A Study on Effectiveness of Safety Management System in Industrial Infrastructure with focus on GPUs and Refineries in India

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A Study on Effectiveness of Safety Management System in Industrial Infrastructure with focus on GPUs and Refineries in India

S. P. Garg, General Manager (HSE) (a), Dr. Atul Razdan (b), Dr. D. K. Punia (c)

(a) Corporate Health, Safety and Environment Department, GAIL India

(b) Assistant Dean, University of Petroleum & Energy Studied, Dehradun

(c) Independent IT Consultant, Jaipur

Abstract – Oil and Gas industries are the leading drivers of world economy, which mainly trigger the growth and industrialization worldwide. With globalization and rapid industrialization, there is significant jump in Oil & Gas production in India post- Independence, which is associated with non-speculative risks of fires, explosions, toxicity, environmental pollution etc. Such emergencies/disasters pose a great threat to human life, flora & fauna.

In spite of having well-structured Safety Management System in place, accidents are regularly happening at large pace in National Gas Processing Plants and Refineries in India. Recent accidents which occurred in Numaligarh Refinery, Gujarat Refinery & HPCL Refinery, Vizag etc. indicated probable failure of Safety Management System at installations. An effective Safety Management System is required to prevent major incidents and eliminate or mitigate their consequences.


Safety Management System, Accident Causation


    Every day, 6,300 people die as a result of occupational accidents or work-related diseases more than 2.3 million deaths per year. 317 million accidents occur on the job annually; many of these resulting in extended absences from work, as stated by International Labour Organization. The human cost of this daily adversity is vast and the economic burden of poor occupational safety and health practices is estimated at 4 per cent of global Gross Domestic Product each year.

    India is the fast growing country in the world and specifically rapid infrastructure growth seen in Oil and Gas Sector all around the country. The worlds devastating incident occurred in Bhopal in year 1984, in which thousands of people died, had given further thrust on requirement of Systematic

    Approach to Safety to reduce the risk to people, property and environment. Traditional Safetyused to mainly focus on reactive controls. Modern approach to Safety is proactive rather than reactive i.e through Safety Management System.

    With increasing demand and production of Natural gas/Petroleum products, Gas Processing and Refinery units are set up to meet the infrastructure and Oil & Gas Processing requirement of country. These Gas Processing Units and Refineries are handling various hydrocarbons like Natural Gas, LPG, MS sprit etc., which are hazardous in nature and pose increased risk to the human lives, property and environment. Government of India has established comprehensive legal framework for Installation, Operation & Maintenance of such industries, to take care of associated hazards and their consequences in case of any release.

    Oil & Gas Industries have established their Safety Management System with an objective of risk reduction. In spite of multi-layer protection system approach, accidents are regularly happening. India is amongst developing countries in the world with highest number of Major Industrial Accidents in Oil & Gas Industries during the period 1917-2011 [1]. India stands 3rd highest even if all developed countries are also added in the list. Out of 319 major accidents in world during above period, 195 accidents occurred in Oil & Gas Industries itself. UNEP (United Nation Environment Program) database categorizes Major Industrial Accidents based on following criterion:

    • 25 deaths or more; or

    • 125 injured or more; or

    • 10000 evacuated or more; or

    • 10000 people or more deprived of water

      Figure 1: Major Accidents in World

      However, on lowering the criterion of classification of incidents, as done by OISD (Oil Industry Safety Directorate), Ministry of Petroleum & Natural Gas, Government of India (as represented in the statistical data and analysis of major incidents in PSU oil & gas companies operating in India from exploration & production, refining, pipe line transportation and marketing & distribution sector, for the period April, 2004 to March 2009, considering following criterion:

      • Fatality or permanent loss of body parts or permanent disability

    • Loss of property more than Rs. 5 Lacs

      Figure 2: Major Accidents in Developing Countries Oil & Gas

    • Shutdown of plant/facility

    • Blow out/Explosion

    • Loss of more than 500 man hours

    • Fire of more than 15 minutes duration

    • Failure of rig critical equipment like draw works, casing line etc, ) we get much bigger number i.e 137 reported incidents, out of which 75 incidents belong to National Gas Processing Plants and Refineries of India, during year 2004-2009. This no. is very large and cause of worry to the industry. For the purpose of our study we have considered figures of fatal accidents (which means loss of lives) and fire incidents involving loss of property only, and compared this data with Pipelines and Marketing Segments (OISD, 2010) [8].

      Figure 3: Fire Incidents in National Oil and Gas Installations

      Figure 3: Fatal Accident in National Oil and Gas Installations

      Large numbers of major accidents are happening in National Gas Processing Plants and Refineries of India, which result into severe injuries, loss of human lives and huge financial losses. This is a matter of great concern for

      such industries already having Safety Management System in place. Generally, National Gas Processing Plants and Refineries have established their Safety Management System based on ILO SMS approach, OHSAS, OISD or combination of two.

