3. What’s Inside
• Leadership Message02
Page #
04
06
07
08
14
15
• ESP Background
What, why & who
• Importance
What is in it for me?
• Relevance
What is my role?
• Gasco’s Methodology
How are we doing it?!
• Customer’s Feedback
• ESP Pyramid

4. 2
Leadership Message
The 2nd Edition of our Process Safety Bulletin has
incorporated your overwhelming feedback, while
keeping the simplicity and structure as its signature.
Ensure Safe Production (ESP) acronym might be
new for us. But most of its components are already
being practiced in Ruwais since long. We take it as an
exciting opportunity to benchmark against the best in
global industry and follow their trail towards achieving
excellence. We expect our Operational leaders and
their teams to contribute their wealth of knowledge
and personal experience in this journey, which is
paramount in delivering adherence & assurance of
process safety excellence within GASCO.
This bulletin covers 5 out of 9 ESP components & share
the incidents, which taught their importance. I assure
my full commitment to this objective & urge all
Ruwais team to gear up for this exciting ride ahead.
VP
“Leaders create cultures by what they systematically pay
attention to. This can mean anything from what they notice
and comment on, to what they measure, control, reward
and in other ways systematically deal with - Edgar Schein”

5. 3
I am glad to hear your feedback on the last
issue and hope you find this issue as useful as
the last one. Technical team has a very strong
“navigator” role to perform in ESP. Starting
from configuring the targets, to analyzing
excursions in operating windows & making
sure the integrity limits are never breached,
my team is ever involved. Ensure Safe
Production constitutes a major portion of
Operating Integrity framework (See figure
on Pg 05) designed to operate asset safely.
Being a socially responsible organization, we
continually seek to share our best practices
across the fence & learn from incidents that
occurred internally & externally. It is only thru
incorporating these learnings, we can stay up
to date with technological progress and keep
our safety barriers strong, round the clock on
an evergreen basis. Ensure Safe Production in
particular and Process Safety management
in general, requires our utmost focus, active
engagement and up-to-date competence,
for which me and my team are ever
committed.
Operations have the lead role in Ensure Safe
Production. Being on the fore front, it is
our job to make sure that processing plant
operation remains within well defined &
understood limits. Multiple serious process
safety incidents have shown that human
error is the most recurring primary cause
or contributor, resulting in both initiation
and/or escalation of an accident. ESP is
designed to support the operator by
providing sufficient information, training
& tools to avoid/minimize abnormal
situations. If, however, an abnormal situation
does come, different layers of protection
are adequately available to mitigate/
normalize the risk back under control.
Adhering to ESP guidelines, will further
strengthen our resolve of “no harm to people”
by keeping “hazardous substances within
process equipments, which are designed to
keep them safely”. I welcome you on this
exciting journey and request to join hands
with us, as we progress towards a safer
tomorrow!
ORT ORO

6. 4
ESP Background
What
“Ensure Safe Production” (ESP) is a basic,
standardized, operational framework that
ensures plant operations within well-defined,
well-understood limits. Goal is to ensure;
“We know our limits and everything
runs within those limits all the time!”
Why
American Institute of Chemical Engineers
(AIChE) created the Center for Chemical
Process Safety (CCPS) in 1985 after the
chemical disasters in Mexico City, Mexico,
and Bhopal, India. The CCPS is chartered
to develop and disseminate technical
information for use in the prevention of
major chemical accidents. One of their
most celebrated book “Guidelines for
Risk Based Process Safety, CCPS, 2007”
was produced in response to the fact
that many organizations continue to be
challenged by inadequate management
system performance, resource pressures,
and stagnant process safety results.
To promote process safety management
excellence and continuous improvement
throughout industry, CCPS created risk-based
process safety (RBPS) as the framework for
next generation of process safety
management.
Brightest minds of industry pointed out
the pivotal importance of developing and
sustaining high standards in the Conduct Of
Operations or Operational discipline.
Execution of operational and management
tasks in a deliberate and structured manner is
an absolute must for any organization, in its
pursuit of excellence in Process Safety. This
fundamental concept evolved in to the
formation of Ensure Safe Production (ESP)
program, designed to minimize human error
and variations in performance.
COMMIT TO
PROCESS SAFETY MANAGE RISK
UNDERSTAND
HAZARDS
AND RISK
ProcessSafetyCulture
CompliancewithStandards
ProcessSafetyCompetency
WorkforceInvolvement
StakeholderOutreach
OperatingProccedures
ProcessKnowledgeManagement
HazardIdentificationandRiskAnalysis
SafeWorkPractices
AssetIntegrityandReliability
PROCESS SAFETY
MANAGEMENT SYSTEM
ContractorManagement
TrainingandPerformanceAssurance
ManagementofChange
OperationalReadiness
ConductofOperations
EmergencyManagement
IncidentInvestigation
MeasurementandMetrics
Auditing
ManagementReviewandContinuousImprovement
LEARN FROM
EXPERIENCE
CCPS Risk Based Process Safety
Figure Source: Guidelines for Risk Based Process Safety, CCPS

