SYMPOSIUM SERIES No.

168 HAZARDS 31 © 2021 IChemE

Process Safety Cards – A Good Deal Safer

David Hatch, Process Hazard Analyst, Process Safety Integrity, Derby, UK ([Link]@[Link])
To improve the awareness of less technical personnel to potential Loss of Containment (LoC) scenarios and
increase their vigilance to such events & their potential causes so they can be promptly addressed; memorable
images are shown on familiar playing cards representing typical LoC events.
Keywords: Process Safety Cards, Bowties, Gamification, Microlearning, Workforce Engagement

Introduction
Process Safety Cards have a simple goal – to improve the awareness of a broad range of personnel to potential major
accident scenarios and increase their vigilance to such events & their potential causes so they can be promptly addressed.

These memorable images represent typical LoC events to deliver knowledge literally into the hands of those who might
contribute to and/or be affected by unplanned events or Process Safety Incidents.

With an ageing workforce and increased outsourcing of maintenance and operations activities, it is vital that time and
knowledge-poor stakeholders (who typically fall outside corporate process safety training strategies) are engaged and
equipped to ensure they play their part in sustaining the integrity of assets.

Challenge
Process Safety Incidents, Major Accidents or Loss of Primary Containment Events continue to occur in the 21st Century
despite better technology and bigger data. For example, on 27th July 2021, a significant release of acetic acid at the
LyondellBasell facility in La Porte, Texas resulted in 2 contractor fatalities and 30 other personnel receiving medical
treatment.

A review (by the author) of the 100+ CSB Investigations [6] indicates 200+ fatalities occurred of which approximately 40%
were Contractors. This does not suggest or imply that the Contractors were at fault, however it does highlight that 3rd parties
are often involved in major accidents.

Although Process Safety initiatives, typically referencing Process Safety Management frameworks including OSHA [7],
CCPS [1] or the Energy Institute [3], are now commonplace, these may exclude external resources including outsourced
Operations & Maintenance personnel who are therefore not as equipped as their internal counterparts to recognize and
address potential Process Safety incidents.

We must also acknowledge that wisdom is being lost with the ageing workforce and that assets are getting older whilst those
responsible for them are getting younger.

Are we possible focusing on the wrong people and/or protection measures?

How do we put knowledge into the right hands?

Workforce Engagement
In order to gain and sustain the attention and participation of the workforce, which may range from novices (who need to be
informed) to veterans (who need to be reminded), it is becoming more common to use Gamification methods. These employ
game design elements e.g., point scoring, competition with others, rules of play to improve user engagement, learning and
knowledge retention.

However, many games require considerable time to setup and play or often cannot be played in the workplace due to the cost
and complexity of deploying electronic devices e.g., laptops or tablets to host the games safely (flammable atmosphere
ignition potential).

Process Safety Cards offer an alternative (analogue) approach which offers the benefits of gamification without the time and
cost burdens and is based on Microlearning e.g., small learning units absorbed in small time units.

Players are encouraged and helped to learn and apply simple principles:

• REMEMBER Events,
• RECOGNISE Causes (Threats) of Events,
• RESPECT Controls (Barriers) which prevent or mitigate Events.
• REPORT Concerns about the presence or performance of the Controls/Barriers,
SYMPOSIUM SERIES No.168 HAZARDS 31 © 2021 IChemE

Thereafter there is an obligation on the duty-holder or owner/operator to:

• RESPOND to Feedback (concerns, questions, or suggestions).

• RECOVER Protection to its original state.

Using this simple & memorable ‘R’ model aims to embed these principles into the minds & memories of frontline personnel.

It is critical that the RESPOND & RECOVER steps are performed otherwise there can be no faith that contributions are
valued and that improvements are being made.

Deployment
Process Safety Cards represent 52 different LoC events that occur in the Process industries which are presented as familiar
playing cards split into 4 separate suits.

• DEGRADATION Failure within design conditions or “under-strength”

• DISCHARGE Open route to atmosphere
• DAMAGE External impact
• DEVIATION Failure beyond design conditions or “over-stress”

These events are drawn from industry publications including the HSE [5] and CCPS [2] and whilst they are not claimed to be
an exhaustive list, they can be attributed to familiar major accidents across a variety of industries.

Cards make it easier to communicate in all directions within, top-bottom, side-to-side and inside-outside the organization by
providing a common visual language. This gets and keeps the workforce onboard with the Process Safety or Asset Integrity
mission.

Sample cards are shown in Figure 1 below.

One of the core concepts of this approach is to “Know your Enemy” [4] where hazards are not the enemy (these are part of
doing business) – it is Loss of Containment that is everyone’s opponent.

There are several different opportunities to deploy the cards in operational arenas, because they are easy to carry &
exchange:

• Simple passive learning (by osmosis) via familiar, informal card games.
• Toolbox talks, e.g., explain your experience of the card you’ve been dealt.
• Quick quiz e.g., name the event on the card (without title)
• Hazard spotting or surveys e.g., punch hole in cards and tag/tie them onto the plant at vulnerable locations
• Hazard reminder e.g., attach relevant cards to Permit to Work.
• Inductions e.g., visitors, suppliers or short-term contractors during outage, turnaround etc.

The cards are not limited to frontline personnel as they can also be used to engage engineering or management personnel.

