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Another Brick in the Wall - Organic Intelligence

April 8, 2016

The Swiss Cheese model (James Reason, 1990) has served us well for over 25 years - but now there's a new kid on the block.

The slices of cheese represent protection measures intended to stop or slow the escalation of a Hazard to the point where it results in Harm (or other undesired Environmental or Asset/Production impact) and the holes represent an existing absence or a potential weakness which may be opened (or widened) when a demand is placed upon it.

Whilst we can visualise the potential weaknesses using holey slices, these can over-simplify the detailed components that make up these barriers, so consider instead the protection measures as walls made of LEGO® bricks.

Like any substantial structure, these walls rely on the integrity of the bricks (or foundations) below them and the strength of the mortar that binds them together. In this model, the mortar is INFORMATION that contiguously links the bricks to each other and the foundations are the key components of a Process Safety (or any other) Management System.

A Corporate appetite to acknowledge risk as an inherent part of doing business and to address these risks by Consulting and Collaborating with all stakeholders. Commitment can also mean Management who stay with the plant for some time and take genuine ownership - not just temporary stewardship as a development stepping stone.

Ensuring that suitable (Competent) and sufficient (Capacity) resources are made available where & when required. They must be Responsible, Accountable, Consult and Inform (RACI).

Clear and consistent Criteria to measure the Performance (including success or failure) of People, Processes (Procedures), Plant (Equipment) & Protection through Leading & Lagging indicators.

Learning (from Incidents) by doing (something about them). This must include Corrective (to stop the same problem happening again - recurrence) and Preventive (to avert similar problems elsewhere - occurrence) actions.

The absence or degradation of these foundations either causes bricks or sections of wall above them to themselves become weaker (and fail on demand) or collapse thus allowing a hazardous scenario to escalate.

For example, consider the protection offered by Safety Instrumented Systems where we can represent the 61511/S84 lifecycle as a barrier assembled from bricks.

Typically the lifecycle representation shows Clauses 5 to 18 (Decommissioning), however the vital element (foundation) of Information and Documentation (Clause 19) is often overlooked.

I mentioned earlier that the bricks are tied together with information, in fact this should really be Intelligence. The Agencies (CIA, MI6 etc) collect, analyse and exploit data to protect their respective citizens and Process Safety Management is no different - we are just protecting our colleagues.

Long before we had Smart Cars and Smart Phones we had Smart Instruments and now we strive for Smart Plants and put our faith in Artificial Intelligence as 'the next big thing'. However this kind of intelligence can't be bought-in or bolted-on, it has to come from within, from those who understand the temperament of the Process and appreciate the vulnerabilities of the Plant - this is Organic Intelligence.

Our facilities are literally buzzing with instruments flooding Operators, Engineers & Managers with data and we have a plethora of software tools to analyse this, but how do we convert numbers into knowledge and efficiently and effectively share and apply that across the organisation?

I've heard it said many times that the biggest threat to the safety and integrity of a facility is Microsoft Excel - unproven formulae, functions or macros, dead or misdirected links and charts based on old or irrelevant data.

So where are the integrated applications that truly & seamlessly connect Modelling, Monitoring, Maintenance & Management ? I've seen a few (many of them here on LinkedIn) but are any of them the true panacea we want and need - "Will no one rid me of this troublesome priest?"

Finally, to quote Pink Floyd:

"We don't need no education
We don't need no thought control"


We still do need education at ALL levels and, whilst thought control is perhaps a step too far, we really do need the "mindfulness" that Judith Hackitt & Andrew Hopkins promote.

We'll always have "dark sarcasm in the control room" but let's not have it in the boardroom when it comes to Process Safety Management.

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