Question 3 – Safety Management Systems [20 Marks in total, target 800 words]

The incident at the BP Texas City Refinery revealed critical failures in various elements of the management
system, as outlined in the Energy Institute framework. The identified deficiencies encompassed a wide
range of factors contributing to the catastrophic event. In technical writing style, here are the extracted
elements of the management system that failed:
1. Leadership Commitment:
Inadequate oversight by the BP Board of Directors, resulting in a lack of effective leadership
commitment to safety culture and major accident prevention programs.
2. Policy and Strategic Objectives:
Failure in articulating and enforcing policies that prioritize process safety over cost-cutting
measures, leading to impaired safety performance.
3. Organizational Structure:
Absence of a member within the BP Board specifically responsible for assessing and verifying the
performance of major accident hazard prevention programs, indicating deficiencies in
organizational structure.
4. Communication Protocols:
Poor communication between supervisors and operators during critical shift turnovers, contributing
to a lack of awareness regarding the hazardous conditions during the startup process.
5. Training and Competence:
Inadequate operator training programs, with reductions in central training department staff and
unavailability of simulators for practicing abnormal situations, such as startups and unit upsets.
6. Fatigue Management:
Extended working hours (12-hour shifts for 29 or more consecutive days) leading to operator
fatigue during critical operational phases.
7. Mechanical Integrity Program:
Deficiencies in the mechanical integrity program resulting in a "run to failure" approach for process
equipment, jeopardizing overall process safety.
8. Reporting Culture:
Lack of a reporting and learning culture, where personnel were not encouraged to report safety
problems, and fear of retaliation hindered the reporting of incidents and near-misses.
9. Safety Metrics Focus:
Emphasis on improving personal safety metrics and worker behaviors rather than addressing
process safety and management safety systems.
10. Timely Response to Safety Issues:
Delayed and insufficient responses to identified safety problems, with surveys, studies, and audits
highlighting deep-seated issues that were addressed inadequately and belatedly.
11. Risk Assessment Methods:
Reliance on a low personal injury rate as a primary safety indicator, failing to provide an accurate
representation of process safety performance.
12. Incident Investigation Procedures:
Ineffectual assessment of changes involving people, policies, or the organization that could impact
process safety, indicating shortcomings in the incident investigation procedures.
13. Equipment Safety Standards:
Failure to replace outdated and unsafe equipment, such as blowdown drums and atmospheric
stacks, despite previous incidents warning about their hazards.
14. Supervisory Oversight:
Lack of supervisory oversight during hazardous startup periods, exemplified by the omission of an
extra board operator during ISOM startups.
15. Cultural Shift towards Safety:
 A prevailing "check the box" mentality, where personnel completed paperwork without ensuring
that safety policy and procedural requirements were met, contributing to a superficial adherence to
safety standards.
These identified failures underscore systemic deficiencies in crucial aspects of the management system,
emphasizing the need for comprehensive improvements to ensure effective process safety management.

3b) Suggest improvements and performance indicators:

