INDEX

Note: Page numbers followed by “t” refers to tables.

Index Terms Links

Abnormal situation management (ASM) 374 520–521

ACC. See American Chemistry Council (ACC)
Acceptable risk 753–754
Accident 457
Accidental Release Information Program (ARIP) 516–517
Active safety systems 405–406
Acute Toxic Concentration (ATC) 600
Administrative Law Judges (ALJs) 87
Administrative safety systems 406
AIT. See Autoignition temperature (AIT)
ALARP. See “As low as reasonably practical (ALARP)”
ALJs. See Administrative Law Judges (ALJs)
American Chemistry Council (ACC) 72–74
American National Standards Institute (ANSI) 74
American Petroleum Institute 74–75
American Society of Mechanical Engineers 75
Analogies 494–495
AND gate 607–611
mathematics of 626–627
power of 630
Anecdotes 751–753
Annual loss prevention symposia 518
ANSI. See American National Standards Institute (ANSI)

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API RP 754 166–169

data submission 169
tiers 167–169
API RP 76 721
ARIP. See Accidental Release Information Program (ARIP)
“As low as reasonably practical (ALARP)” 45–46
ASM. See Abnormal situation management (ASM)
ASPs. See Audit Service Providers (ASPs)
Assessments
benefits of 578–579
expert 570–572
Guidance 578
management 573–579
template 577–578
Asset integrity
engineering standards 398
inherent safety 399–407
overview 398
ATC. See Acute Toxic Concentration (ATC)
Attorney–client privilege 767–768
Audit process 153–154
inadequate follow-up 154
root causes identification 154
senior managers, softened news to 153–154
Audit Service Providers (ASPs) 545–546
Auditor
attributes 545–547
demeanor 546–547
field inspection 555
independent third-party auditors (I3Ps) 569–570
internal 544
interviews 554–555

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Auditor (Cont.)
interview skills 546
outside 544
preparation 553
regulators 690
team 539–540 545
technical knowledge 546
writing skills 546
Auditor/assessor, responsibility of 105
Audits
budget 550
closeout meeting 556
conducting 552–556
findings 559
first impressions 547–548
follow-up 559
formal 539–560
forms 551–552
frequency 543
goals 548–549
host company 547–548
insurance 542
kick-off meeting 553–554
OSHA PSM regulation 538–539 540t
personnel 543–545
planning 548–551
reasons for 541–542
report 556–559
schedule 550–551
scope 549–550
SEMS II 567–570
SEMS rule 560–566

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Audits (Cont.)
standards 542–543
unannounced 559–560
verification 557–558
voluntary 541–542
Autoignition temperature (AIT) 585–586
Availability 674–675

Base Events 613–614

Bathtub curve 679–681
Bayes’ theorem 660–666
combining data sources 662–666
evaluation of tests 661
sequential observations 662
BBS programs. See Behavior-based safety (BBS) programs
Behavior-based safety (BBS) programs 8
BFD. See Block flow diagram (BFD)
Birnbaum factor 630–631
Black Swan events 53–54
Blame
avoidance of 453–455
types of 453–454
BLEVE. See Boiling liquid expanding vapor
explosion (BLEVE)
Block flow diagram (BFD) 182–183 681 683–685
Boiling liquid expanding vapor explosion (BLEVE) 592–593
Bow tie technique 265–267
Bridging documents 726–728
BSEE 102–103
BSEE SEMS 720–721

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CARP programs. See Chemical Accident Release

Prevention (CARP) programs
CCPS. See Center for Chemical Process Safety (CCPS)
Census Of Fatal Occupational Injuries (CFOI) 517
Center for Chemical Process Safety (CCPS) 77 180 411
Center for Offshore Safety (COS) 78
Certification. See Testing
CFOI. See Census of Fatal Occupational Injuries (CFOI)
CFR. See Code of Federal Regulations (CFR)
Change
administrative 419–420
covert 416–417
emergency 418–419
organizational 419–420
overt 416
temporary 417–418
types of 414–420
Charge letter 202–203
Checklists 254–255
Chemical Accident Release Prevention (CARP) programs 80
Chemical Manufacturers Association (CMA) 72
Chemical Safety and Hazard Investigation Board 78
Clients/customers 689–690
Closed Circuit Television 485
Close-out meeting 206
CMA. See Chemical Manufacturers Association (CMA)
Code of Federal Regulations (CFR) 81–82
Combustible gas detectors 534–535
Commissioning 712
Common cause events 503–504 631–632

