Case Study: 14 Elements of PSM by Habi Tech Support

Designed to Fail

2025-06-24 22:17:59 UTC

Lyondell Basell Complex in LaPorte Texas Acetic acid mixture erupted from equipment.

Contract workers inadvertently removed critical components of valve leading release of acidic acid. This shows of poor Training of Contractors and lack of procedure. Instead of just removing of valve actuator they remove the coupler causing valve failor leading acidic acid contamination. Also, Poor design of plug valve and Poor Labelling that should have Warning of hazardous material. Furthermore, Log Out/Tag Out (LOTO) system could have improved and have a better isolation system so maintanance team/contractors can work on the valve safely.

Designed to Fail

2025-07-09 05:03:30 UTC

Which elements are missing or inadequately applied?
The incident shows inadequate proper operating procedures, poor training of the contractors, and lack of warning signs and labels, which contributes largely to maintenance of equipment.
What recommendations can you make to address the issue?
First, the company must develop and provide clear and accessible operating procedures and require strict adherence of contractors.
Second, both the company and the contractor must provide comprehensive training for their staff, focusing not only on hazards and safety protocols, but also the operating equipment and conditions they might encounter.
Third, they must install visible and standardized warning signs and labels on equipment and in hazardous areas to strengthen hazard awareness.
Lastly, the company must conduct regular audits to ensure that procedures are followed safely.

Lyondell Basell Chemical Release

2025-07-09 05:10:31 UTC

Several critical safety elements were missing or inadequately applied, which contributed to the incident. One major issue discussed is the design of the plug valves which allowed workers to inadvertently remove pressure-retaining components—such as vessels—while attempting to remove actuators. Another factor is the valves lacked distinct visual cues or physical safeguards to help workers differentiate between pressurized and non-pressurized components as there were no color-coded markings, warning signs, or mechanical design features that could have prevented this dangerous error. Moreover, the company's failure to assess the task of actuator removal properly and implement the necessary procedures and training. The company did not conduct a hazard analysis for the removal of actuator which resulted to lack of safeguards to prevent exposure to hazardous process fluids. No written procedures were provided, and the task was allowed to proceed without company oversight because it was deemed “simple.”

To mitigate these problems, first is plug valve designs should be comprehensively redesigned to include fail-safes that prevent the inadvertent removal of pressure-retaining components. Components should be clearly marked with color-coded paint or durable warning labels to allow for easy identification. Facilities should also be required to label all existing plug valve components that retain pressure, while industry standards should mandate that all newly manufactured plug valves incorporate designs that account for and prevent this type of human error. Moreover, the company policy documents must be updated to require that formal procedures are developed for safely removing actuating equipment from plug valves. These procedures should include detailed step-by-step instructions, hazard identification, personal protective equipment (PPE) requirements, and isolation and depressurization steps. In addition, a formal permit-to-work system should be implemented for all tasks involving pressure systems, regardless of perceived complexity. Personnel must also receive specific training on valve anatomy, safe disassembly practices, and the recognition of pressure hazards. Finally, supervisors should be required to oversee such operations to ensure that work is performed in compliance with established safety protocols.

Lyondell Bassell Acetic Acid Release

2025-07-25 19:02:11 UTC

First and foremost, the lack of adequate operating procedures related to safely disassembling valves for what seems like routine or common maintenance due to the corrosive nature of the chemical being handled was directly related to the incident. Secondly, the effective training and confirmation of contract workers' qualifications prior to performing any kind of work onsite also contributed to the incident. This situation could have also benefitted from additional warning signs/labels/color coding around the valves to further reduce the risk of human error, even with proper SOPs in place.
My primary recommendation would be to develop specific and straightforward SOPs related to the safe disassembling of valves without removing pressure-retaining components and implementing additional warning signs and possibly color-coding the physical pieces of equipment to make it extremely difficult for an operator or contractor to make a potentially fatal mistake. My next recommendation would be to create rigorous training plans for both contractors and employees to ensure everyone is qualified, competent, and confident in their ability to perform their designated tasks.

LyondellBassell Case

2025-09-24 02:38:16 UTC

Among the 14 Elements, the following were either missing or inadequate in the LyondellBasell case: Contractor Management, Operating Procedures, Training, Process Safety Information, Process Hazard Analysis. The contractors and employees were most definitely lacking in the appropriate training for their task, which violates the elements of Training and Contractor Management. Neither the contractors or the employees were equipped to deal with the situation or were cognizant of the potential risks and hazards associated with the task. Furthermore, LyondellBasell lacked a proper SOP for the removal of actuators from Plug Valves, which violates the element of Operating Procedures. Aside from this, the Elements of PHA and PSI were inadequately applied, as seen by the lack of proper hazard awareness for the acetic acid reactor and the lack of straightforward, effective safety design in the plug valve.A proper PHA would have been helpful in identifying the possible hazards of pipe maintenance around the reactor and more effective plug valve design may have helped prevent the removal of essential valve components.