7. 5
How
ESP explains basic standards for “Safe
Operations” by clarifying “expected
behavior”, based on continuous situational
awareness.
The Ensure Safe Production work process
is build around a number of key concepts:
• Operational limits must be known and
should be within all engineering limits.
Engineering constraints, Operational limits
and predefined responses to Exceedence
must reside in a single repository.
• Philosophy change from “machine calls
man” to “man is ahead of machine”
• Traditional pre-alarm disappears, as a result
of proactive monitoring rounds
• Any deviation from a Safe Limit, follows a
simple alarm hierarchy and has a
predefined, accessible response
• Proactive instead of reactive operation,
always aware of situation. It is not
acceptable to wait for an alarm to get
aware of an abnormal situation.
• Every operator›s duty is to independently
take (predefined) measures to get the
process back into safe limits, including
shutting down. Leadership shall fully
support this through unconditional
empowerment of all operators.
• Elimination of “normalization of the
deviance”, whereby no abnormal situations
are considered normal after sometime.
• Embedding the work process in
management systems (such as
organograms, job descriptions, procedures
etc.), including accountable owners of
(various parts of) the work process.
• Management measures performance by
simple KPIs.
Normalization of deviance is defined as: “The gradual process through which
unacceptable practice or standards become acceptable. As the deviant behavior
is repeated without catastrophic results, it becomes the social norm for the
organization.”
GASCOESP
OperatingIntegrity
Shift log report
and records.
Shift handover
and
Orientation
Shift Team
Meeting
Operating
Procedures and
Work instructions
Statement of
Fitness
PCM Registers
Isolation
of Energy
Operating
Windows
Alarm
Management
Override of
Safeguarding
System
Management
Abnormal
Situations
Proactive
Monitoring
GASCOESP
OperatingIntegrity
Shift log report
and records.
Shift handover
and
Orientation
Shift Team
Meeting
Operating
Procedures and
Work instructions
Statement of
Fitness
PCM Registers
Isolation
of Energy
Operating
Windows
Alarm
Management
Override of
Safeguarding
System
Management
Abnormal
Situations
Proactive
Monitoring

8. 6
Importance
What’s for me?
ESP helps maximize an organization’s value to all of its stakeholders. It focuses on improving
human performance - as an individual and as an organization - by establishing clear
expectations and consistently performing tasks in accordance with those expectations.
In other words, it helps establish a culture in which deeds match words.
Many different industries and organizations have implemented ESP in particular and
Operational Discipline systems in general and have universally seen their performance
improve as a result. The proven benefits include:
Improved
Safety Performance
High Motivation
& team work
Creativity &
subsequent
Profitability
High morale
of organization
Improved
emergency
handling
High levels
of service
Procedural
awareness and
compliance

9. 7
Relevance
My Role
• Emergency Procedures
• Proactive monitoring
• Alarm KPI’S and analysis
• Operating within limits
OPERATIONS • Effective RCA & proactive techniques
• Plant integrity
• Process Equipment integrity
• Maintenance Excellence
MAINTENANCE
• Inherent design Safety
• Risk assessment
• Steward Alarm management
• Compliance to RAGAGEP
• MOC
TECHNICAL SERVICES • HSEIA
• HSE-MS
• Audits
• Leading/ Lagging indicators
HSE
Key Terminologies:
RCA Root cause analysis
KPI Key performance indicators
MOC Management of Change RAGAGEP
HSEIA
HSEMS HSE Management System
HSE Impact assessment
Recognized and generally
accepted good engineering
practices