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Communication skills 735

Communications 455–456
mid-level managers 456
senior managers 456
technicians 455
Compliance and standards 65
analysis 80
BSEE 102–103
commercial information 80
company standards 78–79
development of a standard 71–72
EPA 100
goal-driven approach 68–69
industry information 79
international agencies 110
Occupational Safety & Health Administration (OSHA) 83–92
OSHA PSM standard 93–100
process safety regulations 69–70
PSM, elements of 110–138
regulations 66–70
rule-based approach 67–68
safety case regime 104–109
standards organizations 72–77
state regulations 103–104
United States Federal Regulations 80–83
Conditional probability/Bayes’ theorem 660–666
Consequence analysis
effect of a release 583
event tree 581–582
hole size 584
nature of 581–583
reduction 200

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Consequence analysis (Cont.)

safety 582
Consequence matrix 47–49
Consultants 738–741
marketing 741
as outsider 738–739
quick study 740
response to criticism 741
Contract companies 723–725
Contract workers 725–726
Contractors 716–718
bridging documents 726–728
evaluation 730–731
HSE program 724–725
infractions 731
maintenance contractors 726
management 728–732
OSHA PSM guidance 719–720
OSHA PSM standard 718–719
record keeping 729
regulations and standards 718–721
safety meetings 729–732
selection 728–729
training 729
types of 721–726
Copyright 750
COS. See Center for Offshore Safety (COS)
Cost reduction 145–150
Cost-benefit analyses 630
Critical safety information 152
Culture, elements of 156–158

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Culture and participation 139

API RP 754 166–169
behavior-based safety 173–175
BSEE standard for culture 140–141
creating a strong culture 171–173
culture matrices 155–159
employee participation, developing 176–177
HSE and culture 142
imagination 155
key performance indicators 160
KPI limitations 165–166
KPI selection 169–170
lagging indicators 161–163
leading indicators 163–165
measurement 159–160
National Energy Board 142
stakeholder outreach 177–178
surveys 170–171
thinking backward 154–155
warning flags over an organization 143–154
workforce involvement, difficulties with 177
Curriculum vitae (CV) 736–737
CV. See Curriculum vitae (CV)
Cyclones/hurricanes 57

Database structure 307

Daubert and Frye Rules 765
DCS. See Distributed control system (DCS)
Decommissioning 233–234
Deflagrations 591–592

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Delaware’s Extremely Hazardous Substances Risk

Management Act 104
Deluge systems 536
Demolition 233–234
Depositions 762–763
Design companies 725
Design engineers 690
Detonations 591–592
Direct experience, lack of 150
Discrete event analysis 644–645
conveying statistical uncertainty 645
nonlinearities and complexities 644
Distributed control system (DCS) 371
Document creation 750–751
Documentation
requirements 205
of risk management work 761–762
Dropped objects 58–59
Drugs/Alcohol 463
Duty-holder responsibility 105

Economic consequences 583

Effectiveness 675
Emergency operations 524–525
Emergency planning and response
communications 529–530
emergency response manual 526–527
human response 521–522
investigation and follow-up 526
levels of emergency 523–526
planning 526–530
recovery operations 526

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Emergency Response Planning Guidelines (ERPGs) 597–598

Emergency Response Team (ERT) 522 524–526
Emergency Shutdown System (ESD) 530–531
Employee participation, developing 176–177
involvement in PSM elements 176–177
safety committees 176
Emulators. See Simulators
Engineering information
block flow diagram 683–685
reliability block diagrams 681–683
Environmental consequences 583
EPA (Environmental Protection Agency) regulations 83 100
risk management program 100–102
Equipment, abandonment of 203
ERPGs. See Emergency Response Planning
Guidelines (ERPGs)
Error/statistical significance confidence 40
ERT. See Emergency Response Team (ERT)
Escape routes 535–536
ESD. See Emergency Shutdown System (ESD)
ETA. See Event tree analysis (ETA)
Event tree analysis (ETA) 604 605 638 644
combining event trees and fault trees 642
quantification of 639–642
scope 642
short sequence of events 643
Events 612–614
Base Events 613–614
common cause 631–632
House Event 614
Intermediate Events 613
Top Events 612–613

