One of the weakest elements in OSHA’s PSM and EPA’s RMP standards is the Incident Investigation element. Anyone who has performed a PHA or Audit can tell you that the difference of opinions range from aggressive to the criminally insane! Personally I have heard some of the lamest excuses for not investigating Loss of Primary Containment events, but it gets downright nasty when we ask about “process near misses” being investigated. Since 2016, I now direct those who want to push back about the types of incidents that SHOULD BE investigated to New Jersey’s Toxic Catastrophe Prevention Act (TCPA) Program. In 2016 NJ’s Department of Environmental Protection issued a guidance document explaining, in their opinion, the types of incidents that should be investigated and I for one think they nailed it! The guidance document, Guidance Document on Identifying Process Safety Incidents, is intended to assist TCPA facilities in understanding what incidents must be investigated and how to improve their management systems to identify those incidents when they occur.
Incidents covered by the TCPA rules include all Extraordinarily Hazardous Substance (EHS) accidents and potentially catastrophic events (more commonly known as “near misses”) pursuant to 40 CFR 68.81(a) incorporated with changes at N.J.A.C. 7:31-4.1(c)16.
An EHS accident is defined at N.J.A.C. 7:31-1.5 as an unplanned, unforeseen or unintended incident, situation, condition, or set of circumstances which directly or indirectly results in an EHS release.
An EHS release is a discharge or emission of an EHS from a piece of EHS equipment in which it is contained, excluding discharges or emissions occurring pursuant to and in compliance with the conditions of any State permit or regulation.
A potentially catastrophic event is defined at N.J.A.C. 7:31-1.5 as an incident that could have reasonably resulted in a catastrophic release of an EHS. The Department has stated that it equates the term “potential catastrophic event” with that of “near miss,” which has a long history of use by process safety professionals and organizations such as AICHE’s CCPS.
The American Institute of Chemical Engineer’s Center for Chemical Process Safety (CCPS) defines near miss as
an occurrence in which an accident (that is, property damage, environmental impact, or human loss) or an operational interruption could have plausibly resulted if circumstances had been slightly different.
In another CCPS publication, near miss is defined as
an undesired event that under slightly different circumstances could have resulted in harm to people, damage to property, equipment or environment or loss of process.
Finally, the United Nations Environment Programme (UNEP) DTIE Sustainable Consumption and Production (SCP) Branch, defines near miss as
any unplanned event which, but for the mitigation effects of safety systems or procedures, could have caused harm to health, the environment, or property, or could have involved a loss of containment possibly giving rise to adverse effects involving hazardous substances.
Examples of incidents may help facilities understand what a near miss is. CCPS states that some common examples of near miss incidents might include:
- Excursions of process parameters beyond pre-established critical control limits;
- Activation of layers of protection such as relief valves, interlocks, rupture disks, blowdown systems, halon systems, vapor release alarms, and fixed water spray systems; and
- Activation of emergency shutdown (in some instances)