Health, Safety and Environmental Management System (HSEMS) is a tool used by companies and organization to implement objectives and goals as outlined in the HSEMS Policy Statement. It is a form of Standard Operating Procedures that describes in detail the steps and safety measures necessary at every level of company operation in order to ensure that risk levels are eliminated or significantly reduced (Wolsey 2001). HSEMS is an instrument that companies are required to setup and apply at every level of its operation (Wolsey 2001).
This paper is divided into two parts; the first part will analyze particular major accidents using HSEMS tool in various sectors which resulted in loss of life and properties, including damage to the environment. The second part of this paper will evaluate the challenges faced by the United Arabs Emirates Federal Authority for Nuclear Regulation in implementing an Integrated Management System.
Let us briefly examine the structure of HSEMS and its function in risk management within a company environment and the extent of its depth and breadth in risk mitigation and prevention. HSEMS has four important components: organization, implementation, compliance and review (Baines Simmons International 2010). Organization is a summary of description of the HSEMS Policy and how particular components of HSEMS are aligned to meet these requirements in order to achieve organizational compliance (EHS Management System 2005). Implementation outlines the role of managers and employees in a company towards ensuring that HSEMS is integrated and applied in work procedures at all levels.
Implementation component of the HSEMS describes how work procedures should be carried out in order to ensure health, safety and environmental risks are prevented or mitigated during operations (EHS Management System 2005). Compliance concept outlines existing government directives and all other legal regulations that organizations are required to abide by during it operational activities as described in the HSEMS policy. Review is the final component of the HSEMS; it is a form of an evaluation exercise that re-examines the efficiency of an existing HSEM system (EHS Management System 2005).
The evaluation of an effective HSEMS is usually done from two ends: assessment of how best it meets the ultimate objective of the company which is to mitigate upon and reduce health, safety and environmental risks and the extent in which the system is in line with the government HSEMS Policy Statement (Jacques Whitford Environmental Ltd 2002). Review is an important component of the HSEMS in that it provides an informed basis of readjustment of the system to a structure that is most effective. Having acquainted ourselves with the general structure of an effective HSEMS let us now evaluate particular case studies against the backdrop of a an ideal HSEM System as described above.
Transport: Herald of Free Enterprise Sinking
Herald of Free Enterprise is the name of a ship that capsized on 6th March 1987 resulting to death of 193 persons of those onboard the vessel at the time. The ship was a ferry with compartments for carrying cars and passengers for transport along the route of Dover-Calais that linked England and Europe (Marine Accident Investigation Branch 2010). It had a total of eight decks and a capacity to carry a maximum of 1400 passengers, however at the time of the accident it was carrying 533 persons and more than 100 vehicles. The ship had been designed to accelerate at a top speed of 22 knots within minutes a factor that was significant in contributing to her demise (Marine Accident Investigation Branch 2010).
The reasons behind capsize of Herald of Free Enterprise can be broadly categorized into three major ways: design, work environment and human errors (Boyd 2009). Design causes include all factors that contributed to the occurrence of the accidents which can be directly attributed to the ship structural features. The environmental causes are factors that contributed to the accident as a result of routine operations that were not well implemented. Human errors describe activities done or failure in carrying out designated duties by employees which directly or indirectly contributed to the accident.
Herald of Free Enterprise had various design shortcomings some of which were well known by the owners Townsend Thoresen which managed the fleet of the ships. In fact the ship was scheduled to undergo structural modification later in the same year to have it ramp adjusted to reach E-deck during loading (Dover.com 2010). Another structural limitation was the fact that the captain didn’t have a clear view of the bow doors from the vantage point of the wheelhouse. While this was not exactly a fault in structural design per se, but a problem all the same since the captain could neither observe nor tell in any other way if the doors were open or closed at any given time (Dover.com 2010).
Normally the sheep should have been designed in a way that would alert the captain every time the bow doors were open or closed which is usually done through light codes or alarm. However the ultimate structural design deficit was in the way that the vehicle deck was constructed.
The tradition is that ship lower decks are separated into separate compartments as a form of safety mechanism so that flooding can be contained in one compartment by sealing it off and therefore prevent further flooding that could capsize the ship. Herald of Free Enterprise had neither of this for very deliberate and convenient reasons, the owners of the ship wanted an open deck that would not restrict movement of vehicles during loading and offloading and thereby save on time (Dover.com 2010).