10. 8
Discussion
1 The foundation of good operations is
about getting “Everyone on the same
page”, All components of lower layer are
tailored to ensure that incoming shift has
100% situational awareness on key issues
e.g. Operations, HSE, Overrides etc.
2 Second layer is meant for “knowing the
limits” of a Process. Be it alarm limits,
operating windows or safeguarding
system, all limits must be adhered to at
all times. Procedures must be in place for
guidance on deviation controls, actions &
authorizations. Good understanding of
limits also eradicates normalization of
deviance, by continually challenging
current conditions against process limits,
rather than experience.
3 Proactive monitoring is the centerpiece.
The goal is to monitor and control unit
and equipment, so as to avoid exceeding
a safe limit while meeting all operational
and business targets
4 Abnormal Situation management requires
smooth handling of HSECES non-availability,
reduced manning, impaired competence,
external risks & operating window
exceedences.
ESP Pyramid
Situational Awareness Stage
Monitor & Control Stage
Abnormal Situation Management
Proactive MonitoringProactive Monitoring
9
Shift log report
and records.
6
Shift handover
and
Orientation
7
Shift Team
Meeting
8
Operating
Procedures and
Work instructions
9
Shift log report
and records.
6
Shift handover
and
Orientation
7
Shift Team
Meeting
8
Operating
Procedures and
Work instructions
5
Operating
Windows
3
Alarm
Management
4
Override of
Safeguarding
System
5
Operating
Windows
3
Alarm
Management
4
Override of
Safeguarding
System
1
Management
Abnormal
Situations
1
Management
Abnormal
Situations
Proactive
Monitoring
2
Proactive
Monitoring
2
Abnormal Situation Management
Monitor & Control Stage
Situational Awareness Stage

11. 9
An abnormal situation is one where a
process variable (flow, pressure, temperature,
concentration, level etc.) goes outside its
operating envelope and, if not brought under
control by appropriate response, may
escalate to an emergency situation (e.g. loss
of containment).
It is essential to implement measures, which
reduces residual risk to ALARP/tolerable
level. In GASCO these cover 06 categories
essentially;
Management of Abnormal Situation
PEOPLE
PROCEDURES
PLANT DOWNGRADED
CONDITIONS
INCREASED RISK
(Inherent+External)
system
override
OPERATING WINDOW
EXCEEDENCE
MAINTENANCE
OVERRIDES
The input to the Longford gas plant is a
mixture of gas, light hydrocarbon liquids
and water. The components of the mixture
are separated in a complex process of
heating, cooling and pressure changes. The
morning of the accident, a severe process
upset caused an automatic shutdown of
the circulation of “lean” oil which warmed
the plant. This caused a heat exchanger to
become extremely cold about – 50 degrees C.
The operators and their supervisors then
made a critical error – they decided to
reintroduce the warm oil into the heat
exchanger after it had become super cold.
Just like a cold glass shatters, if boiling
water is poured into it; a metal which has
been chilled below freezing temperature
becomes brittle and can fracture in the
same way, if suddenly warmed. This is exactly
what happened on the day of the accident.
Exchanger fractured in a catastrophic way,
allowing huge quantities of hydrocarbons to
escape, find an ignition point and catch fire.
Inability to handle the abnormal situation led
the company to a crippling catastrophe.
Incidents that taught Abnormal Situation Management - Esso Longford

12. 10
Operator Proactive Monitoring
PRACTIVE
MONITORING
Product Quality
Observations
Pipeline
Surveillance
Area
Operator
rounds
DCS
monitoring
Equipment
Condition
Monitoring
Objective is to ensure that facilities are
proactively monitored, so as to retain best
possible level of situational awareness. This
promotes early detection & appropriate
intervention to an arising abnormal situation.
This monitoring involves field operator, Panel
operator and monitoring by Technical
personnel as well. Each position has an
important role to play, since monitoring
duplication is rare. An abnormal sound in the
pump, a broken stem of a control valve or
deteriorating performance of a column – all
are picked up by relevant discipline and
worked upon to avoid a process upset.
In the predawn hours of March 28, 1979, a
pressure valve suddenly malfunctioned at the
Three Mile Island nuclear power plant near
Harrisburg, Pennsylvania. The accident started
at the plant’s Unit 2 reactor when a small
pressure relief valve failed to close, causing
cooling water to drain from the nuclear core.
The core (fuel) quickly began to overheat.
Ineffective field and panel monitoring and
confusing instrumentation led the operators
to believe that relief valve was closed and
too much water was being injected into the
reactor vessel. So the plant operators shut off
the emergency water system that would have
cooled the core and prevent an accident.
What occurred next was a combination of
technical failure, human error, and bad luck
that resulted in the worst nuclear accident
in American history. For five nerve-wracking
days, engineers struggled to control a
runaway reactor, government officials
debated whether to evacuate the area, and
residents contemplated the ultimate horror
of a nuclear meltdown.
Incidents that taught Proactive Monitoring - Three Mile Island