I recommend that LyondellBasell ensure that SOPs and guidelines are created for each maintenance task and that contractors and employees are adequately trained and made aware of the hazards that they may encounter. Secondly, I recommend that LyondellBasell conduct a PHA on their facilities, while taking special consideration to the conditions of the facilities during repair or maintenance. This could give insight into other SOPs or safeguards that may be lacking in the facility and may help prevent any untoward incidents from occurring again. Furthermore, I recommend that LyondellBasell regularly update and create adequately detailed datasheets and diagrams of their equipment, so as to ensure that all workers are informed about the different components of each equipment and which parts may be crucial to its integrity. Lastly, I recommend that LyondellBasell adequately labels and designates which equipment components are essential for its integrity and put in place appropriate warning symbols on the equipment proper so as to guide employees accordingly.

Case Study | Designed to Fail: Chemical Release at LyondellBasell - Seth

2025-09-24 06:02:16 UTC

1. The Lyondell Basell (LB) acetic acid (AA) release incident shows several PSM elements that were either missing or poorly applied. First and foremost, information around this scenario is scarce due to the underestimated the procedure. A lack of procedures for actuator removal (OP), review of hazards associated with the work (PHA), and even review of similar incidents by both parties (II + PSI). It should be common knowledge that all works with any flammable, reactive, explosive, or toxic substance as well as pressurized or extreme temperatures should require review of hazards associated to the work (PHA) with proper documentation of the equipment and their components (PSI). On the topic of the Turn2 (T2) contractor, there was weak contractor management (CM) and training. Even if the contractor was recommended, there should be evaluations/process in place to verify qualifications. This would also lead to the lack of training for both parties and oversight from LB. This also led to the lack of safeguards as well as proper tools to be used in the work. Moreover, the issue of the plug valve having multiple incidents tied to the same cause should have been a clear sign of poor mechanical integrity.

2. To prevent recurrence, LB should strengthen several key PSM elements. First, update PSI and MI programs to clearly document valve hazards, apply warning labels to pressure-retaining bolts, and evaluate engineered safeguards or valve retrofits. Conduct task-based PHAs or job hazard analyses for non-routine maintenance, especially when it involves hazardous chemical substances and conditions. Develop written Operating Procedures for actuator removal, including isolation, de-inventorying (if necessary), depressurization, safeguards implementation, and verification steps, as well as train both employees and contractors on these requirements along with acetic acid hazards. Improve Contractor Management by verifying qualifications for all tasks, especially high-risk tasks (there should be proper evaluation of the risks-value of tasks), and requiring site-specific training and oversight. Strengthen MOC so any work not covered by existing procedures must undergo formal review before execution. And finally, expand the Incident Investigation process to include similar external incidents from CSB and reports across other industries.

Chemical Release at LyondellBasell Case Study

2026-03-12 02:55:17 UTC

Out of the 14 PSM elements, the elements that are not properly applied or missing are the following: (a) The root cause of the incident is due to a lack of operating procedures (OP) for the removal of actuator in the plug valve. The lack of having a simple written procedures to remove an actuator of a plug valve caused the removal of pressure regulating components the plug valve, that lead to a chemical release. (b) Another factor is Training, both contractor and employees do not have the professional capacity for the removal of actuator, causing them to remove components that are not supposed to be remove. (c) Another element poorly applied is contractor management, since the contractors do not have the proper trainings for the removal of the actuator and are also not provided with the possible hazards that they may be exposed of, that should have given my the LyondellBasell. This lack of information brought by LyondellBasell also leads to (d) poor PSI and (e) PHA. As the possible scenarios, hazards and risk were not written, studies, identified or even evaluated, which lead to this disasters. We can also see this results simply due to the missing safeguards that must be in placed and components that can reduce human errors. Lastly (f) Incident investigation is also lacking as this accidents are also happening at other companies. Should there be a proper incident investigation, the disaster may have been prevented.

2. I recommend that LyondellBasell must make sure to have a complete, accurate, and updated operating procedures especially to processes that may seem unnecessary in order to avoid this events. Moreover, proper trainings should be given to employees for them to have the capacity to properly do their task properly and be informed with the possible hazards and risk present. In addition to that, the company must make sure to have a complete and updated list of PSI, available to all employees and contractors (if necessary), for them to have proper knowledge and guidance. Moreover, despite having a good trust with 3rd party contractors, the company and the contractors must still ensure that the employees involve should have proper training to do their tasks and be informed with the potential hazards present. Lastly, LyondellBasell should more effort with incident investigations, most specially to the processes or equipments that is similar to what they have with the other companies, in order to strengthen the safety of their processes.