      The objective of this technical paper is to present and deliberate on the role of various contributoryfactors in the effectiveness of Safety Management System of National Gas Processing Plants and Refineries in India, which ultimately leads to prevention of major incidents and elimination/mitigation of their consequences.


    Today, it is important to understand that in Indian National Refineries and Gas Processing Plants, whether Safety Management System is impacting the accident statistics, in the same proportion, as claimed under various theories. If not, why? What are the gaps, what are the lacunas in Safety Management System in identification of probable failures or warnings? What are the issues and challenges associated with Safety Management System in National Gas Processing Plants and Refineries?

    For preparing this technical paper we have gone through large number of technical papers /studies available on the Loss Causation Models and Safety Management System world wide. We could not find any particular study on the Safety Management System pertaining to Oil and Gas Sector in Indian context, however several other references are available in the foreign context.

    We came across various Safety Management theories and Loss Causation Models like Heinrich Domino theory/ Accident Causation Model given by H.W.Heinrich, Accident Causation Pyramid, also called as Birds Model given by Frank E. Bird and Swiss Cheese Model given by James Reason etc.We also studied manytechnical papers available on Safety Management System of various industries. Oil Industry Safety Directorate (OISD) a tehnical wing of Ministry of Petroleum and Natural Gas (MOPNG), India studies various incidents and accidents happened in Oil and Gas Sector in India from time to time. Last study was done by them for the incidents pertaining to years 2004-2009. A detailed study of the analysis of various incidents carried out by OISD gives us lot of insight into the subject [8].

  3. Accident Causation and Safety Management Theory

    It is a business need to look into various contributory factors, which are impacting the effectiveness of Safety Management System to address this serious problem.Accident proneness models suggestthat some people are more likely to suffer an accident than others. The first model was created in 1919, based on statistical examinations in ammunitions factory. The model dominated the safety thinking and research for almost 50 years. As a result of this thinking, accidents were blamed solely on employees rather than the work process or poor management practices.

    Accident causation models were originally developed in order to assist people who had to investigate accidents, so that such accidents could be investigated effectively. Knowing how accidents were caused was useful in proactive sense, in order to identify what types of failures or errors generally cause accidents, so that action could be taken to address those failures before their chance of occurrence. One of the first industrial Accident Causation theories was presented by H.W. Heinrich in 1931. This model is now commonly known as Domino theory.

    Heinrich's analysis of 75,000 industrial accidents report found, amongst other things (e.g. 88% of the accidents were due to unsafe acts and 10% to unsafe conditions), that lost time injuries had been preceded by 329 similar accidents (i.e. involving similar unsafe acts or conditions). Later Heinrichs Domino Model of Accident Causation indicated five symbolic factors labelled with accident causes. They were Social, Environmental and Ancestry, Fault of Person, Unsafe Act or Mechanical/ Physical Hazard (Unsafe Condition), Accident and Injury. He defined each of these factors explicitly and adviced on minimizing or eliminating their presence in the sequence, as part of his Safety Management Approach.

    He suggested (based on his Domino Theory) that three corrective action sequence (The three Es) were required to be taken to prevent the accident:

      • Engineering Control Hazards through product design or process change

      • Education Train workers regarding all facets of safety and impose on management that attention to Safety pay off.

      • Enforcement Ensure that internal and external rules, regulations and standard operating produces are followed by workers as well as management.

    Frank E. Bird of the Insurance Company of North America further refined Heinrichs pyramid with his study of 1.7 million accidents involving 297 companies and 3 billion work hours. Frank E. Bird and Germain, stated that 600 no. apparent injury or damage cases could convert in one serious or fatal injury case.

    The requirement for organizations to develop Safety Management System grew as a result of a number of disasters, predominantly in Europe. The Flixborough, and Seveso, in year 1974 and 1976 respectively initiated the thought on Structured Safety Management System whereas devastating accident in Bhopal and Piper Alpha disaster in the year 1984 and 1986 added new dimensions to the importance of Safety Management System in the organizations. Thereafter several Accident Causation Theories like Swiss Cheese Model (Reason, 1990), Energy Damage Model, Epidemiological Model etc. evolved to study accident causation based on Accident Investigation results.

    A comprehensive model of accident causation was presented by James Reason, a Professor in the University of Manchester, who introduced the concept of organizational error [2]. He stated that corporate culture is the starting point of the accident sequence. Local conditions and human behaviour are only contributing factors in the build-up of the undesired event. The latent organizational failures lead to accident and incident, penetrating systems defense and barriers. On way of representing the aetiology of an organizational accident is by the Swiss Cheese Model shown in figure 10. Here, the

    defense portrayed as cheese slices, are shown as intervening between the local hazards and potential losses. Each slice of cheese represents one layer of defense. In an ideal world, all of these layers would be intact. In reality, however, each layer has holes of gap. These gaps are created by active failures the errors and violations of those at the human system interface and by latent conditions arising from failure of designer, builders, managers and maintainers to anticipate all possible scenarios. These holes due to active failures are likely to be relatively short lived, while those arising from latent conditions may remain dormant for many years until they are revealed by regulators, internal auditors or by incidents and accidents. It is also important to recognize that, unlike the holes in Swiss cheese slices, these defensive gaps are not static, especially those due to active failures. They are in continuous flux, moving around and opening and shutting according to local circumstances. This metaphor also makes it clear why organizational accidents are rare events. For such a disaster to occur, it requires a lining up of the holes to permit a brief trajectory of accident opportunity.