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Expert witness 763–768

acceptance by court 764
attributes of 766–767
Daubert and Frye Rules 765
prior testimony 765
privilege 767–768
report 765–766
timeline/story line 765
Explosions 590–593
deflagration/detonation 591–592
dust 593
effects 592
physical 591
vapor cloud 591
Exponential distribution 679

Facility managers 690

Failure modes 676–677
catastrophic, degraded, and incipient failures 677
equipment description 676
primary, secondary, and command failures 676–677
real failures/necessary replacements 677
Failure modes & effects analysis (FMEA) 264–265
Failure rates 677–685
Failure/fault 41
Failure-to-Abate 89
Fault tree analysis (FTA) 604–638
events 612–614
Fukushima-Daiichi catastrophe 632–633
gates 606–612
generic fault trees 633–637

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Fault tree analysis (FTA) (Cont.)

limitations 638
qualitative 638
strengths 637–638
top-down development of 614–630
Fault-finding 453–455
Feedback 515
Findings
nature of 215 253
nonfindings 221
Fire detection 532–535
Fire eyes 532–533
Fires 584–589
detection 532
fighting 536–537
flammability 589
flammable range 584–585
ignition sources 587–589
zones 536–537
Flame detectors 532–533
Flammability hazard ranking 589
Flow sheets 182–186
block flow diagram 182–183
engineering information, editing 186
piping & instrument diagram 184–186
process flow diagram 183
FMEA. See Failure modes & effects analysis (FMEA)
Formal safety assessment (FSA) 107–108
Frequency 39
Frequency analysis 602–603
conditional probability/Bayes’ theorem 660–666
discrete event analysis 644–645

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Frequency analysis (Cont.)

event tree analysis 638–644
failure rate data 660
fault tree analysis 604–638
importance ranking 603–604
Layer of Protection Analysis (LOPA) 655–660
limitations to quantification 650–652
Markov models 646–649
Monte Carlo simulation 645–646
Pareto Principle 603
qualitative insights 649–650
safeguards 652–655
top-down/bottom-up approach 649–650
FSA. See Formal safety assessment (FSA)
FTA. See Fault tree analysis (FTA)
Fukushima-Daiichi catastrophe 632–633
Fukushima–Daiichi nuclear power complex 33
Fusible Links 534

Gas detection 532–535

Gates 606–612
AND 607–611
OR 606–607
VOTING 611–612
General Duty Clauses 82
GHS. See Global harmonization system (GHS)
Global harmonization system (GHS) 190
Go Team’ 461–463
Government agencies 518

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Hands-on workers 718

Hazard and operability method
node selection 245–247
process guidewords 247–248
safeguards 251
Hazard identification (HAZID) 243–244
Hazardous operations 672
Hazards
elimination 199
experience based 198–199
identification 193 196–199
management 195–200
range of consequences 581–583
substitution 199
Hazards analysis 712
benefits/limitations 235–242
charge letter 202–203
documentation 205
indexing methods 267–268
leader 208–212
logistics 203–204
organization of 200–206
report 218–232
scribe 213
special types of 232–234
team 207–214
time required 205–206
HAZID. See Hazard identification (HAZID)
HAZOP (Hazard and Operability) method 244–254
effectiveness of 253–254

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Health 583
Heat Detectors 534
Helicopters 59
Hot Work 128–129
House Event 614
Housekeeping 158
HRA. See Human reliability analysis (HRA)
Human error, nature of 498
Human reliability 685–688
analysis 687
error in an emergency 687
errors of intent 686
fixation 687
incorrect response 687
mistakes 686
slips 686
THERP analysis 688
Human reliability analysis (HRA) 685 687
Hydrogen sulfide 58