Indeed time was an important factor for Townsend Thoresen that oversaw the running of the Spirit Class fleet of the ships. During their construction the company had made specifications to have the sheep engine designed to allow rapid accelerations and high speeds movement. At the time of the accident the ship was doing 18.9 knots a factor that significantly contributed to the rapid rise of water level that flooding the entire car deck approximately within 1 minute (British Broadcasting Corporation 2005).
The human errors that caused Herald of Free Enterprise accident are numerous from every level of the ship operations, compounded by the Townsend Thoresen lack of concise job description for it employees. Foremost the impression is that the company did not clearly describe to employee their job requirement during induction or perhaps the job responsibilities never existed, the perfect recipe for disaster.
The human error originated with the assistant Boatswain, Mark Stanley for failing to have the bow doors closed, on a closer look however it seems Mark was overworked and the timing for closing the doors seemed to coincide with his resting break (Dover. 2010).
The First Officer who is required to oversee the closing of the doors among other activities also failed to verify they were closed, on a closer look again it appears at about that time the first officer was supposed to be on the wheelhouse preparing to depart not overseeing closing of the doors. Finally the captain had no way to tell if the door were closed or in that case opened, the final straw of the disaster. It is therefore clear that the work culture of the crews in the ship lacked in more than one way.
The environmental factors that contributed to the disaster involved work environments that had no systems in place to anticipate or prevent hazards at work place (Withington 2006). A form of checklist should have been in place to facilitate employees work procedures at all time. For instance the accidents happened approximately half an hour later from the time the ship left the harbor, all this time nobody happened to notice the bow doors were open.
Furthermore at the time of the accident the ship was prying Dover-Zeebrugge which was not it regular route, a seemingly subtle point but nevertheless significant to the cause of the accident. It is possible the unfamiliar route in a way distracted the captain and perhaps the rest of crew as well in mundane ways but nevertheless enough to interfere with how they regularly discharged duties.
Gladwell points out that for any disaster to occur a combination of a total of seven system and human errors usually takes place in seemingly unrelated sequence that eventually trigger the disaster (2002).
In the aftermath of Herald of the Free Enterprise accident the government moved swiftly to implement legislations and several other compulsory regulations that were made mandatory in the industry. Some design modifications that were made mandatory by the International Maritime Organization for transport ferries, for instance required ferries to have lightings that indicated the bow doors status. Others were improvements on current ferry designs which included additional compartments immediately after the bow doors that could be sealed off to prevent further entry of flood water. Another new inclusion on the design was freeing flaps, sort of a safe mechanism valve that had the purpose to release flood water back to the sea (Dover.com 2010).
However most ferries designs were restructured in a way that factored out completely the bow doors. The company that run the fleet of the ferries, P&O European Ferries (Dover) Ltd rebranded it name to P&O Ferries while some of its manager were sued in court and replaced in the process of improving the work culture in the company. The accident was the incident behind the Public Interest Disclosure Act that came into effect in 1998. In summary it provides employees with a legal basis of exposing any forms of employer malpractice that could endanger the public.
The Act requires employees providing such information to be protected (Office of Public Sector Information 1998).
Since 1987 after the accidents of Herald of Free Enterprise Britain had never experienced any major accident on it ferry ships, in fact no other accidents have ever occurred at sea that involved ferries. In addition future ships for passenger transports were designed with more safety precautions in mind and management of ferries was revolutionized. Of particular note is the Corporate Manslaughter and Corporate Homicide Act 2007 which finally come into law in 2008 (Office of Public Sector Information 1998). The legislation can be traced to the accident of Herald of Free Enterprise when corporate killing charges were first opened for the managers of the ship. It is no doubt that the bill has gone a long way to act as a deterrent for organizations from becoming negligent during operation in a way that could cause loss of life.
Oil & Gas: BP Texas City Explosion
The BP Texas city explosion was a tragic accident that occurred at the refinery site of the company on 23 March 2005. The accident resulted to immediate death of 15 persons while injuring 170 people. The cause of the accident was explosion on the isomerization facility due to excessive pressure (Chappell 2005). The management system failures at the facility that caused the explosion appeared to be numerous from several angle.
The causative factors can be divided into three main categories: facility design, work environment, and work culture. The Raffinate Splitter column and the Blowdown Drum & Stack which was referred as F-20 were the main components of the Isomerization unit which malfunction and caused the resulting accident (Chappell 2005).