Improvements to the identified elements in the management system at the BP Texas City Refinery should
involve a comprehensive and integrated approach to enhance safety culture, operational practices, and
organizational structure. Performance indicators are crucial to monitor and measure the effectiveness of
these improvements. Here are suggested improvements and corresponding performance indicators for the
identified elements:
1. Leadership Commitment:
Improvement: Establish a Safety Oversight Committee within the Board of Directors responsible for
regularly assessing and verifying the performance of major accident hazard prevention programs.
Performance Indicator: Regular reports and assessments from the Safety Oversight Committee on safety
culture and major accident prevention initiatives.
2. Policy and Strategic Objectives:
Improvement: Revise policies to prioritize process safety over cost-cutting measures, emphasizing a long-
term commitment to safety.
Performance Indicator: Percentage reduction in safety incidents compared to the previous year,
demonstrating a positive correlation with safety-focused policies.
3. Organizational Structure:
Improvement: Appoint a dedicated executive responsible for major accident hazard prevention within the
BP Board.
Performance Indicator: Successful execution of safety initiatives and a decrease in major accidents under
the oversight of the appointed executive.
4. Communication Protocols:
Improvement: Implement a robust communication protocol during shift turnovers, emphasizing critical
information exchange.
Performance Indicator: Regular audits ensuring adherence to shift turnover communication requirements.
5. Training and Competence:
Improvement: Increase investment in operator training programs, including simulator availability for
practicing abnormal situations.
Performance Indicator: Increase in the percentage of operators completing advanced training modules and
simulations.
6. Fatigue Management:
Improvement: Implement a fatigue management program, including defined rest periods and limitations on
consecutive working days.
Performance Indicator: Reduction in incidents related to operator fatigue during critical operational phases.
7. Mechanical Integrity Program:
Improvement: Strengthen the mechanical integrity program to include proactive maintenance and timely
equipment replacements.
Performance Indicator: Reduction in unplanned downtime due to equipment failure.
8. Reporting Culture:
Improvement: Foster a reporting and learning culture by implementing a confidential reporting system and
protection against retaliation.
Performance Indicator: Increase in the number of reported incidents and near-misses compared to the
previous year.
9. Safety Metrics Focus:
Improvement: Shift focus towards improving process safety metrics and management safety systems.
Performance Indicator: Reduction in process-related incidents and near-misses, with a concurrent increase
in process safety compliance metrics.
10. Timely Response to Safety Issues:
Improvement: Establish a proactive safety improvement task force to promptly address identified safety
problems.
Performance Indicator: Decrease in the time taken to implement corrective actions following safety
assessments.
11. Risk Assessment Methods:
Improvement: Implement a comprehensive risk assessment framework that goes beyond personal injury
rates.
Performance Indicator: Adoption of a more holistic risk assessment methodology and a demonstrated
decrease in major safety incidents.
12. Incident Investigation Procedures:
Improvement: Enhance incident investigation procedures to include assessments of organizational changes
impacting process safety.
Performance Indicator: Successful implementation of recommendations from incident investigations
related to organizational changes.
13. Equipment Safety Standards:
Improvement: Establish a robust equipment replacement program based on safety standards.
Performance Indicator: Regular inspections confirming the replacement of outdated and unsafe equipment
according to safety standards.
14. Supervisory Oversight:
Improvement: Ensure adequate supervisory oversight during hazardous periods, including additional
operators during critical phases.
Performance Indicator: Decrease in incidents during startup periods and increased supervisory presence
during critical operational phases.
15. Cultural Shift towards Safety:
Improvement: Promote a genuine commitment to safety rather than a "check the box" mentality through
training and awareness programs.
Performance Indicator: Increase in employee engagement surveys indicating a positive shift in safety
culture perceptions.
Question 4 – HAZOP on Gas Reception Terminal
Plan for the HAZOP study on the Gas Reception Terminal Stabilization Process:

Team Member Skills and Attributes:

1. Chemical Process Engineer: Understanding of the gas reception terminal processes, equipment,
and their interconnections. Proficient in P&IDs and PFDs.
Justification: A chemical Process Engineer is essential for understanding the intricacies of the gas
reception terminal processes, ensuring a comprehensive analysis of the entire system. Their
proficiency in interpreting P&IDs and PFDs enables them to identify potential hazards associated
with process equipment, flows, and interconnections.
2. Safety Engineer: Expertise in process safety and loss prevention, familiar with hazard
identification methods, and risk assessment techniques.
Justification: A Safety Engineer brings specialized expertise in process safety and loss prevention.
Their familiarity with hazard identification methods and risk assessment techniques is crucial for
systematically evaluating potential risks throughout the gas reception terminal. This role ensures a
focused approach on preventing and mitigating safety-related incidents.
3. Instrumentation and Control Engineer: Knowledgeable about control systems, emergency
shutdown systems, and instrumentation.
Justification: The role of an Instrumentation and Control Engineer is vital for assessing the
reliability of control systems, emergency shutdown systems, and instrumentation. Their knowledge
ensures a thorough examination of the integrity and functionality of safety-critical instruments and
controls, which is paramount for maintaining safe operating conditions.
4. Operations Personnel: Operators with practical experience in handling the stabilization unit,
emergency shutdown procedures, and familiarity with the control room operations.
Justification: Having Operations Personnel, specifically operators with practical experience in
handling the stabilization unit, is invaluable. Their firsthand knowledge of day-to-day operations,
emergency shutdown procedures, and familiarity with control room operations provide practical
insights into potential operational risks and contribute to a realistic assessment of the facility's
safety measures.
5. Fire and Safety Expert: Specialized knowledge in fire protection systems, fire and gas detection,
and emergency response procedures.
Justification: A Fire and Safety Expert plays a critical role in evaluating and enhancing the
facility's fire protection systems, fire and gas detection mechanisms, and emergency response
procedures. Their specialized knowledge ensures a thorough examination of measures in place to
prevent, detect, and respond to fire-related incidents, contributing to the overall safety of the gas
reception terminal.

b) Keywords to be applied during the HAZOP, with justification. (8 marks)

Keywords for HAZOP:

1. Overpressure: Evaluate potential overpressure scenarios, such as relief valve failure, emergency
shutdown valve failure, and their consequences.
Justification: Overpressure scenarios pose a significant risk to the gas reception terminal. A failure
in relief valves could result in uncontrolled pressure buildup, leading to equipment damage,
potential leaks, and, in extreme cases, catastrophic failure. Evaluating these scenarios is crucial for
maintaining safe operating conditions and preventing equipment overloads.
2. Temperature Deviation: Analyze deviations in temperature indicators, potential overheating
risks, and the impact on equipment integrity.
 Justification: Temperature control is vital for the stability of the gas reception terminal process.
Deviations in temperature indicators could indicate potential overheating risks, jeopardizing the
integrity of equipment and causing material degradation. Analyzing temperature deviations helps
ensure that the system operates within safe temperature limits.
3. Flow Control: Investigate issues related to flow control, including failures in control valves and
their impact on the stabilization process.
Justification: Flow control issues, such as failures in control valves, can impact the proper
functioning of the stabilization process. Inadequate control can lead to irregularities in product
separation and distribution, affecting the overall efficiency and safety of the system. Investigating
flow control ensures the reliable and consistent operation of the stabilization unit.
4. Emergency Shutdown: Assess the effectiveness of the emergency shutdown system, potential
failures, and the consequences of delayed or ineffective shutdown.
Justification: The emergency shutdown system is a critical safety measure for rapidly halting
operations in case of emergencies. Assessing its effectiveness and potential failures is essential for
preventing or mitigating incidents that could result in severe consequences. Delays or failures in
the shutdown process may exacerbate the impact of hazardous events.
5. Fire Protection: Scrutinize the fire protection measures, including water deluge and foam injection
systems, to ensure their reliability in case of fire incidents.
Justification: Fire protection measures, such as water deluge and foam injection systems, are
integral for preventing and controlling fires. Scrutinizing these systems ensures their reliability
during fire incidents. Effectiveness in containing and extinguishing fires is vital for minimizing
damage to equipment, protecting personnel, and preventing the escalation of fire-related risks.
6. Human Factors: Consider potential human errors in initiating safety systems, response time during
emergencies, and adherence to operating procedures.
Justification: Human errors can significantly contribute to accidents and incidents. Considering
factors such as the initiation of safety systems, response time during emergencies, and adherence
to operating procedures is crucial. Understanding and mitigating potential human errors enhance
the overall reliability of the gas reception terminal.
7. Environmental Factors: Evaluate the environmental conditions, such as wind direction and
stability, to understand the potential impact of hazardous events on the surroundings.
Justification: Environmental conditions, including wind direction and stability, play a pivotal role
in the dispersion of hazardous substances in case of a release. Evaluating these factors helps
estimate the potential impact on surrounding areas, enabling the implementation of adequate safety
measures and emergency response plans.
8. Reliability of Safety Systems: Assess the reliability of safety-critical systems, including relief
valves, level indicators, pressure indicators, and emergency shutdown valves.
Justification: The reliability of safety-critical systems is paramount for the overall integrity of the
gas reception terminal. Assessing the reliability of relief valves, level indicators, pressure
indicators, and emergency shutdown valves ensures that these systems can be depended upon to
function as intended during critical moments, reducing the likelihood of accidents and enhancing
overall safety.

