leaders in the field such as DuPont.

Reductions in work forces, stretching
Safety professionals have been very successful in
manpower and causing a loss of
training and coaching leaders and senior
corporate memory, and;
managers in the behaviours required to drive
improvements in personal safety and, very
Frequent merging and demerging of
importantly, bringing to prominence at board companies, increasing the possibility of
level safety performance statistics such as lost buying assets or operations with risk
time injury frequency rates (which are also exposures that are not well understood.
required by regulatory authorities). In many
cases the focus on driving down injury rates All of these factors were present in the
(which are easily measured) may have diverted background to the BP Texas City incident.
attention from process safety (which is not easily
measured); this was clearly brought out in the And finally, while changes in business practices
CSB and Baker Reports. Worse, many senior have the potential to make process safety
managers and safety professionals may have management more challenging, the increasing
come to assume that in improving personal age of many facilities and the extension of asset
safety performance they would also improve life beyond the original design intent has the
process safety performance. It has taken BP potential to increase the likelihood of major
Texas City to point out that such an assumption process incidents, either due to failure to keep
has limited validity. pace with increasing maintenance needs or due
to failure modes that were not anticipated over
So two important factors may have combined to the expected lifetime of the asset. Evidence from
hold back developments in process safety; the within the insurance industry has emerged that
assumption that it could be dealt with “behind ageing assets may already be contributing to

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 increasing losses in the oil refining sector (Marsh no immediate feedback to enable
Risk Consulting, 2003). This sector is unlikely to recovery.
be alone.
The lack of personal experience of
process safety incidents means that most
All these factors combine to make a compelling learning must come from outside of the
case to take up the challenge of the Baker Report organisation.
and focus increasing attention and resources on
the management of process safety. These differences warn us against assuming that
the “hearts and minds” approach to safety
improvement, which works well when
Personal and process safety influencing personal behaviour to keep oneself
Before considering the challenges of developing safe and act as “brother’s keeper”, will be
process safety leadership and culture it is worth equally effective in securing improvements in
pausing to review some important differences process safety. It has a part to play, but avoiding
between the management of personal safety and process safety incidents involves the combined
process safety and the implications of these efforts of large numbers of people, many of
differences. whom will not be able to see the full picture

The relative rarity of process safety from day to day.
incidents compared to injuries within an
organisation means that conventional This leads us to consider leadership and culture
lagging performance indicators are of in relation to process safety.
little use. We cannot wait to learn from
bad experiences. Proactive and predictive
metrics that are specific to process safety
Process safety leadership
are required. Although aspects of the role of leadership in

The relative complexity of causation of process safety management have been discussed
process safety incidents compared to in connection with incidents where the failures of
injuries, combined with the fact that the senior management have been apparent, such as
agent of a process safety incident is often the Piper Alpha oil rig disaster of 1988 (Cullen,
not the victim, means there is a need to 1990), the emergence of models of required
influence the organisation as a team leadership behaviours have only emerged more
rather than as individuals. The focus must recently, for example in the writings of Hopkins
be on organisational practices rather than on the Esso Longford (1998) and BP Texas City
individual mindsets. incidents (Hopkins, 2009). Examples of required
leadership behaviour include:

The previous point is underlined by the
fact that causes of process safety
Leading by example in terms of personal
incidents and their effects can be interest, communication and the setting
separated in time by many years is an of process safety goals.
indication that un-revealed or latent
Ensuring that there is process safety
failures can exist. When we return home expertise at levels of the organisation that
uninjured each day we have immediate are appropriate to the decisions that could
feedback that we have been successful in affect process safety management,
our efforts; however a design error or principally resource and investment
poorly executed modification may not decisions.
reveal itself for many years; there is often

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The operation of reward or incentive events and are ever “mindful” of the
systems that give appropriate emphasis to impact of failure.
process safety activities and goals.
Just organisations that exhibit a strong

The investment of financial resources to atmosphere of trust and understand that
undertake periodic process hazard human errors are not the root causes of
reviews and - importantly - implement incidents but rather are caused
the risk reduction opportunities that they themselves by personal, and
may identify. organisational factors.

