SITE DETAILS Name of Company: ineos Chemicals Grangemouth Limited Inspection Title: Part A Competency Management Inapection EAddress of Company: Bo?ness Road . - . Grangemouth Service order No. 430405 Site ID. 4249978? FK3 QXH Inspection Date: 27' May 2015 Case No: 4246533 Visiting lnspector{s): Discipline: Unit Team: HSE Regulatory Inspector CEMHD ?13 HSE Process Safety CEMHD 6A I Specialist Inspector SUPPORTING INFORMATION Intervention Report (discipline): See note 2 to enable drop down menus Keyword: Keywords relevant to topics being I . considered Please select appropriate trey i word(s) from drop down menu - Process Safety Strong Leadership Containment - Competence - from board to front line Mitigating the consequences of MAH Main Persons seen: Position: David Duffas Graeme Johnstone SHE Compliance Manager KG Asset Manager inn-Godfrey Mc'lvor Specialist Team Leader I George Gratton Operations Trainer Availability Supervisor Availability Technician Page 1 of 1s iTkvoe_2_o4,, 5' Duncan Macintosh Learning Development Manager Relevant documentation seen 1. Spread sheet sent by company to the Competent Authority by email on 20 may 2015 entitled Case HRA Reviewers? Operating instruction, 36.0li170101, Issue 11, 21.03.14 Operating instruction, 36.0li170201, Issue 122103.14 Excerpt from operating instruction, 36.0l/170301, Issue 05, 23.11.12 Ineos Chemicals Grangemouth Limited (ICGL) Safety Report, Version 1.0, 14 March 2014 5-"wa Note: post inepection the company has provided by email (04.06.15): a copy of the SCT review project plan; a copy of the CMS improvement project plan; an updated copy of OI 36.17.0301; and a copy of maintenance instruction entitled ?Release and Handbaok of: 36-P-302C DE and NDE Seal Repairs and Bearing Replacement? which was written and approved on 29.05.15. Inspection Summary: The purpose of this inspection is to undertake a Part A inspection of the competence management system (CMS) of this upper tier establishment in accordance with the . Competent Authority's operational delivery guide ?Inspection of Competence Management Systems at COMAH Establishments? (CMS i The inspection focused on safety critical tasks associated with major accident hazards (MAHs) arising from activities being conducted at the KG Ethylene Plant. Step 6.7 in Operating Instruction (OI) 36.17.0301 and Step 3.1 in OI 36.17.0201 were selected for walk throug hitalk through. Step 6.7 was selected as this step forms part of the plant?s routine tasks and had been given the highest criticality rating of SCTs associated with MAH cases 7 and 8 in the safety report. Step 3.1 was selected as being representative of a non-routine safety critical activity contained within a start-up procedure. it was found that there were no designated competency standards for the SCTs selected. For Step 3.1, there was a lack of clarity around exactly what was required and who could perform it. For Step 6.7, it was found that the task was required to be conducted routinely but this was not what the plant management wanted or what was happening. When this task was subject to walk through, however, the operator showed a good understanding of how to undertake it although some aspects relating to risk reduction measures which were i found to reside in a maintenance procedure covering this activity were not mentioned. The company has taken action to remove Step 6.7 from its routine task procedure for the plant and it will review Step 3.1 in CI 36.17.0201 to clarify the nature of the task and who I can conduct it. The company is also undertaking two projects: one project will review SCTs at the establishment in response to an action legal from the Competent Authority; and the other has various works streams to address gaps in the site's CMS following gap assessment against the principles set out in the CMS ODG. Page 2 of 16 2 Given the actions already taken by the company and those actions I no further actions legal are proposed from this inspection. A OMS performance rating of 30 has been agreed based on this inspection. Strategic topic performance rating [where applicable]: egai already in place ?air" gay?i3; EEC. lien; EFL. Emergency Preparedness (on-site} Emergency Preparedness (off-site] I 55?; malt Report author:_ First draft: 11 June 2015 Final: 12 June 2015 Location: Glasgow Page 3 of 16 Purpose of visit: Fiefer to item 6-2015r16 on the intervention plan. i i i The purpose of this inspection is to undertake a Part A inspection of the competence 5 management system (OMS) of this upper tier establishment in accordance with the Competent Authority's operational delivery guide ?lnspection of Competence Management Systems at COMAH Establishments' (CMS 5 Method and pro-inspection work - inspection involves a walk through andror talk through of one or more critical taskfs) {paragraph 34 of CMS - Figure 2 of the CMS ODG provides a schematic of the format of the inspection; 1 The CA has selected ms?jor accident hazard (MAH) cases 7' and 8 from the i company's safety report and the company has provided details of what it believes are critical tasks associated with these MAH cases; Having reviewed the further