IDLH. See Immediately Dangerous to Life and

Health (IDLH)
Ignition temperature/energy 585–586
Illustrations 362–364
Immediately Dangerous to Life and Health (IDLH) 598
Importance ranking 603–604
Birnbaum factor method 630–631
Fussell–Vesely method 631
perturbation method 631
using cut sets 630–631
Incident databases 515–518

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Incident Investigation
and analysis philosophy 448–453
categorization 497–498
communicating 455–456
corporate support 470
documentation 482–483
engineering information 483
evaluation 468–469
executive management 447–448
facility management 447
fault tree analysis 500–502
follow-up 443–444
information gathering 460
initial 459
interviewer attributes 481–482
interviews 477–479
investigation process 458–461
limitations of 445–446
lying to investigators 454
management levels 446–448
operating information 483–484
photographs 484–485
project management 453
reasons for 446
recommendations 504–511
regulations 448
regulatory/legal interviews 479–480
report 461 463–467 504–511
supervision 447
team 459–460 462–463
team formation 469
team members 470–473

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Incident Investigation (Cont.)

timeline 461 485–491
trust 449 481
witness interviews 480–481
Incident/risk register 514–515
Incidents
definition of 456–457
open communication 446
potential incident 457–458
publicizing 446
reporting 454
safety as a cause of 455
Independence and randomness 41
Independent third-party auditors (I3Ps) 569–570
Industrial experience 735
Information flow, departmentalized 151–153
Information security
chain of custody 205 512 515
record retention 512
Instrument expert 213
Interface hazards analysis 269–271
Intermediate Events 613
International Organization for Standardization (ISO) 75–77
Investigators
lead 471
outside 469–470
Iron sulfide 589
ISO. See International Organization for Standardization (ISO)
ISO 9000/14001 27

Job Safe Practices 302

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Kick-off meeting 206

KPI limitations 165–166
activity and quality 165
management elements 166
quality of reporting 165–166

Lagging indicators 161–163

OSHA recordable rate 162
process safety 162–163
Law of unintended consequences 404–405
Layer of Protection Analysis (LOPA) 6 655–660
human response 659
implementing 659–660
IPLs 657–659
process 656–657
single scenarios 657
Leading indicators 163–165
near misses 164
process safety incident 164–165
unplanned maintenance 164
Level of Concern (LOC) 600
Levels of Protection 496
Lightning 588–589
Likelihood 200
and failure rate 40
Litigation support 760–763
LOC. See Level of Concern (LOC)
LOCA. See Loss of Coolant Accident (LOCA)
Logistics 203–204

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Lognormal distribution 679

LOPA. See Layer of Protection Analysis (LOPA)
Loss of Coolant Accident (LOCA) 33
Low oxygen detectors 534

MACs. See Manual Call Points (MACs)

Maintainability 675–676
Maintenance
contractors 726
expert 213
procedures 279 302
Major Accident Reporting System (MARS) 517
Major Hazards Screening (MHS) 243–244
Malicious Acts 453
Management
incident investigation 446–448
trust 454
Management elements assessment 573–579
Management of Change 129–132
benefits of 409–410
builders 435
committee 438–440
coordinator 434
definition of 410–412
evaluation of 432–438
follow-up 443–444
form 426–428
implementation 443
informal 420–421
initiator 423–424
in-kind/not-in-kind 412–414

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Management of Change (Cont.)

justification 428
new limits 441
notification 442
process 422
process hazard analysis 440
recommendations 438
request 424–426
reviewers 429–431 436
software 436
sponsor 424
variance procedures 441
Manual Call Points (MACs) 535
Markov models 646–649
MARS. See Major Accident Reporting System (MARS)
Material safety data sheets (MSDSs) 188–189 371
Materials of Construction table 187
MDT. See Mean downtime (MDT)
Mean downtime (MDT) 678
Mean Time between Failures (MTBF) 678–679
Mean time to failure (MTTF) 678–679
Mean time to repair (MTTR) 678
Mechanical Integrity 125–128
Mechanical safeguards 655
Media, exposure to 755
Meetings 742
Mergers, acquisitions, and divestitures 153
Mergers and acquisitions 158
MHS. See Major Hazards Screening (MHS)
Modules 304–306
adding and removing 316
design 317–329
numbering 317