The investment in process safety training
Disciplined organisations that understand
and competence assessment and the the importance of operational discipline,
safeguarding of corporate memory, or everybody combining to perform every
including retention of process safety task right first time.
expertise.
Learning organisations that take the time

The establishment of effective assurance and allocate resources to implementing
or governance processes to provide lessons from failures in other
assurance that process safety organisation as well as their own.
management systems are being
implemented effectively across the
organisation. High reliability organisations

The development of process safety The informed, “mindful” or resilient organisation
performance indicators which provide is the subject of ongoing work on high reliability
performance information at different organisations (Weick and Sutcliffe, 2007). These
levels of the organisation that is are organisations that are complex, operate in
appropriate to the types of resourcing and environments where the consequences of failure
investment decision made at each level. are high and yet have better-safety performance

The fostering of a strong process safety than might be expected; examples are nuclear
culture. submarines, electricity grid controllers and air
traffic controllers. Studies have defined five
This leads to the concept of a process safety characteristics that distinguish these
culture. organisations’ behaviours in unexpected or fast-
moving situations; behaviours that provide the
resilience to prevent the development of serious
Process safety culture incidents and return to normality.
The relevance of culture to process safety has
A preoccupation with failure - the
been discussed by several authors (Reason, 1997 recognition that weak signals of failure
and Hopkins, 2005). These sources define a may be symptoms of bigger problems
number of characteristics of organisations with a and demand a strong corrective response
strong process safety culture. They are: to prevent further degradation towards an

Cognisant organisations that understand incident. This would include errors that
the nature of the process safety war as “a do not result in near-miss situations.
long guerrilla struggle with no final
A reluctance to simplify – a desire for
victory” (12). detailed understanding of issues through

Informed (reporting) organisations that the sharing of diverse opinions as
encourage the reporting of near miss opposed to the temptation to categorise
issues by generic type.

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Sensitivity to operations – paying close structured hazard reviews and process
attention to what is actually happening; hazards analysis revalidations with the
comparing what is happening to what involvement of front-line staff to increase
was expected and interacting to build a the focus on human factors.
clear picture of the real situation with a
Establishing process safety expertise in
focus on front-line staff as the key appropriate parts of the organisation to
players. complement personal safety management

A commitment to resilience through the resources, recognising that many safety
active development of the skills and managers are insufficiently trained or
knowledge or front-line to staff to handle experienced to hold process safety
unexpected situations. management responsibilities.

Deference to expertise – the capability to
Undertaking assessments or audits of
take a flexible response to an unexpected process safety management systems and
situation and allow the person or team the health of protective layers relating to
best placed to respond to take authority. key process hazards to establish baselines
for improvement plans.
This work provides an example of research that
Establishing process safety committees to
is aimed at developing blueprints for promote process safety at senior and local
transforming organisations that will be operating levels.
increasingly valuable in the process industries.
Developing process safety goals and
Other models and blueprints will emerge over metrics at site and higher levels to
time. In the meantime, what are organisations provide an appropriate focus on
doing now to re-emphasise process safety? performance and demonstrate effective
corporate governance.
Practical steps to improved
process safety management Conclusion
The efforts that different organisations are
In conclusion, the process industries have been
making to raise the profile of process safety and
presented with a challenge to improve the
improve performance obviously differ according management of process safety as a result of the
to the respective organisations’ perceptions of investigations into explosions and fires at BP’s
where they stand in terms of performance, Texas City Refinery in 2005. There are many
management systems and culture as well as their examples of companies and industry
aspirations. While there is no widely accepted organisations taking up this challenge and
blueprint for a transformational process, it is starting to embrace the concepts of leadership in
possible to identify a number of activities that process safety and process safety culture. These
various organisations are using to improve the concepts will doubtless undergo further research
management of process safety. Some of these are in an effort to establish methodologies for
listed below: transforming performance. But in the meantime,