information provided by the company, the CA has selected operating procedures 301101.01; 36.17.0201 and, if time permits, 1 36.110301 which contain critical tasks to review; At the start of the inspection the company is to outline the purpose of the operating procedures and to explain the basis upon which certain steps have been identified 5 by it as being critical; - Site visit to walk through andror talk through the critical task(s) with those performing the taskts); - Review of supporting documentation for the selected critical tasks; and Determine performance rating with reference to success criteria established under 1 paragraph 40 and performance rating scheme established under paragraph 55. Table 1, of the CMS ODG. Note: Critical tasks are defined as those that have the potential, it not undertaken i correctly, to initiate; propagate or exacerbate a major accident (paragraph 44 of CMS ODG). Planned intervention Enforcement compliance check Factual observations and findings: Site pfant overview and MAH selection 1. The company provided a brief overview of the site?s activities. A number of plants at the site have been closed and areas of the site are to berare being rte-commissioned in phases. in parallel to decommissioning activities the company is in the midst of a significant investment to build a new storage and handling facility for ethane which it i will. shouldered .i9_EQWE_Q??ti9??fl immediacy .. Page 4 of 16 of years and will supply ethane for use in the processes operating at the establishment. In preparation for this inspection the CA decided to review critical tasks which contribute to the prevention or limitation of MAHs associated with the KG Ethylene Plant (KG). This plant is a significant asset at the establishment and has not been earmarked for closure. KG produces ethylene by a steam cracking and recovery process. Currently, the plant takes LPG and gas feeds from the BP Kinneil terminal and the adjacent Petrolneos refinery. in order to utilise the new ethane supply the company has plans to undertake modifications to KG to enable it to increase its ethane capacity. It I was explained to me that these modifications will also include changes to allow the plant to increase its capacity for heavier components such as propane. For the purposes of this inspection, MAH cases 7' and 8 were taken for review. These MAH cases are taken from the representative set in the establishment's safety report5. Both MAH events are associated with a teak or rupture from the tap section of the propylene tower (SB-T8018) with the potential for a fireball or vapour cloud explosion (VCE) which could give rise to multiple on-site fatalities. In accordance with the CMS ODG (see Figure 2) the next step in preparing for the inspection was to identify a safety critical task(s) associated with these MAHs cases to review. Safety critical task sefecti'on 5. Section 110 in the company's safety report5 sets out the approach to be taken to the identification of safety critical tasks (SCTs) human error. Within this section of the safety report, Figure provides a useful flowchart which gives an overview of the process to be taken for SCT identification and human reliability assessment Figure 7.8 and Table 15 set out how these SCTs are assessed for their criticality and how this is used to prioritise action taking into account also the frequency. According to the safety report there are 4 levels of critical ity ranging from level 4 which is essentially the least critical to level 1 being the most critical. All the SCTs associated with cases 7 and 8 were assessed as being either level 3 or 2. Level 3 means that there is an additional procedural layer which would mitigate against human error. Level 2 means that there is some indication of human error that could be detected which would allow the situation to be recovered. Both of these levels require HHA to be performed. Prior to the inspection the company was asked to send through details of what it considered to be the SCTs associated with MAH cases 7 and 8 on KG. The company provided a spread sheet which identified Specific steps within operating instructions which it had determined to be SCTs during a project in 2008MB. The spread sheet also assessed the criticality of the SCTs in accordance with the approach summarised in Figure 718 of the safety report. in preparing for this inspection I noted that the processes that the company use for SCT identification and were examined on 3 8 4 December 2014 during a H?sescien; its. a result of that Page 50116 and to their risk assessment in respect of determined that it was necessary to set an action legal (deadline of end April 2016) to require the company to identify SCTs associated with the MAHs at the establishment. Post-inspection the company has provided a copy of its project plan I for the review, and where necessary revision, of SCTs which it has created in order to meet the requirements of this action legal. This plan takes each of the establishment in sections and runs from June 2015 to February 2016. 