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Monte Carlo simulation 645–646

random number generators 645–646
seed numbers 646
speeding 646
MSDSs. See Material safety data sheets (MSDSs)
MTBF. See Mean Time between Failures (MTBF)
MTTF. See Mean time to failure (MTTF)
MTTR. See Mean time to repair (MTTR)

National Emphasis Program (NEP) 570

National Fire Protection Association (NFPA) 77
National Response Center (NRC) 516
Near Miss/Hit 457
NEP. See National Emphasis Program (NEP)
New Jersey Toxic Catastrophe Prevention Act 103 104
NFPA. See National Fire Protection Association (NFPA)
NGOs. See Nongovernmental organizations (NGOs)
“Nonessentials,” reduction of 147
Nongovernmental organizations (NGOs) 755
Notes, projection of 204–205
NRC. See National Response Center (NRC)

Occupational Safety & Health Administration (OSHA) 83–92 180 392–393

citations 87–89
entry process 86–87
inspections 84–85
interpretations and guidance 91–92
Process Safety Management training standard 375–378
standards 89–91

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Occupational safety 4
Occupational safety performance 150–151
Ockham’s Razor 452
Off-the-job safety 175
Operating manual
design of 313–317
instructions 321–323
modules 304–306
writing team 332
Operating Procedures
authorization block 323–325
batch 297–298
content development 329–332
definition of 277–279
emergency 528
level of detail 329–330
links to information 325
maintaining 344–347
overview 273
quick assessment 283–284
shut down 292–294
software analogy 302–313
sources of information 331–332
standard 298–301
start-up 290–292
steady-state 289–290
temporary 296–297
training 327
two-page modules 327–329
users 285–286
Operational readiness 390 712–713
Operations expert 213

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Operator/contractor bridging document 726–727

OR gate 606–607
mathematics of 625–626
Organizational spread 150
OSHA. See Occupational Safety & Health
Administration (OSHA)
OSHA PSM guidance
for contractors 719–720
OSHA PSM standard 93–100
for contractors 718–719
OSHA standard 83–92
Trade Secrets 756–759
Other-than-serious violation 88
Outsourcing 149
Overload, initiative 145

P&IDs. See Piping & instrument diagrams (P&IDs)

Pareto Principle 603 668
Passive fire protection 589
Passive safety systems 405
PCDV. See Pressure control deluge valve (PCDV)
PELs. See Permissible exposure limits (PELs)
Permissible exposure limits (PELs) 598
Personal protective equipment (PPE) 730
PFDs. See Process flow diagrams (PFDs)
PHAs. See Process Hazard Analyses (PHAs)
Piping & instrument diagrams (P&IDs) 184–186
design phases 185
equipment and line designations 185
instrument designations 186
updating 186

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PPE. See Personal protective equipment (PPE)

PRA. See Probabilistic risk assessment (PRA)
Precommissioning 708
Predicted frequency 40
Presentations 741–742
Pressure control deluge valve (PCDV) 537
Prestartup safety review. See Operational readiness
Pre-start-up reviews (PSR) 390
asset integrity/reliability 397
knowledge management 396
operating procedures 397
organizational responsibility 395–396
OSHA’S PSM 392–393
process safety management 396–397
regulations 392–393
reviews 395
SEMS 393
training/performance 397
types of 394–395
Probabilistic risk assessment (PRA) 6 688
Probability terms 40
Probit equations 596
Procedural safeguards 654
Procedures-writing team 332
Process expert 213
Process flow diagrams (PFDs) 183 704
Process Hazard Analyses (PHAs) 94 738
leadership 232
Process safety 4
Process Safety Beacon 518
Process Safety Information (PSI) 112–113

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Process Safety Management (PSM) 14–26

compliance audits 136–138
contractors 122–123
definition of 16
elements of 110–138
emergency planning and response 133–136
employee participation 110–111
holistic 25–26
Hot Work 128–129
incident investigation 132–133
involvement 25
management of change (MOC) 129–132
measurement strategies 21–24
Mechanical Integrity 125–128
metrics 695–696
operating procedures 117–120
operating, safe, and emergency limits 19–20
plan 696–698
prestartup safety review 124–125
process hazards analysis 114–117
Process Safety Information (PSI) 112 113
program organization 690–699
safe limits 16–18
set point values 18
thoroughness 25
training 120–122
Production creep 144
Production records 144–145
Program organization 690–699
Project cutbacks 149
Project management
commissioning and start-up 712–714