• Safety moments e.g., discuss your role related to the card you’ve been dealt.
• HAZOP validation e.g., ensure all deviations (cards) have been discussed.
• Performance dashboards e.g., incidents categorized according to LoC type (or card)
• Hazard potential e.g., sum (add) the values of each card i.e., Ace = 11, King/Queen/Jack = 10 & other cards
numbered
• Campaigns e.g., each week showcase specific events or cards.
• Relate cards to client or industry incidents e.g., CSB investigations [6].

Just as a pack of cards can create a variety of different games e.g., poker, blackjack, bridge etc. Process Safety Cards utilize
the same playing cards elements (or ‘pips’) which offers an organic approach to gamification that can grow with peer or
community feedback i.e., facilities, organizations or industries can develop their own games based on their technology and
culture.
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Figure 1 Sample Playing Cards

Scenario Summaries
Playing cards increase awareness of the potential LoC events, however in order to address these, an appropriate level of
insight is necessary. Visualizing the LoC scenarios in bowtie format provides a clear, concise summary which is more easily
understood and retained than textual or numeric data.

A one-page representation of each type of LoC event i.e., playing card, provides typical:

• Cause (Threat)
• Controls (Barrier)
• Effectiveness or Vulnerabilities (by barrier type)
• Degradation factors (by barrier type)

These are not intended to replace existing analyses and should not be considered sufficient to properly monitor & manage
barriers, however they do provide memorable context with a particular focus on the Degradation Factors which create and/or
enlarge the holes in the Swiss Cheese model and are controlled via asset and/or safety management systems e.g.,
competence, information, maintenance, change etc.

A sample scenario is provided in Figure 2 below:

SYMPOSIUM SERIES No.168 HAZARDS 31 © 2021 IChemE

Figure 2 Sample Scenario Summary

SYMPOSIUM SERIES No.168 HAZARDS 31 © 2021 IChemE

Scenario summaries can be posted inside or outside populated or high traffic areas such as control rooms, canteens,
workshops, or meeting rooms and rotated on a campaign basis e.g., a different LoC per week. They can also be published
online e.g., intranet, SharePoint, or newsletter.

Online Collaboration
Although Process Safety Cards are designed to be physically handled, the current COVID-19 pandemic prevents or
discourages such personal interaction, therefore digital solutions can be used to use or play the cards via collaborative
platforms e.g., virtual whiteboards to connect remote or isolated team members.
Using familiar Office® platforms, informal quizzes and structured surveys can be created to gauge the awareness and
adoption of the events and associated cards. These use the same images as the cards to provide continuity and familiarity and
the results can be used to identify areas of potential weakness and therefore improvement opportunities.

Knowledge Access
The increase in adoption of digital equipment in the field (where safe to do so) presents an opportunity for ‘players’ i.e.,
safety card users, to use their devices to directly access relevant process safety knowledge via QR codes on the cards as per
Figure 3 below:

Figure 3 Sample Card with QR Codes

The code can direct or link to an intranet or portal page or other external resource. These may be corporate or industry
guidance, more detailed bowties, relevant incidents or any other documents or media that will help the card holder better
understand the control of each event (card).

Frontline Feedback
Although the cards have been provided to operations personnel in a variety of industries (including Onshore & Offshore Oil
& Gas, Petrochemicals, Mining, Chemicals & Water) and jurisdictions (including UK, EU, Australia, North America &
South America) current COVID-19 restrictions have limited the opportunities for substantial knowledge exchange, however
initial feedback from prototype sites has been positive and it is hoped that measurable results (based on significant
reductions in unplanned events) will be forthcoming as wider adoption encourages and facilitates conversations about
complex & critical issues in an intuitive and engaging way.

Cards have been customised to suit specific operations, including mining & drilling as well as common themes including
control of ignition sources, human & organisational factors, process safety fundamentals & process safety stewardship
(management).

Conclusion
Although based on gamification principles, the Process Safety Cards are not a game in themselves i.e., there are no rigid
rules to follow. They simply provide a knowledge exchange toolkit to facilitate communications (in both directions) between
management and frontline personnel to share learning using universal images and local languages.
SYMPOSIUM SERIES No.168 HAZARDS 31 © 2021 IChemE

These are not a new strategy (although they are a novel idea), they simply help deliver or reinforce established Process
Safety (Asset Integrity) initiatives which are designed to ‘Protect the Protection’ i.e., look after the systems (hardware &
humans) that look after you.
The cards increase awareness, the bowties enhance understanding, knowing your enemy improves vigilance which drives
better protection and more robust asset integrity.

References
[1] American Institute of Chemical Engineers (AIChE), Center for Chemical Process Safety (CCPS) Risk Based
Process Safety (RBPS) Framework ([Link]
guidelines-risk-based-process-safety).
[2] American Institute of Chemical Engineers (AIChE), Center for Chemical Process Safety (CCPS) “Guidelines for
Chemical Process Quantitative Risk Analysis”.
[3] Energy Institute High Level Framework for Process Safety Management
([Link]
management).
[4] Tze, Sun “The Art of War”.
[5] UK Health & Safety Laboratory “Loss of Containment Incident Analysis” HSL/2003/07.
[6] U.S. Chemical Safety Board (CSB) Investigations ([Link]
[7] U.S. Department of Labor, Occupational Safety & Health Administration (OSHA) Process Safety Management of
Highly Hazardous Chemicals (29 CFR 1910.119) ([Link]