c) Mark candidate nodes on the Stabilisation Process PFD and submit this with your assignment.
Justify your selection of these nodes in the narrative submission. (7 marks)

1. Slugcatcher (V101): The Slugcatcher is critical as it initiates the separation of gas and liquids.
Overpressure scenarios pose a hazard, especially if the pressure exceeds the design limits, leading
to potential equipment failure. Liquid carryover can result in downstream contamination, affecting
the efficiency of subsequent processes. Failure of level control may lead to inadequate liquid
removal, impacting the overall stability of the gas reception terminal.
 2. Stabilizer Column (V102): The Stabilizer Column is a key component in separating Natural Gas
Liquids (NGLs). Temperature control deviations may result in inefficiencies, affecting the
separation process and compromising product quality. Reflux system failures can lead to improper
separation, impacting the composition of the products. Pressure-related incidents, such as
overpressure, pose a risk to the structural integrity of the column and associated equipment.
3. Reboiler (E102): The Reboiler is crucial for maintaining the pressure within the Stabilizer Column.
Overheating hazards can lead to thermal degradation of the condensate, impacting product quality.
Control valve failures may disrupt the heat input, affecting the stabilizing process. Pressure-related
incidents, such as inadequate pressure control, can influence the entire column operation, leading
to potential safety risks.
4. Condenser (E103): The Condenser is vital for condensing column overheads. Cooling system
failures can result in insufficient condensation, affecting product separation and potentially causing
downstream issues. Pressure deviations may impact the column's overall stability and efficiency.
Overpressure scenarios pose risks to the structural integrity of the condenser and associated
components.
5. Pressure Relief Valve (PRV1): The Pressure Relief Valve is essential for relieving excess pressure
and preventing overpressure scenarios. Potential hazards include PRV failure, which may result in
the inability to vent excess pressure, posing risks to the entire stabilization unit. Inadequate relief
capacity can lead to uncontrolled pressure buildup, impacting the integrity of connected equipment
and processes.
6. Reflex Drum (V103): The Reflex Drum plays a crucial role in collecting condensed overheads
from the Stabilizer Column. Hazards may include liquid carryover, affecting downstream
processes. Inadequate reflux flow control can impact the efficiency of the stabilization process,
influencing product quality. Overpressure scenarios may pose risks to the structural integrity of the
drum.
7. Emergency Shutdown Valve (ESDV1): The Emergency Shutdown Valve is critical for rapidly
isolating the Slugcatcher in case of low liquid levels. Failure of this valve may result in inadequate
isolation, allowing potential hazards like liquid carryover to propagate downstream. Proper
functioning of the ESDV1 is essential for preventing unsafe conditions and ensuring a swift
response to abnormal situations.