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Project management (Cont.)

concept selection 703–704
detailed engineering 707
fabrication and construction 707–712
hazard analysis 701–702
phase/gate system 700–701
preliminary design 705–706
project organization 714–715
Project managers 690
Project organization 333 714–715
Prototyping 311–312
Pseudorandom numbers 645
PSI. See Process Safety Information (PSI)
PSM. See Process Safety Management (PSM)
PSR. See Pre-start-up reviews (PSR)
Public communication 753–756
Publishing 342 365–368
Punchlists 708–709
Pyrophorics 589

QFTA. See Qualitative fault tree analysis (QFTA)

Qualitative fault tree analysis (QFTA) 638
Quality management 26–27
ISO 9000/14001 27
Six Sigma process 27
statistical process control (SPC) 26

RACI chart. See Responsible, Accountable, Consult and

Inform (RACI) chart

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Radiant heat 587

RAGAGEP 47 98–99 407
RAM programs. See Reliability, availability, and
maintainability (RAM) programs
Random number generators 645–646
RBDs. See Reliability block diagrams (RBDs)
“Reasonable” risk 767
Recommendations 215
Reliability 667–668
benefits of 669–671
definition of 673–674
redundancy 683
and safety 672–673
Reliability, availability, and maintainability (RAM) programs 667
Reliability block diagrams (RBDs) 681–683
Repeat violation 89
Report writing 742–751
active voice 352
completeness/thoroughness 744
draft report 743–744
imperative tense 352
language 744
minimalist writing 348
multiple languages 369
personal information 744
reading grade level 353
vigorous writing 348–351
writing style 347 351–355 744–749
Responsible, Accountable, Consult and Inform (RACI) chart 697
Responsible Care® program 72–74
Resumé 736–737
Revalidation hazards analysis 234–235

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Reviews 570–572
and sign 342
Risk 27–28
acceptable 43–47
components of 28–32
consequence 29–30
economies of scale 32
hazards 29
predicted frequency 30
presence of persons 31–32
rank 199 253
safeguards 30–31
single contingency events 32
Risk, quantification of 39–43
FN curves 41
limitations 41–43
mathematical terms 39–41
Risk, subjective nature of 34–39
availability 39
bias toward positive evidence/prior beliefs 38–39
comprehension time 38
degree of control 35
direct benefit 36
familiarity with the hazard 35–36
natural vs. man-made risks 36
perception of the consequence term 36–37
personal impact 36
randomness 38
recency of events 36
regression to the mean 38
Risk management 1
Black Swan events 53–54

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Risk management (Cont.)

common cause events 33–34
consequence matrix 47–49
environment 26
environmental programs 10
examples 60–64
frequency matrix 49–50
health issues 11
historical development 4–9
in offshore oil and gas 55–59
in oil refineries 54–55
major events 9
prescriptive/nonprescriptive standards 11–14
process safety management (PSM) 14–26
quality management 26–27
risk matrix 50–52
safety 11
Risk management professional 733
anecdotes/storytelling 751–753
attributes 734–737
communicating with management/clients 741–742
communicating with public 753–756
communication skills 735
consultants 738–741
copyright 750
education and certification 734
expert witness 763–768
holistic 734
industrial experience 735
knowledge of past events 735
litigation support 760–763
meetings 742

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Risk management professional (Cont.)

network 736
numerate 735
presentations 741–742
prior testimony 765
privilege 767–768
professional engineers 737
professional involvement 736
report writing 742–751
responsible document creation 750–751
resumé/CV 736–737
sensitivity 753
technical knowledge 734
timeline/story line 765
Trade Secrets 756–759
Risk matrix 50–52
limitations of 52–53
Risk register 217–218 514–515
Risks associated with pipelines 59–60
Root Cause Analysis
definitions of 451
levels of 492–493
types of 450–451 461 494
Rule compliance, overconfidence in 151