8. Whilst it is not the purpose of this inspection to re?examine the company's processes for SCT identification, or indeed HRA, asked for a brief overview of where the 3 company is in relation to this action legal in order that I could to set into context any findings from this inspection. The company explained that it was at the start of . reviewing SCTs for operational plant to ensure that they aligned fully with the MAH 1 identified by it. This review hasn?t been undertaken for the KG plant yet and so it will be necessary for this inspection to take prima facie the SCTs identified by it previously as part of the project undertaken in 2008109. The company also confirmed that none of the SCTs for KG had been subject to and, consequently, that the operational instructions selected for review had not been reviewed in any way in response to an assessment of risk associated with human failure. Finally, it was also confirmed that operational staff tasked with performing I the steps set out in these operational instructions would not be aware that the company had identified some of them as being safety critical. 9. Based on the information provided by the company1 the CA had selected operating I instructions 36.11-01.01, 361102.01 .and 36.110301 which contained several SCTs as candidates for review in accordance with the CMS ODG. The company was asked to provide an overview of these operating instructions, with emphasis on the SCTs, at the inspection to enable the CA to make a final selection of the it wanted to subject to walk through?talk through during the on-plant visit later. I 10. Before discussing the selected operating procedures in any detail the KG Asset i Manager provided an overview of the plant?s approach to operating instructions. It was explained to me that the KG plant is designed to be fairly self-sufficient whereas some of the older assets at the establishment are far more integrated, and hence reliant, upon site-wide services such as utilities and effluent treatment. The i 5 autonomy of the plant is reflected in the overall structure of the operating instructions I in place there as well as their content. I was told that the plant is split into 50 operating systems each of which have their own operating instructions some of which are descriptive and some of which are task based. These instructions include I activities associated with startvup and shut down as well as those for day-to-day I 1 operation and maintenance of the plant. It was explained to me that there are somewhere in the region of 600900 controlled procedures associated with KG and that these are subject to review on a 5 yearly cycle or earlier as required. 11. In terms of nomenclature the operating instructions or Ols are numbered to identify the plant, the system (physical area of plant], section (what type of instruction this is) and the title of the instruction. For example, 361101.01 represents the KG plant, i system 11 (propylene fractionationr?product send out}, section 01 (start-up) and 01 (pre-commissioning instruction). la 9939 its}: .. Page 6 of 16 author an operating instruction but in order to get it approved the procedure would require the signature from the plantfasset manager, operations engineer and shift supervisor or another engineer. It was also confirmed that the person authoring a procedure can not also be the approver of that procedure. 13. I was provided with a copy of operating instructions 36.17.01.012, 36.17.02013 and 36.17.03.014. The KG asset manager provided a brief overview of the purpose of the procedure and of the safety critical stepts). 14.As mentioned previously, OI 36170101 is a pre-commissioning instruction for system 17 on KG. It was explained to me that the purpose of the procedure is to take the plant from its maintenance state to the point where it is ready for hydrocarbon introduction. Within this procedure the company had identified that Step 8.2 was a SGT. This step is concerned with undertaking a full check of the (piping and instrumentation diagram) to ensure that all vents and drains are closed and boxed up and that the system is lined up as per the diagram. This step was assigned category 3 using the company's approach (see paragraph 5) which identifies it as requiring 15.0l 3617.01.02 is entitled ?F?adding Out The Propylene Fractionation System With Vapourised (333'. It was explained to me that this procedure was about introducing propylene vapour to the plant to reduce the risk of any loss of integrity from the equipment due to temperature embrittlement at start-up. Within this procedure steps 3.1 and 15.1 had been identified as SGTs. As it was explained to me at the time, Step 3.1 is concerned with ensuring that all the blanks in System 17 have been removed but that certain blanks at the boundary with System 16 are retained to ensure that the propylene vapour introduced to System 17 for padding doesn't escape via System 16 when it is not yet ready to receive hydrocarbons. As will be discussed later, however, the actual requirements of this step are somewhat more variable than this. Step 15.1 is concerned about padding out the export line to the jetties should this be required. Both steps have been determined to be criticality level 