CDOIF Guidance

Safety and environmental standards for fuel storage sites

Final report

142

Appendix 5 Guidance for the

management of operations and human

factors

Introduction

1 The purpose of this appendix is to identify the guidance necessary to address the following

MIIB

Design and operations

report recommendations:

Recommendations 6 and 7, relating to fuel transfers by pipeline.

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Recommendation 9, record retention and review.

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Recommendation 10, process safety performance.

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Recommendation 19, high reliability organisations.

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Recommendations 23, 24 and 25, delivering high performance.

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2 However, all the SMS elements and associated human factors issues that are relevant to the

control of major accident hazards, and specifically tank overfill situations, are also important.

3 A high reliability organisation has been defined as one that produces product relatively error-

free over a long period of time (see the Baker Report

). Two key attributes of high reliability

organisations (see ‘Managing the unexpected’

) are that they:

have a chronic sense of unease, ie they lack any sense of complacency. For example, they do not

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assume that because they have not had an incident for ten years, one won’t happen imminently;

make strong responses to weak signals, ie they set their threshold for intervening very low.

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If something doesn’t seem right, they are very likely to stop operations and investigate. This

means they accept a much higher level of ‘false alarms’ than is common in the process

industries.

4 Recommendation 19 identified a number of high reliability organisational factors that were of

particular importance in the context of the Buncefield investigation.

5 This appendix aims to provide a route-map to existing good practice guidance, where such

guidance exists. In situations where no such guidance has been found this appendix establishes

what constitutes good practice. Examples of the latter include the industry-specific guidance

relating to fuel transfer and storage.

6 This appendix is structured as follows:

Leadership and safety culture:

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Leadership, and development of a positive safety culture.

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Process safety:

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Process safety management.

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Hazard identification and layers of protection.

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Organisational issues:

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Roles, responsibilities and competence.

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Staffing, shift work arrangements and working conditions.

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Shift handover.

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Organisational change, and management of contractors.

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Management of plant and process changes.

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