Node Deviation Consequence Safeguard Risk

Pressure relief
valve (PRV1)
Slugcatcher Potential with regular
(V101) Overpressure equipment failure testing High
Level control
Downstream measures and
Liquid Carryover contamination alarms Medium
Emergency
Shutdown Valve
Failure of Level Impact on overall (ESDV1) and
Control stability regular testing High
Temperature Inefficiencies and Continuous
Stabilizer Control compromised monitoring and
Column (V102) Deviations product quality control system Medium
Improper
separation and Backup systems
Reflux System product and regular
Failures composition maintenance High
 Pressure relief
systems and
Pressure-Related Risk to structural emergency
Incidents integrity shutdown High
Temperature
control systems
Overheating Impact on product and regular
Reboiler (E102) Hazards quality inspections Medium
Backup control
Control Valve Affecting the valves and routine
Failures stabilizing process checks High
Pressure relief
Influence on systems and
Pressure-Related overall column emergency
Incidents operation shutdown High
Insufficient
condensation and Regular
Condenser Cooling System downstream maintenance and
(E103) Failures issues backup systems Medium
Pressure relief
Pressure Impact on stability systems and
Deviations and efficiency control measures High
Pressure relief
systems and
Overpressure Risk to structural emergency
Scenarios integrity shutdown High
Regular testing,
Inability to vent backup relief
PRV Failure excess pressure systems High
Pressure Relief Inadequate Relief Uncontrolled Adequate sizing
Valve (PRV1) Capacity pressure buildup and redundancy High
Level control
Reflex Drum Downstream measures and
(V103) Liquid Carryover process efficiency alarms Medium
Regular
Impact on inspections and
Inadequate Reflux stabilization control system
Flow Control process efficiency checks High
Pressure relief
systems and
Overpressure Risk to structural emergency
Scenarios integrity shutdown High
Emergency Inadequate
Shutdown Valve isolation during Regular testing
(ESDV1) Failure of ESDV1 low liquid levels and maintenance High
Downstream Redundant
Impact on Liquid propagation of shutdown systems
Carryover hazards and alarms High
d) Outline any other important elements of the Plan. Explain why they you believe these will be
important. (5 marks)

Other Important Elements:

1. Proof Testing of Alarms and Shutdown Systems: Regular proof testing ensures the reliability
of safety-critical systems, reducing the risk of undetected failures.
2. Personnel Distribution: Consideration of the number of personnel on-site during different
hours’ aids in evaluating potential consequences and response times during emergencies.
3. Separation Distances: Understanding the distances to the nearby village and residential areas
helps assess the potential impact of hazardous events on the surrounding population.
4. Meteorological Data: Wind direction and stability data are crucial for evaluating the
dispersion of hazardous substances in case of a release.
5. Process Hazard Analysis (PHA): Continuous PHA ensures that the safety plan remains
dynamic and adaptive to changing conditions, equipment modifications, and process variations.
Regularly assessing potential hazards and risks helps in identifying emerging threats, allowing
for timely adjustments to safety measures. This element fosters a proactive approach to safety
management.
6. Incident Investigation and Root Cause Analysis: Establishing a robust incident investigation
and root cause analysis process is crucial for understanding the underlying causes of incidents.
Learning from past incidents enables the implementation of corrective actions to prevent their
recurrence. This element contributes to a culture of continuous improvement, enhancing the
overall effectiveness of safety measures.
Question 5 – Bowtie [25 Marks, 800 words target]
Bowtie Diagram Analysis: Loss of Containment in a Fuel Storage Depot
1. Threats (Top Event):
The identified top event in the Bowtie diagram is the "Loss of Containment." This critical event signifies
a substantial failure within the fuel storage system, resulting in an unintended release of fuel. The
potential severity of this event necessitates a detailed examination of its causes, consequences, and the
safety measures in place to prevent and mitigate it.

2. Causes:
a. Equipment Failure:
Storage system components, such as tanks and valves, are susceptible to wear and tear over time.
Regular equipment inspections are essential to identify potential failures before they escalate. A
breakdown in these components could compromise the integrity of the entire system, leading to the
loss of containment.
b. Human Error:
Operational and maintenance activities involve human intervention. Mistakes during these
activities can pose a significant risk to the storage system's integrity. Employee training programs
are crucial to minimizing the risk of human error by ensuring informed decision-making during
critical tasks.
c. External Factors:
Events beyond the facility's control, such as natural disasters (e.g., earthquakes or floods), can
introduce unforeseen challenges. While these events are unpredictable, their potential impact on
the storage system's containment capabilities must be considered and addressed in the facility's
overall risk management strategy.