3 which identifies them as requiring 16.The final procedure, OI 3717.03.01, is concerned with routine checks of System 17 whilst the plant is in normal operation. Step 6.7 was identified as being a SGT with a criticality level of 2 requiring (see also paragraph 5). Step 6.7 requires weekly draining of water from vessel 0301 to grade by means of a manually operated valve arrangement. There was some uncertainty expressed from the KG Asset Manager about whether or not this step was actually being carried out as part of a routine procedure and concerns expressed by him about its safety. It was agreed, however, that it would be useful to establish whether in fact this step was being carried out and if so, how. Flefer to the next section of this report for further discussion. 17. After a short discussion with the regulatory inspector it was agreed to select Step 6.7 in OI 36.17.013.01 and Step'3.1 in OI 36170201 for walk throughftalk through on plant. Step 6.7 was selected as this step had been given the highest criticality rating (level 2) of the SCTs associated with MAH cases 7 and 8 and also due to the comments made by.KG Asset Manager (refer to the previous paragraph). Step 3.1 was selected as being representative of a non-routine safety critical activity contained within a start-up procedure. Page 7o116 Visit to KG Piant - discussion with KG Operations Trainer and walk throughrtaik through of 3 safety critical tasks 18. 19. 20. 21. 22. I went to the KG plant where I met with an on-duty Shift Availability Supervisor and one of the Availability Technicians. I had a desk top ?talk through? of Step 3.1 with the Shift Availability Supervisor and KG Asset Manager and I then visited the plant to be given a ?walk through? of Step by an Availability Technician. Refer to the next section of this report for details of what was discussed and my conclusions. Whilst on-plant I also met with the KG Operations Trainer to understand how his role contributes to the CMS. I discussed the approach taken to a new start Availability Technician to get some understanding of how someone new to the plant would be inducted and their competency assessed. I went on to discuss the approach taken to turnaround (TAFI) where systems in the plant are taken offline to enable maintenance, revamp and other significant modifications to be undertaken. The KG Operations Trainer explained to me that typically a new Availability Technician {plant operator) would take around 6-12 months to be deemed competent. During that time they would be taken through training packs which explain the purpose of the plant, provide the and relevant OIs. There are also a series of assessments which need to be undertaken and passed. A buddy would be assigned to the new start to assist them in undertaking their new role. It was explained to me that ultimately the competency of the new start would be signed off by the Operations Trainer. This could involve asking them undertake a walk~through of sampled tasks or reviewing responses to some of the assessment topics. The Operations Trainer explained that he would review the individual?s performance and target his assessment of their competency based on that and based on any other relevant feedback obtained from hisiher line manager or peers. The KG Operations Trainer also explained that the training approach taken to a is not demonstrably different to that for routine operations training. Given the infrequent nature of the activities, however, there was emphasis on hazards which may have greater relevance during due to the nature of the activities such as integrity issues associated with failure due to low temperature during plant re- instatement. The training also reinforced some key safety systems in order to manage the risk from such hazards such as decommissioning packs, isolation schedules and how work in general is to be controlled through the permit to work system. Finally, the KG Operations Trainer confirmed to me that there was no particular approach taken to assure a persons? competency in undertaking SCTs. Indeed he confirmed that he was not aware of what steps within a given OI were SCTs. His comments in this regard aligned to those made to me earlier in the inspection from the SHE department refer to paragraph 8. Discussion with UK Learning and Development Manager 23. I He provided menii?an Upon my return from plant I met with the company?s UK Learning and DeveIOpment Page 8 of1? midst of undertaking to improve its OMS. I 24. I was told that the company had embarked upon various work streams to improve their OMS. One of the first stages in the project was to understand what was currently in place so interviews had been held with plant operations trainers and i held on plant were reviewed. I was told that this exercise had found that varying standards for defining and assessing competency existed and the way in which information was recorded varied too. 25. In addition to understanding what currently exists I was advised that the company had undertaken a gap assessment of its OMS against the principles set out in Annex - 2 of the CMS ODG. This, in combination with the