The Raffinate Splitter is a form of a column that isolates various elements that are used to blend gasoline, F-20 is a type of a safety valve that is used to channel out pressure and steams from the Splitter column (Mogford 2006). The day the accident occurred, the startup protocol of the splitter column was openly flouted and key steps in the process skipped. In the process the operational levels of the Splitter was exceeded well beyond it capacity, to correct the mistake and regulate the levels the operators applied manual processes by opening up external valves. This was not only ineffective but precipitated the reaction that took place at the Splitter column.
The external valves were adjacent to a heater that slightly warmed the incoming contents of Splitter column; however as a result of the high temperatures of the discharges the content of the Splitter column were overheated. First of all manual process should not have been used to ease off the contents of Splitter column since the automatic system was functioning. In addition the external valves should never have been located adjacent to the heater; a poor structural design at the least and which unfortunately was not the only one. The F-20 which acted as stopgap for easing excess contents from Splitter column was a disaster waiting to happen and it glaring structural deficit should have been rectified ages ago.
Normally, the F-20 should have been designed in a way where vapor discharges are channeled to an isolated compartment underground and then flared before they are released to the environment (Mogford 2005). The work environment and work culture at the site was like a booby trap, almost no supervisory oversight existed at the plant among the employee while employee themselves exhibited questionable skill levels and competency. For instance no supervisors oversaw Splitter startup which was one of the most critical procedures in the facility. The whole procedure for Splitter startup had long been customized to a dangerous short hand form by the operators while an alarm fitted to alert incase of un procedural startup was disabled (Chappell 2005).
The proximate distance of the trucks and trailers was another glaring risk hazard due to risk of ignition fire which sparked the explosion on the day of the accident. In the consecutive events that led to the disaster, the operators had ample time to contain and reverse the overheat process in the Splitter column but the approach to the crisis appeared casual at best. But in retrospect this was hardly surprising, the incident rate of the facility read like a flight itinerary with a total of 15 major accidents at a glimpse on it accident log entries, we can assume there were more since other records that dated back to the commissioning of the facility were lost in the explosion (Kamalick 2007). However what is clear is that during this instance the culture of work indifference to safety procedures prevailed.
The investigations reports prompted the government to initiate chain of regulations to ensure plant facilities conformed to the minimum level of standards.
The immediate change on the facility and all other similar plants was the F-20 vent system which was replaced with a different model that was safer and which had a flare system (Kamalick 2007). Next online was a requirement for BP Company to undertake safety and work culture investigation on its plant and implement the recommendations which required that BP ensure its plants facilities adhered fully to all safety policies (Kamalick 2007).
The company was supposed to develop more proactive employee management tools and describe job procedures to employees to be enforced through supervision. Other recommendations required trailers to be sited as far as possible from plant operations with their engines switched off unless necessary. The alarm system was even expanded to cover other areas that were critical to the facility operation as well as ensuring they were observed by employees (Kamalick 2007).
The investigation report exposed tendency of employee to contravene safety regulations which castigated Occupational Safety and Health Administration (OSHA) and Environmental Protection Agency (EPA), the regulatory bodies that has the mandate to oversee safe operations in plant facilities (Gerard and Strock 199). The incident exposed negligence on part of OSHA and EPA in enforcing regulations; they are now required to carry out regular plant inspections and safety audits.
In the process OSHA an EPA have requested more powers to enforce existing safety regulations. Currently all plant facilities in the United States must obtain a certificate of safety issued by EPA that indicates the plant facilities are compliant to all legislations as regulated by the two authorities of which there are more than 20 in total (Gerard and Strock 199). It can be assumed that stringent regulatory oversight by EPA and OSHA has helped evade imminent disaster that could have happened without them.
Chemical: Flixborough Explosion
Flixborough explosion was a chemical plant accident in England that happened on 1st June 1974. It caused a death toll of 28 persons and injured dozens of others. The accident occurred as a result of rupture of a pipe that was channeling heated compound of cyclohexane caused by an adjacent fire (Gene 2005). This caused immediate leakage of approximately 40 tons of cyclohexane compound that is highly flammable to the atmosphere. Once in the atmosphere the compound exploded to massive fire that completely engulfed and destroyed the whole plant in a matter of minutes. However later investigations of the incident attribute the accident to plant system pressure regulation controls, which is thought to have caused the internal increase in pressure that ruptured the steel pipes (Cox 2005).
