Combustible Processes

Oct. 8, 2008
Process manufacturers put themselves and the surrounding community in danger when complacency sets in.

A common scene throughout many high-performing manufacturing plants are banners hanging from the walls or rafters proudly exhibiting thousands of consecutive days without a safety incident or lost time.

No question, having zero incidents over an extended period of time is an admirable accomplishment, but it's not necessarily an indicator of a truly safe plant.

This appears to be the case with a 2006 Thanksgiving eve explosion at a factory in Danvers, Mass. A video released by the U.S. Chemical Safety Board (CSB) in August 2008 shows a computer-generated re-enactment of the incident and highlights critical mistakes plant operators at ink and solvents manufacturer CAI Inc. made before the explosion. The segment, which can be viewed online at, illustrates the CSB's conclusion that a steam valve used to control the temperature of a 2,000-gallon batch of flammable solvents inside an ink-making process vessel was likely inadvertently left open by a CAI production supervisor, allowing the solvents to boil and flammable vapor to escape.

CSB determined in May that CAI was at fault for the blast, which destroyed 24 houses and six businesses, despite the plant having what CAI treasurer Paul Sartorelli described at the time as an "impeccable" safety record. As it turns out, CAI may have dodged some bullets prior to the incident since the plant "did not have automated process controls, alarms, or other safeguards in place," according to the May 2008 CSB report. Consequently, CAI and the Danvers community experienced a scene that's become too familiar in process manufacturing plants.

At issue in many of the plants where major safety incidents have occurred is a false sense of security that sets in when the facility hasn't encountered any mishaps for an extended period, says Scott Berger, director for the Center for Chemical Process Safety (CCPS). "One of the mindsets that's hard to overcome is when you say, We haven't had any accidents in our company in a really long time, so we must have this process safety thing figured out.' What happens is that when you lose the thought that it can happen to you, things start to slip a little bit," he says.

Another problem is what Berger calls a "normalization of deviance," which is when plant employees take shortcuts without any repercussions. "So the next time you take a little more of a shortcut, and so on -- eventually you get to a position where your luck runs out."

Berger's recommendation to process manufacturers is a common mantra among safety gurus. There needs to be a "safety culture," he says, where company-wide dedication to safety is as much a part of the daily operations routine as measuring productivity.

But Berger says there's one other thing that appears to be missing: a comprehensive set of metrics for process safety. "If you can believe it, until fairly recently there was no good measurement of performance in process safety," he points out. While general industry can refer to the Occupational Injuries and Illness statistics, that measurement system "does a pretty insufficient job of addressing process safety," he adds. The result is an overreliance on the federal data, which Berger says is lacking in many areas, to measure safety success. In response, the CCPS published its own recommended set of metrics in December 2007 called Process Safety: Leading and Lagging Metrics.

One measurement the CCPS recommends is that all companies implement a "near miss" reporting metric. "A large number or increasing trend in such events could be viewed as an indicator of a higher potential for a more significant event," according to the report.

Berger says adopting such standards could help process manufacturers measure the success of their safety programs more accurately.

"One of things missing all these years is some way of knowing if things are getting better or not, so I think this is an important contribution to the practice," Berger says.

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