intelligence gathered on plant, had enabled it to set out a programme of work to improve the OMS. 28. It was explained to me that the CMS improvement project will comprise of two main I aspects: development of a site-wide system to act as a repository for information and records which need to be kept by the OMS in order that these can be managed; and the design and roll out of competency matrices. Beneath these aspects the company proposes a roll out across the different parts of the establishment in varying phases starting with population of the new site-wide system with what?s available through to testing competency against the newly developed matrices. I asked the company to provide a copy of the project plan which has been provided i post inspection. I note that the project plan runs throughout 201516 with the majority of the work being completed by mid-2016. Refer to the next section of this i report for further discussion. i Discussion and conclusions: KG Operations trainer?s role in OMS i 27. The plant has a dedicated resource for training and competency assurance of those tasked with operating the plant which includes non-operational activities such as Based on my discussion with the KG Operations Trainer there would appear to be systems in place for providing information to Availability Technicians to an I increasing depth starting with familiarisation with the plant?s general purpose through i i to details of how particular systems work, their and how these relate to the actual plant installed. 1 28. In terms of competency assurance I was told that a mix of formal assessment, on? plant mentoring and a final competency check from the Operations Trainer provide the basis upon which new starts are deemed as competent. i 29. in relation to new Ols, or amendments to existing Ols, The KG Operations Trainers explained that these are issued to a master file held in the plant?s control room and a training sheet is provided for relevant staff to acknowledge and sign. With respect to the CMS ODG, particularly paragraph 40, there is no awareness of what activities in i a given OI have been determined as being safety critical although it should be acknowledged that the KG Operations Trainer was aware in broad terms as to what Page 9 of 16 i i 30. As mentioned in paragraph 7 the company is in the midst of reviewing its SCTs and has yet to embark upon any HRA for the activities conducted at this plant. There are also several projects underway to improve the company?s OMS [refer to paragraph 26) and as these were described to me I would expect them to impact upon the role of the KG Operations Trainer in so tar as heishe should have a key role to contribute to training and competency assurance of SOTs on their plant. However, since these various work streams are not yet complete (and in some cases not yet started) I didn't look any further into the general training and competency systems described to me by the KG Operations Trainer at this inspection. Once there is confirmation as to what activities on this plant are SCTs, suitable has been performed and competency assurance standards developed then it would seem to be appropriate to - undertake a walk throughitalk through of sampled tasks to determine whether there I is an improvement in performance of the CMS. action Taik through of Step 3. i 31.Step 3.1 in OI 36.110201 requires the following: ?Ensure that sit blanks within System 17isoiation timits have been removed and 0A is signed up for the introduction of hydrocarbons. Do not remove btanks/turn spectacie blinds on boundary With System 16 {or other adjoining hydrocarbon systems) if this has not been prepared for hydrocarbon feed. I The procedure also requires someone to sign and date that they have undertaken this task. As mentioned previously, this OI forms part of the start-up procedures for the plant and is concerned with padding the plant with CS vapour in readiness for operation. . 32. According to the information provided by the company1 this task was identified as I being safety critical as it was considered that there was the potential for something to go wrong which could result in, or contribute significantly to, a MAH with similar consequences as that described by case 8 in the safety report. The team assessing this SCT considered that there was 'potential (sic) out of sequence deblanking has potential to cause leak?. During my ?talk through? it became apparent, however, that this step was not requiring that anyone actually perform the dewblanking of this section of the plant (Le. that they actually remove the blanks at the System 1? isolation limits) since this had been done already in another start-up procedure. The KG Asset Manager clarified, after some discussion, that this step was essentially a ?check point' to require the approver to pause and cross-check that this had been done, and done correctly, by someone else before proceeding to the next step in the Qt. As currently written, however, the purpose of this step as a cross?check is not clear. Furthermore, I would also suggest that it wasn?t clear to the team assessing the SCTs given their remarks that de-blanking described by this step could be undertaken out of sequence. ?owered deadbeat; Page1nof16 someone to go on plant and check that the blanks removed or left in place aligned with the system isolation blanks schedule or would a paper check of the 0A documentation suffice? After some discussion was left with an impression that a paper check would probably suffice at this stage but it was agreed that this should be discussed further internally and clarified in the procedure. 