The management system failures at the plant can be attributed to the plant piping system and human error of the plant engineers (Vassilakis 1999). Whichever the two reasons might have caused the accident, the plant should have been fitted with alarm system to alert operators about critical temperature and pressure levels of the piping system. Better still, it should have been fitted with safety valve mechanisms that automatically release pressure and heat when at critical levels (Lagadec 2001). Neither of this happened at the day of the accident and the operators were not aware of the increasing pressure and temperature from their control room. The investigation report noted that the plant engineers were not skilled in fitting pipe system that could sustain high pressures and temperatures (Lagadec 2001).
The engineers did not carry simulation tests of the pipes in the laboratory before they carried out the fitting as required.
This was one of the recommendations that the investigation stressed and which was later implemented by the government. In the aftermath the government implemented legislations that are contained in COMAH legislation in addition to other requirement of safety procedures at chemical facilities (Health and Safety Executive 2008). Control of Major Accidents Hazards Regulation 1999 Act and subsequent amendments to the legislations was implemented to regulate safety standards for chemical plants. The Act describes the Major Accident Prevention Policy which is enforced by the United Kingdom Health and Safety Executive.
The COMAH regulations were further amended in 2005 in a bid to address safety concerns in the wake of the Seveso disaster that are contained in the Seveso II Directive. The COMAH regulations now require all chemical plants to regularly undergo safety audits for two main reasons: to enable the facility managers undertake corrective measures that prevent plant accidents at all cost, and to ensure that environment and personal life are substantially mitigated or avoided all together in the event of any accident (Health and Safety Executive 2008).
Nuclear: Chernobyl Reactor Accident
Chernobyl disaster is one of the worst historical nuclear accidents that had ever happened. The accident happened in Ukraine 1986 on 26th April causing death of approximately 50 peoples while thousands others are expected to eventually succumb to various cancers as a result of the radiation exposure (Chernobyl. Info 2005). The cause of the accident originated from the reactor number 4 during a routine facility test exercises. Several human errors occurred that facilitated the meltdown; the crew facility operators disconnected the automated system that controlled the plant operations. The reactor 4 absorbed an electrical surge that initiated the meltdown and caused the chemical elements within it to explode destroying the structural design of the reactor as well as the plant (World Nuclear Association 2009)
After the explosion the reactor core was left open and exposed, causing a fall out of various forms of the most hazardous radioactive elements in the environment. The cause of the Chernobyl disaster was mainly due to the human error and as a result of minimal shortfall in facility design that eventually caused the sad demise of the plant. At the time of the disaster the engineers were undertaking test experiments for purposes of trying to bridge a 1 minute lag time where the facility experienced electrical blackout every time there was a power loss (Chernobyl. Info 2005).
Nevertheless the plant should have been fitted with tamper proof safety mechanisms that would have prevented the test engineers to shut down the automated system in the first place. The burden of the blame however was the inability of the test and design engineers to foresee the implications of power excursion on the plant operational parameters when automated system was shutdown.
The advances that have so far been made in nuclear power plants safety regulations makes it impossible now for an accident triggered by similar cases of facility failure and human error from happening.
The World Operation of Nuclear Operators (WONO) body was formed in the wake of the disaster to oversee the safety design operations for all existing nuclear plant in the world. All similar Russia nuclear plants have been modified to correct the lag time experienced by such plants during power loss which has now been eliminated.
More importantly it is now mandatory for nuclear plants to be designed in a way that protects the core of the nuclear from exposing the radioactive elements to the environment in case of accidents. This is now the main safety feature of nuclear plants where reactor is designed to explode without releasing radioactive components. Since the occurrence of the Chernobyl disaster, an exchange program that is focused on nuclear plant safety has been taking place between Russian engineers and their western counterparts.
Needless to say the Chernobyl disaster was not a disaster in vain, many countries moved swiftly to appraise every level of safety procedures of their nuclear plants. The safety procedures focused on engineers trainings of plant safety protocols and internal designs of facility safety mechanisms. Indeed since the Chernobyl disaster there has not occurred another nuclear disaster to date. Current safety audit of nuclear plants is done by International Atomic Energy Agency (IAEA), an international organizations which has the oversight authority of all nuclear plants worldwide (2009). The IAEA is also required to regulate and oversee all aspect of nuclear plants with main focus on safety protocols.