LyondellBasell Case Study

2026-04-08 14:59:23 UTC

The LyondellBasell acetic acid release incident shows how routine maintenance can easily turn into a catastrophe when a simple step is overlooked or neglected. Among the 14 elements of PSM, the most significant failure for this case was Process Hazard Analysis because of the lack of assessing a risk assessment before removing the valve's actuator, specifically assessing the valve design and identifying the risk of removing the pressure-retaining bolts. There was also an oversight of Contractor Management since the Turn2 contractors were not guided with the right procedures and information, leading to the contractors to rely on their own intuition in handling a highly technical problem in the plant. The lack of Operating Procedures and Training was also evident as the standardized instructions and associated hazards were not provided and the employees were not properly informed for the scenario. Lastly, the unclear color-coded labeling proves that there was a lack of Mechanical Integrity which easily makes room for human error.

To prevent such the recurrence of such event, it is best to ensure safety by implementing prevention through design. Rigorous labelling systems must be in place especially for highly hazardous equipment and components. It is also a must to develop and enforce detailed procedures in removing actuators and to formalize other important maintenance procedures by having a step-by-step written procedure. Lastly, it is important to ensure that the right contractors with the specific experience they are servicing are chosen and well-guided.

Case Study on the LyondellBasell Acetic Acid Release

2026-06-25 07:22:50 UTC

The root causes of the LyondellBasell Acetic Acid Release were the inadequacies or lack of these elements:

1.) Safe Valve Design

The design of the valve made the repair prone to human error for reasons with the likes of lacking safety indicators. Additionally, the Chemical Safety Board (CSB) also reported four other cases of plug valve incidents, solidifying the need for a redesign.

2.) Process Hazard Analysis

The CSB found that LyondellBasell did not thoroughly assess risk to ensure safety procedures and safeguards were in place before the start of the repair.

3.) Operating Procedures and Process Safety Information

According to the CSB, LyondellBasell did not provide the Turn2 repair crew with written procedure because of its perceived simplicity which is an utter disregard of safety considering that the chemical contained is hazardous.

4.) Contractor Management

Neither Turn2 nor LyondellBasell trained the crew on steps necessary to safely remove the actuator. Further, LyondellBasell did not give the crew an oversight to guide them during the repair, thus, the consequent failure.

5.) Employee Participation

Lastly, while it is not stated and may possibly have occurred, the crew also lacked initiative to not request for the safety procedures nor training to safely handle the valve.

Realistically, a redesign of the valve would be too costly and will take time considering the weight of that task. Hence, the addition of safety indicators would make repairs safer for the mean time if the company opts for the redesign. Furthermore, safety procedures must strictly be constructed, distributed, and enacted to prevent mishaps or human error from occurring. Experienced technicians or handlers of the equipment must also train and supervise the repairmen or contracted workers to minimize risk.

As precautionary measure, workers should also always wear their Personal Protective Equipment in the face of extraneous or uncontrollable factors.

LyondellBasell Acetic Acid Release Case Study

2026-06-25 07:31:26 UTC

The key process safety management element to be performed inadequately was a process hazard analysis. Overall, the entire LyondellBasell accident could have been outright avoided had sufficient risk assessment taken place. If done properly, the analysis should have shed enough light on the fact that the actuator was lacking safety procedures entirely. This leads to another missing element: Operating procedures. Had either LyondellBasell or Turn2 properly evaluated the equipment and prepared a concrete, certified plan, the employees could not have disregarded key pressure-retaining components during the removal. Relating this, both companies ultimately failed to provide proper training and contractor management to the foreman and pipefitters. In other words, the employees were left alone to perform an assumingly ‘simple’ procedure which, unfortunately, should have observed significantly more preventative measures.
As mentioned by the Chemical Safety Board, the pressure-retaining plug valves should be momentarily labeled or color-coordinated to prevent the near repetition of the issue, with a more permanent solution being the redesigning of the components altogether. Also noted, proper risk assessment of the actuator removal should be conducted to effectively produce new safety plans and procedures. More thorough training for all involved personnel and work crew should also be reinforced. To add further upon the CSB’s instructions, preparatory sessions should also be set into place when performing any procedure on high-risk equipment. This could potentially include presenting an action plan stating the methodology in which the fix should take place, especially when the involved parties are unfamiliar with said process. These plans should then be reviewed and approved by other safety consulting firms or experts. More frequent compliance audits could also be implemented, ensuring that all possibilities are covered. Considering that at least four other similar valve incidents had been recorded by the CSB before such changes were called upon, more comprehensive risk assessments should also be undertaken.