Promoting a shared understanding of recognising culture change as a long-term
process safety and process safety aspiration, companies are taking steps towards
management at all levels of the raising the profile of process safety across their
organisation by means of training. organisations and improving their understanding

Reassessing or updating the company’s of process risks and their management systems.
process safety risk portfolio by means of

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 References Moosemiller and Antrobus (2009), Your Money
or Your Life, The Chemical Engineer (tce)
Babic, Z and Losso, I (2003), Explosion of an December 2009 – January 2010, 28-30.
Auxiliary Boiler, Vol. 44, AIChE Ammonia
Safety Symposium Denver, CO. Nightingale, P J (1990) Major Incident
Following the Failure of an Ammonia Injector on
BP US Refineries Independent Safety Review a Urea Plant, Vol.31 AIChE Ammonia Safety
Panel (2007). Symposium San Diego, CA.
Bridges, M G and Mason, J (2010) Ammonia Othman M N, Niwa K and Bakkerud P K (2002)
Terminals Risk Management Improvements, Downgraded High Temperature Converter and
Vol51 AIChE Ammonia Safety Symposium San Explosion in Air Line to Secondary Reformer,
Francisco, CA. Vol. 43 AIChE Ammonia Safety Symposium
San Diego, CA.
Clark, R W (1981), Failure of a Process Air
Line, AIChE Ammonia Safety Symposium Pattabathula, V (2010) Review of 12-months of
Montreal, Canada. Ammonia Industry Incidents Reported in
Industry News (private correspondence).
Cullen (1990), The Public Inquiry into the Piper
Alpha Disaster, HM Stationery Office. Reason, J (1997), Managing the Risks of
Organisational Accidents, Ashgate Publishing.
Davis, G (1986). Investigation and Repair of an
Auxiliary Boiler Explosion, Vol. 27, AIChE Raghavan R, Reddy P H N and Singh R (2010)
Ammonia Safety Symposium Boston, MA. Major Ammonia Leak from HP Ammonia Feed
Pump, Vol.51 AIChE Ammonia Safety
Duisters, H (2005) Safe Use of Gas Fired
Symposium San Francisco, CA.
Equipment in Fertiliser Plants, International
Fertiliser Society Proceeding No. 562. Schlaug, M (2010) Explosion of Aqueous
Ammonia Scrubber Tank at Yara Italia, Ferrara,
Flamme, A, Broeck S V D and Versteele W
Vol.51 AIChE Ammonia Safety Symposium San
(2010), Ammonia Plant Primary Reformer
Francisco, CA.
Explosion, Vol.51 AIChE Ammonia Safety
Symposium San Francisco, CA. Sparrow, E (1985). Firebox Explosion in a
Primary Reformer Furnace, Vol. 26, AIChE
Henderson, D (1974) Explosion of Ammonia
Ammonia Safety Symposium Seattle, WA.
Liquor Tank, Vol. 17 AIChE Ammonia Safety
Symposium Salt Lake City, UT. UK Health and Safety Executive (2003), Major
Incident Investigation Report, BP Grangemouth
Hopkins, A (2009), Failure to Learn – the BP
Scotland 29th May – 10th June 2000,
Texas City Refinery Disaster, CCH Australia.
US Chemical Safety and Hazard Investigation
Hopkins, A (2005), Safety, Culture and Risk -
Board (2007), Investigation Report – Refinery
The Organisational Causes of Disasters,
Explosion and Fire, Report No. 2005-04-I-TX.
Hopkins, CCH Australia.
Weick and Sutcliffe (2007), Managing the
IFA Safety Handbook (2009). Establishing and
Unexpected 2nd edition, Wiley.
Maintaining Positive Safety Management
Practices in the Work Place.
Marsh Risk Consulting (2003), The 100 Largest
Losses 1972 – 2001, 20th Edition.

AMMONIA TECHNICAL MANUAL 312 2011

2011 [312] AMMONIA TECHNICAL MANUAL