Capacity Development Programme

in
Industrial Disaster Risk Management

Crisis Management:
Avoiding and Mitigating Major Accidents

Prof. Dr. Christian Jochum

India, February 2009

Prof. Jochum
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Professional Profile Christian Jochum

Born 1943 in Frankfurt a.M./Germany

PhD in Chemistry, certified Safety Engineer
Honorary Professor at Frankfurt University
28 years experience in large chemical/pharmaceutical company (Hoechst
AG)
1969 1979 Pharmaceutical research and pilot plant operations
1979 1997 Safety department (Site and Corporate Safety Director and Major
Accident Officer since 1987)
EHS and crisis management consulting for different types of
businesses and administration since 1997
Commission on Process Safety (formerly Major Hazard Commission) at
the German Federal Minister for the Environment (Chairman since 1998)
European Process Safety Centre (Rugby/UK): Director of Centre since
2007

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European Process Safety Centre (EPSC) www.epsc.org

Network funded by 40+ mainly European based (petro)chemical

multinationals to develop best practice in major accident/process safety
Objectives:
Information/know how exchange
Legislation (esp. Seveso II & ATEX)
participation & co-ordination of EU funded projects
Outputs:
Internal reports & books
User groups & public conferences
EU projects & working groups
Major topics 2008/09:
Process Safety Indicators/Learning from Accidents
Safety Critical Equipment
Fostering Senior Management Involvement in Process Safety (with EFCE)
LOPA Experience & Development

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Commission on Process Safety (Kommission fuer Anlagensicherheit [KAS])

Mandated by the Federal Emission Control Act

Advises government as well as plant operators and state and local authorities on
process safety
32 members with different professional and educational background representing
different stakeholders (Round Table)
Any group needs allies to win votes
Consensus intended, but majority decisions possible
About 55 guidelines issued on different topics, e.g.
Land Use Planning (Safety distances)
Risk evaluation and perception
Emergency Planning
Industrial parks
Provisions against terrorist attacks on chemical plants
All publications of the Commission are available (partly in English) at
www.kas-bmu.de

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Outline

1 Case Study: Hoechst Incidents 1992

2 Lessons Learnt

3 Improving Existing Plants

4 Conclusions

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Case Study: Hoechst Incidents 1993 1

In 1993 three major incidents occurred at 2 Hoechst sites near

Frankfurt/Germany within 6 weeks
Feb. 22
Runaway reaction after an unnoticed stirrer failure. Emission of 10 tons
methanol containing a possibly carcinogenic substance,
contaminating a large residential area
March 15
Explosion of methanol air mixture during maintenance in a process
plant. 1 worker killed, 1 seriously burnt
April 2
Major sulphur trioxide emission in a process plant
The series of incidents caused a lot of public concern and nationwide
media coverage.

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Hoechst Incidents: Severe Consequences 1

Although the Feb. 22 emission did not cause serious injuries, it led to
the most serious consequences for the company and the most lessons
learnt:
Prevention would have been possible by a thorough risk analysis leading
to a simple safety device (stirrer control acting on charging valve)
Confidence in the companys competence in emergency response was
torn down by
Gross underestimation of the affected area
Incomplete knowledge of the hazardous properties of the emitted
substance
Inadequate wording in the first press conference
Aggravation of adverse reactions by neighbours, media and authorities
by arrogant behaviour of site representatives long before the incident

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Outline

1 Case Study: Hoechst Incidents 1992

2 Lessons Learnt

3 Improving Existing Plants

4 Conclusions

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Hoechst Incidents: Lessons Learnt 2

Crisis management assessment should cover all parts of emergency-

and crisis- management ...

identify hazards comprehensively

avoid or control risks

communicate remaining risks

mitigate consequences

remediate damages

restore trust

... pursuing the goal to define and train as much as possible in

advance

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Hazards 2

Hazards have to be identified systematically ...

Operation
eg. classical EHS-hazards, loss of production, ...
hazards

Network
hazards
eg. failure of utilities, supplies, transportation ...

Environmental eg. natural hazards, adjacent plants and traffic ways, ...
hazards

Environmental
eg. densely populated areas/buildings, natural reserves, ...
vulnerability

Terrorist threats eg. plant vulnerability, neighbourhood/environment sensitivity,

company image, ...