3. Consequences:
a) Release of Fuel into the Environment:
An unintended spill or leakage of fuel beyond the facility's boundaries can have severe
environmental implications. Implementing spill containment measures is crucial to limit and
control the spread of spilled fuel, minimizing the impact on the surrounding environment.
b) Fire and Explosion:
The potential ignition of released fuel poses a significant threat. Emergency response and
firefighting capabilities are paramount to swiftly control and contain incidents, preventing the
escalation to a fire or explosion.
c) Impact on Human Health and Safety:
Risks to personnel due to exposure to fuel or associated hazards must be addressed through
adequate training and awareness programs. These initiatives ensure that personnel are well-
prepared to respond effectively during emergencies, reducing the potential impact on human health
and safety.
d) Property Damage:
The release of fuel can lead to potential damage to infrastructure within the facility. Safety audits
and risk assessments play a crucial role in identifying and rectifying weaknesses in safety measures,
mitigating the risk of property damage.
e) Environmental Pollution:
Contamination of the surrounding environment due to the release of fuel requires proactive
measures. Environmental monitoring helps detect anomalies promptly, enabling timely responses
to limit environmental pollution.
 4. Safety Barriers:
a. Proactive Barriers:
I. Regular Equipment Inspections:
Periodic checks are essential to identify and rectify potential equipment failures before they
escalate. Proactive inspections contribute to early detection, preventing the progression to a
critical failure.
II. Employee Training Programs:
Education initiatives are aimed at empowering personnel to make informed decisions, minimizing
the risk of human error during operational and maintenance activities. Well-trained personnel are
a crucial proactive barrier to prevent incidents.
III. Safety Protocols and Procedures:
Established guidelines ensure consistent and safe operations within the facility. Following
standardized protocols minimizes deviations that could lead to the loss of containment.
IV. Environmental Monitoring:
Continuous tracking of environmental conditions allows for the prompt detection of anomalies.
Proactive monitoring contributes to early intervention, reducing the likelihood of environmental
pollution.
V. Installation of Safety Valves:
Mechanisms to control pressure and prevent overloads are crucial in preventing equipment
failures that could lead to the loss of containment. Safety valves act as a proactive barrier against
critical system failures.

b. Event:
I. Represents the Actual Occurrence of the Top Event:
This component serves as a focal point, acknowledging the actual occurrence of the top event, the
"Loss of Containment." It is a critical aspect that connects causes and consequences in the Bowtie
diagram.

c. Reactive Barriers:
I. Emergency Response and Firefighting Capabilities:
Swift actions are required to control and contain incidents immediately after the loss of
containment. Effective emergency response and firefighting capabilities are reactive barriers that
minimize the impact on human health, safety, and property.
II. Safety Audits and Risk Assessments:
Periodic evaluations are necessary to identify and rectify weaknesses in safety measures. Reactive
safety audits and risk assessments contribute to continuous improvement, reducing the likelihood
of similar incidents in the future.
III. Adequate Training and Awareness Programs:
Ongoing education ensures effective emergency responses by personnel. Reactively, well-trained
personnel contribute to an efficient and coordinated response, mitigating the consequences of the
loss of containment.
IV. Spill Containment Measures:
Strategies to limit and control the spread of spilled fuel are crucial reactive measures. Prompt
implementation of spill containment measures reduces the environmental impact and prevents the
escalation of consequences.
V. Emergency Shutdown Systems:
Mechanisms to rapidly halt operations in emergency situations are essential reactive barriers.
Emergency shutdown systems prevent the continuation of processes that could exacerbate the
situation after the loss of containment.
VI. Fire Detection and Suppression Systems:
 Early detection and control of fire incidents are reactive measures to prevent the escalation of
consequences. Fire detection and suppression systems are crucial in limiting the impact of potential
fires.
VII. Community Emergency Plans:
Collaborative plans to safeguard the surrounding community are reactive measures that come into
play in the event of a significant incident. Community emergency plans ensure a coordinated
response to protect residents in the vicinity of the fuel storage facility.

