Safety Moment #26: Once upon a time . . .

Trevor Kletz story teller
Trevor Kletz

This Safety Moment is our third in the series to do with the topic of process safety “wisdom”. The background to the series is provided in Safety Moment #24: Where Then Shall (Process Safety) Wisdom Be Found?

Pulling People In

Moses in the bullrushesOne of the founders of the discipline of process safety was Trevor Kletz. He understood that human beings communicate best not by reading reports, articles or presentations but through stories. Which is why, following his death in the year 2013, we wrote the eulogy That would be telling. Few of us have followed his leadership.


Bill Baker, principal of BB&Co Strategic Storytelling, states,

Storytelling is the mother of all ‘pull’ marketing strategies. It encourages dialogue, engagement and interaction among equals – an exchange of meaning between people. Yet many companies and brands are still relentlessly pushing messages out, hoping that with enough repetition, something will stick.

Managers and technical leaders tend to see communication in terms of conveying information to the work force. For example, at one facility a pressure vessel exploded. In the follow up to the event it became clear that the lead technicians did not understand the concept of Maximum Allowable Working Pressure (MAWP) and that they did not know the MAWP values of the vessels under their control. So management and their process safety consultant implemented a training/education program to do with the concept of MAWP and they then made sure that information to do with specific MAWP values was readily available in the control room. There was nothing wrong with this communication strategy. But it would have been much more effective if it could have been supplemented with stories and videos showing what happens if pressures do go above MAWP.

Above all, people like stories about other people. In our Safety Moment #25: “There’s No Substitute for Knowing What You’re Doing” we shared a story about a retired boiler house superintendent. This person was not named — indeed, the story has taken on so many lives that we can reasonably treat that superintendent as a fictional character. Nevertheless, it is a story about a person and his interactions with other people — in this case the managers of the company. It is the people part of the Safety Moment that packs the punch.

Dramatic Pictures

Not only do humans like stories, they particularly like stories that are dramatic and even sensational. Which means that we should share stories about incidents that have taken place elsewhere. We are currently developing an Operational Excellence Assessment system. One of the 18 sections in that system is ‘1. Culture’. And an important part of culture is having a good knowledge of incidents, including near misses.

If a story can incorporate pictures or videos then its impact will be dramatically enhanced. For example, the video clip of the moment when the Piper Alpha riser ruptured shows us just how bad incidents can be.

Piper Alpha newspaper clipping

In earlier Safety Moments we have talked about some of the difficulties to do with the fact that “Information is endlessly available” to us on the Internet. But one of the upsides of the internet is that it allows us to communicate using pictures and videos. The following picture from the organization is a fine example.

Bypassed switch shows the power of pictures

Story Time

An oil refinery located in a major metropolitan area used a hydrogen fluoride (HF) alkylation process. HF is a liquid, but, on release to the atmosphere, it forms a highly toxic vapor cloud. HF was delivered to the refinery about once a month by tank (rail) car. Operators connected the tank car to the HF storage tanks using special hoses and fittings. A major leak from either the hose or its fittings could create a catastrophe.

Management decided to implement a process safety program. And they then decided, sensibly enough, to start by conducting a HAZOP (Hazard and Operability Study) on the alkylation process and its related activities — including the tank car unloading operation.

The HAZOP team asked for a copy of the Unloading Procedures. It turned out that those procedures had “gone missing” — no one knew where they were. Eventually, after a day of hunting through files the unit supervisor proudly produced the missing document and shared it with the HAZOP team. A careful evaluation of the procedures, including a field walk-through, showed that — were they to be followed as written — there would be a major release of HF. This was not a “maybe”, it was a “will be” — the event was a certainty. But, no worries, since no one ever used the procedures there was no need to take action.

Footnote: The refinery was an old one and HF had been unloaded from tank cars many, many times. There had never been a significant release of HF from any part of the process in  all those years.