... and transposed into scenarios.

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Prevention 2

Avoid or control risks

Assess
Minimise hazards ( Inherent Safety)
procedures

Define
safety measures Engineering/organisation/human factor/Security
update necessary?

Assess
safety measures eg. Audit programs

Prevention is the best remedy

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Risk Communication 2

Communicate remaining risks

Internal eg. training, drills

External Towards customers, neighbours, authorities but careful

regarding security risks!

who always claims `zero risk, has no credibility in his ability

to control risks!

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Mitigation 2

Mitigate consequences

Internal emergency planning (above all organisation, equipment, drills)

Cooperation with external services (neighbouring plants, public

services)

Important: ability to react fast!

The bigger a corporation,

the higher the expectations even for small sites

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Claim management 2

Remediate damages

... do not handle damages as insurance cases only

... fears may not be justified, but are always real

... be prepared for problems of competency and competition (internal

and external)
... identify free-riders

well treated wounds heal better

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Confidence Management 2

Restore trust

... prepare the fundament before the crisis

... communicate open and clear (possible conflict regarding terrorist

threats!)
... do not downplay fears

... give the company one face

You may lose trust in hours. Restoring trust needs years

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Crisis Management Systems: can the unpredictable be planned? 2

Define as much as possible in advance, because ...

... crisis always happen at the wrong time and place

... your regular organisation is not sufficient to handle crisis

... all resources of the whole company have to be available in due time

... public, media and authorities expect professional handling of crisis,

too

Will the crisis management system be adapted

to todays frequent organisational changes?

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Drills 2

Major incidents hopefully become less frequent. This makes drills even
more important ...

... to train seldom used procedures

... to reduce mental stress during incidents

... to optimise emergency- and crisis- management

... to make sure that necessary resources are available

The gap between resource consuming full drills should be filled

with frequent smaller drills.

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Outline

1 Case Study: Hoechst Incidents 1992

2 Lessons Learnt

3 Improving Existing Plants

4 Conclusions

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Plant & Process Safety: improvement of existing (old) plants 3

Make best use of limited resources by a stepwise approach:

1. Have full knowledge about hazardous properties of all substances (e.g.
Material Safety Data Sheets, data bases, etc.)
2. Identify and rank critical points (human- and eco toxicity, hold-up of
hazardous substances, reaction conditions, mechanical and physical
hazards)
3. Document this in a safety study as a tool for use by the plant and by
authorities
4. Focus improvements (manpower, money, additional safeguards etc.) and
inspections on the most critical points
5. The higher the risk, the more independent safeguards (barriers) should
be considered
6. Use the scenarios developed under (2) for emergency planning

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Swiss Cheese Model (after J. Reason, modified by Mike Broadribb, BP)

Lagging Indicator

Leading Indicator

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Plant & Process Safety: Use existing knowledge 3

Most accidents and eco incidents have a previous history ...

Preliminary events leading up to the accidents (failure of preliminary
safeguards) have not been identified
Prior to most major accidents similar smaller incidents or near misses
have happened, but not evaluated

... which should be used for prevention

Raise the awareness of the workers
Use the experience of workers
Encourage reporting of deviations, near misses and even minor
incidents as well as suggestions for improvements. Consider
contests and awards for groups working together
Have a system for following up such reports/suggestions

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Plant & Process Safety: The Human Factor 3

Workers are risks and resources for safety

They have to know the risks to cope with
Detailed written procedures are a tool both for workers and for
management. They should ...
describe the procedure as it is in the plant step by step
use a language and expressions which are understood by the
workers (no scientific or technical paper)
highlight hazards, safety measures and critical process parameters
(temperature, pressure, ...)
make independent double checks mandatory for critical parameters
and procedures
include start-up, shut-down, maintenance and process-specific
information for emergencies
Use other procedures (e.g. Quality) for safety purposes, too
Include normal and abnormal situations in training

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Safety Operating Procedures 3