13. 11
Alarm Management
Alarm management is meant to define and
verify limits and alerts. Whenever an alarm
becomes active there should be sufficient
time to respond. It also requires
consideration of human factors, along with
adequate design & architecture of the
alarm system in order to direct the operator
attention.
A huge explosion and subsequent ensuing fires
disrupted the silent town on July 24, 1994 at
Milford Heaven, UK. An abnormal situation
occurred at site because of electrical storm.
Poor handling of that situation led to release of
about 20 tonnes of flammable hydrocarbon,
which formed a huge vapour cloud, that found
an ignition source from nearby flaredrum.
Direct causes of the incident were attributed
to poor design, maintenance, training and
management of alarm system.
Incidents that taught Alarm Management - Texaco Refinery
Alarm
Philosophy
Document
No
Unnecessary
Alarms
Operating
Window
Definition
Training &
Information
of Users
Audits
Top 10
Alarms &
Resolution
Alarm/Limit
Database
Alarm Off
Registers

14. 12
Disabling an alarm or safeguarding device
(instrumented or non instrumented) needs
to be authorized by to appropriate level
depending on the risk level. High risk will lead
to stabilizing, slowdown and shutdown of
production. Current facility status needs to
be clear to operations and management..
Disaster initiated from a Hydrocarbon leak
thru pipe work connected to a condensate
pump. A safety valve had been removed from
this pipe work for overhaul and maintenance.
The pump itself was undergoing maintenance
work. When the pipe work from which
the safety valve had been removed was
pressurized at start-up, the leak occurred
from removed PSV flange.
Automatic fire water deluge system was put
on manual due to a job that occurred earlier
that day. After completion of job, system was
not taken back in service, which resulted in
absence of an important mitigation system.
Closeout
Implementation
And Monitoring
Risk Evaluation
And Approval
Identification
Incidents that taught Prevention of Unnecssary Overrides - PiperAlpha
Override of safeguarding systems

15. 13
Shift team meeting & communication It
ensures thorough understanding, awareness,
confirmation of current plant status &
discussion on way forward. Non-compliance
to this requirement makes Operations
vulnerable to Process Safety Incidents.
Most paper mills use chlorine dioxide
(Cl02) to bleach pulp. The RIO Cl02 process
requires the mill to periodically take a short
outage to “boil out” for improving efficiency
of the Generator and an opportunity to
perform maintenance activities on other
parts of the Cl02 process. After the boilout
is complete, liquor is transferred back to
the generator (reactor) and the process is
restarted.
During a routine boilout, mill management
elected to do some maintenance work on
the filtration system, requiring that the
system be isolated, drained, rinsed, and
opened up. The work was executed safely.
However, dayshift personnel failed to close
one of the drain valves on filter. When
evening-shift personnel arrived at 6:00 p.m.,
day-shift personnel reported that they had
restarted the process and that it was almost
time to bring the filter online.
During the turnover, there was no mention
of the work done on the salt cake filter, and
there was no record of it in the shift log.
Assuming that all valves were in their normal
position, night-shift personnel brought the
salt cake filter online in the standard manner,
causing an immediate release of C102
solution. Fortunately, the release was
promptly detected and the line was isolated
with no injuries or harm to the environment.
CURRENT
CONDITION FUTURE PLAN
• Planned Maint
• Training, Manpower
• Activity Prioritization
• Adjoining Facilities
Out going In Coming
• HSECES PMs
• Compliance Audits
• Planned Mitigations
• Foreseen Issues
• Instructions
• Special Monitoring
• PTW Details
• Ongoing Maint
• Housekeeping Needs
• Safety issues
• HSECES Functions
• Safety/Environment issues
• Production Targets
• Production Issues
Incidents that taught Importance of Communication - Paper mill Accident
Shift team meeting & Communication