Safe limits
management of change 441
Safeguards 30–31 652–655
emergency response 655
installing 200
levels of protection 652

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Safeguards (Cont.)
mechanical 655
normal operations 653–654
passive 655
procedural 654
safety instrumented systems (SISs) 654–655
SafeGulf (program) 388
Safety and Environmental Management Systems (SEMS) 393 720
training requirements 375
Safety case regime 104–109
assessment 108–109
elements of a safety case 105–106
performance measurement 109
preparation and implementation 108
structure of a safety case 106–108
Safety critical items 406–407
Safety data sheets (SDS) 187–189
Safety diamond 190–192
Safety instrumented systems (SISs) 654–655
Safety management system (SMS) 106–107 718
Safety meetings 729–732
SCBA. See Self-contained breathing apparatus (SCBA)
SDS. See Safety data sheets (SDS)
Security, sabotage 453
Seed numbers 646
Self-contained breathing apparatus (SCBA) 374
SEMS. See Safety and Environmental Management
Systems (SEMS)
SEMS Audit Rule 560–566
Senior management 689–690
Serious violation 88
SHI. See Substance Hazards Index (SHI)

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Ship collision/mooring failure 59

Short-term exposure limit (STEL) 599
Simulators 384–386
SISs. See Safety instrumented systems (SISs)
Six Sigma process 27
Smoke detectors 533–534
SMS. See Safety management system (SMS)
Social media 741
SPC. See Statistical process control (SPC)
Spontaneous combustion 586–587
Standards
incident investigation 448
industry 543
internal 543
Static electricity 587–588
Statistical process control (SPC) 26
STEL. See Short-term exposure limit (STEL)
Storytelling 751–753
Stretch goals 144–145
initiative overload 145
production creep 144
production records 144–145
Subcontractors 725
Substance Hazards Index (SHI) 600–601

TCCC. See Transfer of Care, Custody, and

Control (TCCC)
Team leader/facilitator 208–212
Team player culture 152–153
Technical information 179
flow sheets 182–186

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Technical information (Cont.)

global harmonization system (GHS) 190
material safety data sheets (MSDSs) 188
Materials of Construction table 187
process description 182
safety data sheets (SDS) 187–189
Table of Contents 180–181
Technical safety 3–4
Tenth Amendment to the United States Constitution 82
Testing 387
THERP (Technique for Human Error Rate Prediction) analysis 688
Third Law of Thermodynamics 44
Threshold limit values (TLVs) 599
Title block 318–321
TLVs. See Threshold limit values (TLVs)
Top Events 612–613
Top-down development 308–311
Toxic gases 593–601
effects of 595–596
exposure limits 596–601
location of monitors 601
models 593–595
Trade Secrets 756–759
Training
budget 381–382
computer-based 384–385
contractor 729 731
economics of 383–384
elements of 372–375
emergencies 528–529
initial/basic 373–374
levels of competence 371–372

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Training (Cont.)
management of training program 380–383
matrix 381
OSHA PSM 375–378
pipeline operator training 389
procedures 379–380
refresher 374–375
SEMS 375
site 374
Transfer of Care, Custody, and Control (TCCC) 709
Transient stresses 672
TRIZ 240–241
Troubleshooting 294–296 522–523

United States Federal Regulations 80–83

Code of Federal Regulations (CFR) 81–82
EPA 83
General Duty Clauses 82
regulatory process 80–81
Tenth Amendment to the United States Constitution 82

Vacuum trucks 587

Visitors/consultants 726
VOTING Gate 611–612
mathematics of 627

Warning flags over an organization 143–154

departmentalized information flow 151–153

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Warning flags over an organization (Cont.)

excessive cost reduction 145–150
ineffective audit process 153–154
“it cannot happen here” belief 150–151
overconfidence in rule compliance 151
unrealistic stretch goals 144–145
What-If Method 255–263
What-If/Checklist Method 263–264
Why Tree process 498–499
Willful violations 87–88
Witnesses to fact 763
Worker’s Compensation programs 5
Workforce, reductions in 147–148
Workforce involvement, difficulties with 177
inefficiencies 177
labor/management relations 177
unwillingness to accept change 177
Write procedures 341–342
Writing and publishing 332–333

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