    Figure 5 Swiss Cheese Model

    The Safety Management Theory and Application Mark II model was developed by him in the early to mid- 1990s [2]. Through a construct, James Reason described

    co-relation of three different factors: the organization, workplace/condition/environment and person or individual in a Safety Management System, as shown below:

    Figure 10- James Reason Safety Management Theory

    The organization box included Corporate culture, Organizational processes as well as Management decision. This was a time when the impact of Safety Culture was becoming more and more evident. The model described that no single failure human or technical, was sufficient to cause an accident. Rather, it involved the unlikely and often unforeseeable conjunction of several contributing factors arising from different levels of the system. The theory of Reason became very popular and seemed relevant in all aspects of business, at all times.

    As described earlier, active failures are unsafe acts committed by people who are in direct contact with the system and consist of slips, lapses, mistakes, procedural violations, etc. Whereas, latent failures are pre-existing conditions that can lie dormant in the system for many years before they combine with active failures to create an accident opportunity. The Organizational and Environmental/Task Factors i.e latent conditions and Individual Factor i.e active conditions can be broadly summarized in Refineries and Gas Processing Plant as follows:

    Table 1: Proposed Organizational/Environmental/Individual Factors

    Organizational Factors



    Individual Factors

    Latent Conditions

    Active Conditions


    Physical Environment

    Unsafe Act


    Local Procedures

    Knowledge & Skill

    Risk Analysis or Risk Assessment

    Control and Display


    Equipment and Technology


    Physical Capabilities




    Operation & Maintenance

    Work Life Quality


    Staffing or Mnpower Resources

    Supervision etc.


    Standardization of Procedures

    Attitude & Competency etc.



    Review/Assess of System Emergency

    Planning etc.


By looking in to the accident statistics and losses occurred due to various incidents inIndustrial Infrastructure in India, it becomes necessaryto understand as to how accidents are happening and what are contributory factors leading to failure of established Safety Management System in such organizations.

Identification of failure of individual factorsis important to identify short term mitigation methods, but identification of failures of latent or organization factors require systematic structured assessment through complete study and researchonSafety Management System. These latent or organizational conditions can be identified and remedied before an adverse event occurs.

It is need of the hour to research on effectiveness of Safety Management System, considering the Organizational,

Environmental and Individual factors. For enhancement in

safety performance of Industrial Infrastructure specifically in Gas Processing Plants and Refineries in India such work would be quite relevant and would be able to provide some useful insight into the subject, for further guidance.

List of Abbreviations used:

MOPNG : Ministry of Petroleum and Natural Gas, Government of India

UNEP : United Nation Environment Program

OISD : Oil Industry Safety Directorate, MOPNG

HPCL : Hindustan Petroleum Company Limited LPG : Liquefied Petroleum Gas

MS : Motor Sprit


  1. Dr. Matthew J W Thomas, A system review of the effectiveness of Safety Management Systems, 2012

  2. Efthimia K. Mihailidou, Konstantinos D. Antoniadis & Marc J. Assael, The 319 Major Industrial Accidents Since 1917, 2012.

  3. Eurocontrol Experimental Section, Revisiting the Swiss Cheese Model of Accidents, 2006

  4. James Reason, Achieving a Safe Culture: theory and practice, 1999.

  5. Nick Horst, Developing assessment tools for Safety Management System and Safety Culture 2002

  6. N. McDonald *, S. Corrigan, C. Daly, S. Cromie, Safety Management Systems and Safety Culture in aircraft maintenance organisations, 2000.

  7. Pekka Tervonene, Harri Haaspasalo and Maarit Niemela, Evaluation of Safety Management and System, 2009.

  8. Prof. Patrock Hudson, Safety Management and Safety Culture The Long, Hard and Winding Road, 2009.

  9. Safety Institute of Australia, Models of Accident Causation, 2012

  10. Refineries Statistics from MOPNG, http://petroleum.nic.in/

  11. Regulations of Petroleum & Natural Gas Regulatory Board, www.pngrb.gov.in

  12. Standing Committee on Petroleum and Natural Gas, Fifteeenth LokSabha (2011-2012): Safety in Oil Installations

  13. Standards from Oil Industry Safety Directorate, http://oisd.nic.in/index.htm#

  14. United States Army Safety Center, Safety Management Concepts Series Theories of Safety Management, 1979.


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