16. 14
Ensure Safe Production
Gasco’s Methodology
GASCO is in the process of ESP roll out at all
sites. However, both strategic and operational
guidance documents have been formulated
& being practiced.
Objective is to shift from “machine calls man”
to “man is ahead of the machine“, thereby
promoting proactive actions.
Pre-alarm is removed, to optimize total
number of alarms. Alarm exists only when an
Action has to be taken.
Every operator’s duty is to autonomously
take measures to get the process back into
safe limits, including slowing or shutting
down. Leadership fully supports this through
unconditional empowerment.
Operators run the plant, know their equipment,
understand and manage the limits in
operations
In the strategic document, ESP is introduced
& further subdivided in nine distinct activities,
each described in a separate manual.
ESP APPLICATION MANUAL STRATEGIC GUIDANCE
GASCO - RUWAIS - OPERATIONS
ENSURE SAFE PRODUCTION (ESP) - ASSOCIATED TASKS FOR OPERATIONS - 2015
ACTION BY TARGET
1
2
ALARM
MANAGEMENT
SYSTEM
ALARM OPTIMIZATION
REPORT OF ACTION
TO BE TAKEN ON
AN ALARM
ON THE ALARM DISPLAY, WHEN
AN ALARM IS CLICKED - A
DIALOGUE WINDOW WILL OPEN
DESCRIBING THE ACTION TO BE
DONE. ALL CRITICAL ALARMS WILL
HAVE THIS WINDOW.
TRAIN 1-
PROCESS
TRAIN 2-
PROCESS
TRAIN 3-
PROCESS
TRAIN 4-
PROCESS
UTILITY-
TRAINS-
1/2/3,
TRAIN 3
BOILERS
UTILITY-
TRAINS-4
TRAINS 4
BOILERS
SRU -
53/59/45
SWS/FLARE
SYSTEMS
PROPANE
STORAGE
BUTANE
STORAGE
PN
STORAGE
JETTY-
BERTHS
1/2/3
Waiting for
clearification
from Inst-
Systems engg
ongoing
DCC ADAD B BC
PANEL OPERATORS TO REPORT IN THE PANEL LOG BOOK AS TOTAL NUMBER OF ALARMS RECEIVED AND NO OF ALARMS PER
HOUR, TRAINS 1 & 2 ALARM REPORTS ARE TO BE SEGREGATED AND REPORTS TO BE FILED SEPERATELY. SEPARATE AMS REPORTS
CAN BE GENERATED FOR EACH TRAIN. Weekly reports are being generated by Process Control Team with CAUSE & EFFECT study
report with corrective actions are being generated by OEs.
OPERATIONS AND PROCESS CONTROL JOINT STUDY
BA
SHIFT GROUPS WILL GENERATE
THE ‘ACTION TO BE TAKEN’ FOR
EACH CRITICAL ALARM
NO OF ALARMS PER HOUR
RECEIVED IN EACH PANEL-
AREAWISE (ALARM/HR/
AREA OR TRAIN)
RATIONALIZATION STUDY TO BE
DONE. FIRE AND GAS ALARMS ARE
TO BE SEGREGATED.
TO REACH IEEU STANDARD
OF 6 ALARMS/HOUR/
OPERATOR WITH A
STRETCH TARGET OF 4
TRAIN 4 ALARM
TATIONALIZATION
ALARM OCCURENCES
ALARM OPTIMIZATION
3
4
ACTION DETAILSOBJECTIVEPURPOSE

17. Customer’s Feedback
15
1 2 3 4 5
5
|
|
|
|
|
|
|
No
No
No
No
No
No
No
Disappointing Exceptional
Thanks, for providing your valuable feedback.
Aamish J. Khan, CSP
Asset Integrity Engineer
aakhan@gasco.ae
GASCO Ruwais
1 2 3 4 5
1 2 3 4
Help us improve, by providing feedback
Vision behind the bulletin is to “Promote Process Safety
knowledge at all level of organization”. We intend to do
this by clarifying concepts, emphasizing its importance,
publicizing roles and responsibilities expected - in an easy
to understand way.
Please fill out this questionnaire and send it to us, so
we can improve this experience for you & our
community at large. Thank you.
The contents of the publication has been able to achieve
the vision behind Process Safety Bulletin
(mentioned above)?
Selection of content/topics has covered the theme
“process safety awareness” properly
Which of the current chapters you like to see in next
issue…
Customer’s Profile;
Name
Designation
Company
E-mail
Discipline
Sector
Leadership messages
Background
Importance
Relevance
Lesson learnt
GASCO’s methodology
Leadership commitment
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Country
Petrochemical
Ops/HSE/Maint/etc.
Oil & Gas
Others
Others, please define:
Disappointing Exceptional
Disappointing Exceptional
What are the three good things about this issue?
What are three areas of imporovement in this issue?
Have we met your expectations in this issu? if not,
Please elaborate.

18. Gasco’s Methodology Learnt (Continued)
18
Aamish Khan, CSP
Asset Integrity Engineer
Ruwais Plant Division
P.O.Box 665
Abu Dhabi Gas Industries Ltd (GASCO)
Abu Dhabi, UAE