Examples for visualization of safety information

Acetone Ladders

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Emergency Preparedness 3

Accidents may happen even in most modern plants. They cannot be

planned, but they should be considered.
Use the scenarios identified for prevention of major incidents for
emergency planning and training, too
Cover all relevant scenarios in the emergency plan
Assign responsibilities rather than regulating details
The emergency organisation is different from the normal organisation,
but has to be empowered to use it
Adjust the emergency organisation to the dimension of the incident (e.g.
blue, yellow, red alert)
Clearly document all available resources (site, company, neighbouring
sites, authorities, ...) for the different scenarios. Ensure that they can be
used in emergencies (e.g. co-operative agreements)
Before you rely on off-site resources, consider the time until availability
Industrial zones with many companies close together need special
attention (domino-effects)
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Emergency Response 3

The basic principle: the faster and more effective the initial response,
the smaller the consequences for men, environment and economy.
Provide the infrastructure for fast response (fire brigade, emergency
control room, notification and availability of key personnel, etc.)
Encourage immediate reporting of incidents (not to wait until own efforts
failed ...), do not blame for false alarms
Site fire brigades (or shared with adjacent sites) usually are faster and
more efficient than municipal brigades, which rather serve as a back-up
If the fire brigade is (partly) staffed by operators be aware of the risks of
understaffed production
Better start with a higher level of alarm (worst case assumption) and
grade it down later than vice versa
Notify and involve public fire brigades and authorities as soon as
possible
Analyse every incident and the response without blaming anyone to
improve the emergency organisation

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The Role of Authorities 3

The cooperation between authorities and companies at an incident

depends on their cooperation before the incident.
Open communication about risks and safety measures on a regular basis
(e.g. in a local or regional committee) builds up trust which is urgently
needed during emergency response
Authorities need to know about the possible scenarios for major
accidents to do their own preparations
Authorities should have clear rules about their responsibilities in
handling major incidents to avoid conflicts between the different
agencies (e.g. labour safety, environment, civil protection, police etc.)
Mitigation of consequences should come first, legal prosecution of
individuals responsible for the incident later

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Neighbours, Journalists and Environmentalists 3

The basic issue: Neighbours and the general public share the risks of
industrial sites, but not necessarily the benefits.
Communication of relevant risks has to be done openly and in an
adequate form (not scientific) prior to incidents (e.g. neighbourhood
councils, brochures, ...)
to build up trust in the competence of the company to handle risks
to enable the neighbours to react adequately during an incident
The response of neighbours etc. to incidents is strongly influenced by
the companys response to requests and complaints prior to the incident
Fast and open information after an incident is crucial
Fears and worries of neighbours etc. have to be taken seriously even if
they are based on emotions rather than science
On the long term, conflicts with neighbours etc. endangers the licence
to operate
Committees with all stakeholders as the German Commission on Process
Safety are an effective tool for cooperation and communication.
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Outline

1 Case Study: Hoechst Incidents 1992

2 Lessons Learnt

3 Improving Existing Plants

4 Conclusions

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Conclusions 4

Investing in safe and eco-efficient plants pays off at least on the long
term
The (remaining) risks of industrial plants can be assessed and are the
basis for scenarios for emergency planning
The knowledge and experience of the operators should be used by all
means
Risks should be communicated as well as benefits to all stakeholders,
esp. the neighbours
The resources for emergency response (manpower, equipment,
communications, organisation etc) have to be planned in advance and
readily available in case of an incident. People usually accept the risk of a
chemical/pharmaceutical plant, but not incompetence in handling it
Authorities should involve themselves actively in emergency planning,
balancing this out with their law enforcement duties
Combined efforts will definitely lead to safer and more accepted plants,
as the figures from Germany may show

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Development of Accidents in Germany since 1950 4
120

109,18

100 98,65

83,12
80

Arbeitsunflle
60
Wegeunflle
54,51

40 Arbeitsunflle
34,9 = occupational
accidents

21,13 20,45
Wegeunflle
20 18,08 16,79 15,78 14,93
= acc. on the
13,92
way to work
8,96 8,16
5,85 5,42 5,37 5,31 5,01 4,96
0
1950 1960 1970 1980 1990 2000 2001 2003 2004 2005
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Thank you for your attention!

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