Fanr Management System
An Integrated Management System is a tool that allows organizations to combine several management systems within a single framework that has similar objectives. IMS groups together several systems by aligning the underlying operational requirements for each one of them with common goals (Pojasek 2006). The result is a single system that incorporates all the measurement variables of each particular management system standard and which can be used to implement any of them through a single interface. IMS is ideal for organizations that are faced with array of management system standards that they are required to conform to through their daily operations (Pojasek 2006).
An IMS has three immediate benefits to the organization beside the fact that it is one of the most superior and effective management system. It enables an organization to effectively cover all the aspects of risk factors. It saves time and financial resources as well, since a single management system is used which requires less manpower. Finally it boosts the organizational image and increases investor confidence.
The Federal Authority for Nuclear Regulation (FANR) is the regulatory body for United Arabs Emirates that has the mandate to regulate all nuclear operations in the country. As a regulatory body the FANR routine duties involve safety inspections and audit of nuclear plants operation at every level (World Nuclear Organization 2010). On the other hand nuclear plants require an internal system for plant operational inspection and audit. In both cases the most appropriate tool for the task is the IMS due to the breadth and depth of areas that nuclear plants incorporates that require auditing.
In such a case both FANR and nuclear plants will have to design an effective IMS that must include the following components.
An ideal IMS is one that is able to combine the three main management systems: quality, environment, health & safety, however a system that combines any of the two is also considered to be effective (The British Standards Institution 2010). After making sure the IMS has incorporated the above system standards the next step is to fine tune the IMS to address specific components of the systems which must be categorized in related groups. Typical specific components include but are not limited to the following documentation, policy, planning, identification, documents & data control, communications, management, process control, internal audit, data analysis, training, objectives among others (The British Standards Institution 2010).
An IMS for nuclear plant regulation will require to have more focus on documentation, policy, planning, training, internal audit, data analysis, process control, and plant maintenance. This is because this are the areas that have direct bearing to the efficiency of a nuclear plant and which can directly compromise its operations in a way that might lead to accidents.
Implementation of an IMS in UAE context might be hampered by the lack of baseline data that is necessary to set average standards of safety and work procedures once the facility has been commissioned. For instance a new upcoming nuclear plant might not be able to strike a balance between the data recording that should be done by employee for efficient plant operation and at the same time prevent taxing employee with unnecessary paperwork.
In the same way training programs would not be able to be customized in a way that focus on particular areas of employee weakness until after some time when initial trainings have been reviewed. Implementing IMS system in new organization is a delicate process since management personnel as well as the employee are required to rapidly familiarize themselves with every component of the IMS system which usually incorporates numerous variables.
An audit plan that is meant to appraise an IMS should be designed in a way that would asses all the components of IMS that we have discussed earlier. An effective audit plan should have four main components: data capture, indicators monitoring, evaluation and finally recommendations (The British Standards Institution 2010). The first component of the audit plan should assess the ability of the IMS to capture accurate data and examine how the data is analyzed. The next component of the plan is monitoring of pre-agreed indicators which will determine the efficiency of the MIS. For instance one of the indicators could be number of incident that occurred within a month that had not been foreseen and which resulted to injuries, or perhaps level of competency among employees during drill exercises.
The purpose of indicators is to function as sort of trip wires or benchmarks for evaluating progress. Evaluation is a form of an assessment that provides a scorecard at the end of review of the indicators. Depending on the indicators the evaluation will provide recommendations that are in line with the findings, which is the final step of an audit plan.
Usually the recommendations will focus on areas that need improvements and also indicate areas that the IMS is effective.
Ideal IMS guidelines should seek to incorporate all variables of work processes of an organization, this way every aspect of organizational activity can be analyzed and monitored. However an IMS guideline that is tailored for a specific sector such as nuclear facilities will be limited in terms of breadth and depth. This is because the type of organizational work processes and functions are the ones that determine the form of guidelines that an organization must adopt. In that respect FANR IMS guideline will only feature components that pertain to nuclear plants with emphasis on safety and health.
However as FANR progress and continue to apply IMS guidelines in various nuclear facilities, it is important for the IMS guidelines to be constantly modified and expanded to include all other aspects that are identified during the inspection process. Ultimately as more health and safety audit reports are done more baseline data will be generated and more weakness in management systems, employees and facility design will be identified. The initial audit process will be invaluable in providing crucial data for future IMS improvement which will in turn be used to further advance employee safety skills, eliminate system weakness and inform on appropriate plant design modifications
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