34. then had a conversation around who was to undertake the task. This is not defined in the Qt and it was clear from my discussions that differing views were held by those around the table as to who would have the correct authority to sign off on this step. It was agreed that rolefs) in the OI. 35.As mentioned previously (paragraphs 8 and 29) there was no competence standard for this SGT and the didn?t identify this step as being safety critical. 36. Another aspect which came across during the discussions was the fact that the detail of what could be de-blanked and what was required to remain isolated would vary depending upon two things: the nature of the shut-down activities being undertaken in System and, secondly, the status of the adjoining plant such as System 16. in other words, for this step to be effective and add value in terms of risk reduction, it requires that the person has a very good understanding of what state System 1? is in (with respect to isolation) and a very good understanding of what is going on in any plant adjoining that system. This understanding would come about from having a detailed knowledge of how the systems inter-connect and through having a very good understanding of what is involved in the shutdown activities and of their current status. Whilst the selection of the role or roles responsible for undertaking and approving this task is ultimately a matter for the company I would suggest that no one person is likely to have all this information to hand and as such communications and information exchange is likely to be very important in performing this step well. 37. It?s clear that the failure to de-blank this system without due consideration as to the status of the adjoining systemts) could result in hydrocarbons being released from that system depending upon its status. Without prejudice to the outcome of the company?s SGT review it is likely that a release from this type of failure could result in similar consequences to that described in the safety report which models the effects of ignited losses from leaks in the top section of the propylene tower ranging from 13 to 100mm. 38.The assessment, however, of what is actually safety critical and in how to reduce human error which may arise from undertaking the task should take into account of the arrangements to control blanking and de-blanking as a whole. This would include assessing the various systems in place such as the system isolation responsible for this task needed to be clearly defined schedule and the fact there may be opportunities provided for someone to potentially identify an error created by someone else. In order to do this, however, the company will need to consider this activity in the round and it should be careful not to constrain itself by looking at Ole or systems in isolation. Whatever the outcome of the SCT review this step, should it be retained, should establish precisely what is required and by whom. Page1tcf16 . Waik through of Step mentioned previously, the KG Asset Manager advised that he did not believe that this step was being carried out as a part of a routine check refer to paragraph 16. Step 6.1 in OI 36.17.0301 requires the following: ?Any water which passes into from T-300 is coiiected in 0?301. This water then migrates to the low point of the system. in this case the stagnant low point is the ott-iine Facilities for draining the water from the off-tine pump are provided by a valved stub on the pump biowdown line. Water shouid be drained to grade as a weekly routine. The procedure has no requirement for someone to sign and date that they have undertaken this task. As mentioned previously, this OI forms part of the routine tasks for the plant. .According to the information provided by the company1 this task was identified as being safety critical as it was considered that there was the potential for something to go wrong which could result in. or contribute significantly to, a MAH with similar consequences as that described by case 8 in the safety report. The team assessing this SGT considered that there was ?potential to leave drain open' and it was ranked criticalin level 2 by them as there was no engineering or procedure control to mitigate the risk. I asked the Shift Availability Technician and Availability Technician separately whether they were aware of this task. Both confirmed to me that they were but only as part of a maintenance activity in preparing the pump for repair or overhaul. They also confirmed that this activity did not form part of their routine tasks for the plant to the best of their knowledge. The feedback I received from them supports the view expressed by