Q5b

1. Impact of reducing staff on Bowtie Diagram:

a. Proactive Barriers:
Regular Equipment Inspections:
Before Scenario: With a higher number of staff, there might have been more resources available for regular
equipment inspections. This could result in more thorough and frequent checks on storage system
components, reducing the likelihood of equipment failures.
After Scenario: A reduced staff might lead to fewer inspections or less comprehensive checks, increasing
the risk of undetected equipment issues.

Employee Training Programs:

Before Scenario: A larger workforce may facilitate more extensive and frequent training programs. Well-
trained personnel are better equipped to respond to emergencies, minimizing the risk of human error.
After Scenario: A reduced staff might limit the scope and frequency of training initiatives, potentially
impacting the preparedness of personnel in responding to critical situations.

Safety Protocols and Procedures:

Before Scenario: A higher number of staff could mean better adherence to established safety protocols and
procedures, fostering a culture of safety within the facility.
After Scenario: A reduced staff might result in a less robust adherence to safety protocols, potentially
increasing the likelihood of deviations that could lead to the loss of containment.

Environmental Monitoring:
Before Scenario: A larger workforce may facilitate more effective environmental monitoring, allowing for
prompt detection of anomalies and early intervention.
After Scenario: A reduced staff might result in less frequent or less comprehensive environmental
monitoring, potentially delaying the detection of abnormal conditions.

Installation of Safety Valves:

Before Scenario: Adequate staffing levels could ensure proper installation and maintenance of safety
valves, critical in preventing overloads and pressure-related incidents.
After Scenario: A reduced staff might lead to challenges in maintaining safety valves, increasing the risk
of critical system failures.

b. Reactive Barriers:
Emergency Response and Firefighting Capabilities:
Before Scenario: A higher number of staff could contribute to more efficient and coordinated emergency
response and firefighting capabilities.
After Scenario: A reduced staff might result in delays or inefficiencies in responding to incidents,
potentially allowing them to escalate.
Safety Audits and Risk Assessments:
Before Scenario: A larger workforce may facilitate more thorough safety audits and risk assessments,
leading to better identification and rectification of weaknesses.
After Scenario: A reduced staff might result in less frequent or less comprehensive safety audits, potentially
overlooking critical safety vulnerabilities.

Adequate Training and Awareness Programs:

Before Scenario: A higher number of staff allows for more extensive training and awareness programs,
ensuring personnel are well-prepared for emergency responses.
After Scenario: A reduced staff might result in less emphasis on ongoing training, potentially impacting the
effectiveness of emergency responses.
Spill Containment Measures:
Before Scenario: Adequate staffing levels may ensure swift implementation of spill containment measures,
limiting the spread of spilled fuel.
After Scenario: A reduced staff might lead to delays in implementing spill containment measures,
increasing the environmental impact.
Emergency Shutdown Systems:
Before Scenario: Properly staffed facilities could ensure the efficient functioning of emergency shutdown
systems, rapidly halting operations in emergencies.
After Scenario: A reduced staff might lead to challenges in maintaining and promptly activating emergency
shutdown systems.

2. Risk Matrix Illustration:

A risk matrix could illustrate the potential changes in risk levels based on staffing scenarios. The matrix
typically considers the likelihood and consequence of an event. In this context, the reduction in staffing
levels might result in higher likelihoods and consequences, leading to an overall increased risk.
Likelihood/Consequence Negligible Minor Moderate Major
Almost Certain Low Medium High High
Likely Low Low Medium High
Possible Low Low Medium High
Unlikely Low Low Low Medium
Rare Low Low Low Low