the KG Asset Manager that this step doesn?t form part of the routine tasks for the plant. Step requires that this task be conducted weekly so clearly there is a gap between what this routine OI requires and what is considered by plant management to be appropriate. There is also appears to be issues to address in respect of compliance 3 and quality assurance. Were people aware of this step but not doing it (albeit they may have had good reason) or are people simply not as aware as they should be as to the content of these Ols. i went on plant with an Availability Technician and he walked me through how he would go about draining the water off to grade. In my discussions with him he described (with a little prompting) checks he would undertake to ensure that the equipment was isolated and, as I expected, he also described how he would ?crack! open the valve to remove the water as a precautionary measure in case there were hydrocarbons present. Once off plant I asked for confirmation as to whether this task was described by a maintenance inStFUCtiUF??ince I had I Page 12 of 16 the task would actually be undertaken. Post inspection the company has provided a copy of a maintenance instruction which is entitled ?Release and Handback of: 36-P- 3020 DE and NDE Seal Flepairs and Bearing Replacement. 46. note that this maintenance procedure is dated 29.05.15 (Le. after the date of my inspection). 1 am not able to draw any conclusions from this since I have not seen any previous revisions of this procedure. i Step 3 in this procedure includes an instruction on how to go about draining water from the pump. Interestingly, this instruction is broken into two parts whereas Step 6.7 only had one part. Step 3.1 contains the same text as Step and is marked as being for information only. I would agree with this statement since this step essentially explains that water could be present 3: where and it also explains why it needs to be drained off. The methodology for executing Step 3 is contained in Step 3.2 and this was the missing element from Step as written in the routine task OI sampled. Step 3.2 provides a method and, amongst other things, it requires that the valve be opened slowly, and briefly, and it also gives some expectation as to how long the valve is expected to remain open. lmportantly, this step also requires that the valve be closed upon completion of the draining and that this be signed for. i 48. Step 3.2 also contains some information in red text which states that the step involves venting to atmosphere and that an area around the side drain valve should be cordoned off to prevent access. It also requires that the person carrying out the task have a personal gas detector when entering the cordoned area or if conducting the draining activity. As I?ve only seen this procedure post-inspection I haven?t been able to ask the company what the purpose of having some text in red is although it would seem reasonable to presume, given the content and colour, that this is perhaps important information. I'll leave the design and presentation of Ols to my HF colleagues but from a process safety perspective i would comment that if it is important to restrict access to an area either for the purposes of fire and explosion or from a health perspective than the hazard(s) should be made clear and the means by which risk reduction be implemented be made clear. As it stands, this section of the maintenance procedure is not clear on how much of an area requires to be cordoned off because it's not clear on what the hazard is that one is trying to mitigate against. Finally, it should be noted that none of the requirements set out in red were described to me by the Availability Technician during the walk through. 49.As mentioned previously this step (albeit in another procedure) was identified as a SCT although not subjected yet to During its review of the company will need to consider whether the current arrangements can give rise to a MAH similar to that described by case 8 and whether the measures taken reduce the i risk of leaving the valve open to as low as is reasonably practicable. 50. Prior to leaving the site the company informed me that it would be removing Step 6.7 from the routine task procedure OI 301103.01. Post-inspection the company has confirmed that this step has been deleted and provided a copy of the amended OI. SC Ta and CMS improvements of?ecembsr Page130f15 address non-compliance issues around SCT identification and assessing risk from human error. 52.The company has been proactive in undertaking a gap assessment against the principles set out in Annex 2 of the CMS ODS and their own CMS and has developed a project to address these gaps. The CA may wish to consider how effective this project has been by re-assessing the CMS at a future intervention although I would recommend that this not be done until there is clarity on the SCTs and their linkto MAH at the establishment. Summary of main conclusions 53. Paragraph 40 in the GSM ODG sets out the success criteria for a Part A inspection. With reference to these I have concluded the following based on the critical tasks sampled: Designated competence standard which is being met In both cases the sampled SCTs don?t have a designated competence standard although the company has been proactive in explaining why that is and on their plans to fill these gaps; Task tutiy understood inctuding MAH potentiall The persons I spoke to did understand the risk of not doing the task correctly although there is still some room for improvement. As might be expected, the KG Asset Manager showed a good understanding of the MAH potential of failing to isolate System 17 from System 16 under certain circumstances. The Availability Technician was also very aware of the personal safety issues around leaving the drain open but less aware of the MAH potential; Activity foiio we documented procedure There is a documented procedure for both SCTs sampled but the task specification for Step 3.1 in OI 36.17.02.01 wasn?t clear as to what was required. how it should be executed and by whom. in the case of Step 6.7 this step did not describe how to drain the water safely return the plant safely in order to reduce the risk of hydrocarbon loss from leaving the drain open. In addition, Step 6.7 was present in a routine OI when the company believe that it should not have been but for some reason this has gone unnoticed. It shouid be acknowledged that the company has since provided a maintenance procedure which does address some of the missing aspects found in Step but there is still some ambiguity around the importance of safety measures such as cordoning and around how, in practice, they should be delivered to reduce the risk reasonably practicable; Piandprocess enables procedure to be undertaken As far as Step 5.7 is concerned I am satisfied that the plant provided would to be in relation. Page140f1? to Step 3.1 ldidn't examine this aspect in any depth; Person has sufficient resources to undertake task I didn't examine the allocation of timeiresources to the tasks given my other findings. This is an aspect 'which the CA may wish to consider at a future intervention; and Operator performs effectiveness checks to correct standard Given the lack of any competence standard the operator isn?t able to perform effective checks to demonstrate that this standard is being met. 54. On the basis of the conclusions above would recommend a score of 30 taking into account the guidance set out in paragraph 40 and Table 1 of the CMS ODG. 55.The company has confirmed that it has removed Step from OI 361103.01. 56.The company has provided a maintenance procedure which covers the draining of water from P-302 which was essentially Step 6.7. The procedure is an improvement upon Step since it provides details of how to execute this task and, importantly. that the valve must be closed upon completion which is the hazard being considered in this case. However, this procedure still lacks clarity around the safety measures required for cordoning off the area prior to undertaking the task and this should be clarified. Once this step has been re-evaluated as part of the SCT review (see paragraph 59) this procedure may require to be subject to to determine whether the activity to drain water from P-302 reduces the risk reasonably practicable. 57. in relation to the draining of water from P-302 it was noted that the Availability Technician giving the walk through did not mention any of the risk reduction measures set out in red in the maintenance procedure. The company may want to consider, therefore, whether some further awareness training of this procedure is requned, 58.The company should review the requirements of Step 3.1 in 0136.17.02.01 and set out clearly what is required and who can approve this step. It was agreed that this should be completed by 31 August 2015. Once this step has been re-evaluated as part of the SCT review (see next paragraph) this procedure may require to be subject to to determine whether the activity to de-blank System 17? as a whole reduces the risk of a lleH to as low as is reasonably practicable. 59.The company has already conducted a gap assessment of its CMS against the ODG and has presented its plans for addressing these gaps. In parallel, the company is also addressing an action legal to review, and where necessary revise, SCTs at the establishment. The aim of this action is to identify those SCTs which will result in, or contribute to, a MAH. Following categorisation of these SCTs the company will embark upon HRA. Given that the company has many work streams in the early stages of implementation the CA should consider revisiting this aspect at a future intervention to determine whether the performance scoring has improved based on Page15 oftE .. -. .n .1 these projects. It is recommended that this not be done, however, until such time as the actions legal following the December 2014 HF inspection has been met. action Actions Legal Given the actions already taken by the company and those actions legal already in place no further actions legal are proposed from this inspection. References a. Inspection of Competence Management Systems at COMAH Establishments, Operational Delivery Guide, COMAH Competent Authority Page 16 M16