Process Safety Beacon: More than PPE
The CCPS Process Safety Elements
This post continues our series to do with formal incident reports from organizations, including the BSEE (Bureau of Safety and Environmental Enforcement), the CCPS (Center for Chemical Process Safety), and the CSB (Chemical Safety Board). In each case, we attempt to identify the process safety elements that failed in this particular incident.
The November 2025 Process Safety Beacon is entitled ‘PPE only works when you wear it correctly!’
The article describes the following situation:
A pressure gauge required replacement.
Four operators were sent to carry out the task.
The first valve that they needed to close was visibly broken.
Therefore, they decided to close the valve closest to the pressure gauge.
An internal obstruction prevented the valve from closing completely.
The pressure gauge was removed with no adverse consequences.
It is thought that the internal pressure in the line removed debris in the piping.
A gas consisting of flammable hydrocarbons and hydrogen sulfide was released.
All four operators were injured.
As the Beacon’s title suggests, the lesson learned from this event was to do with Personal Protective Equipment (PPE). Doubtless, the incident would have been much less serious had the people involved been wearing PPE. But PPE mitigates consequences, not causes. Nevertheless, the other item that jumps out here is the process safety element: Mechanical Integrity.
In other posts in this series we have examined the incident described using the elements of process safety as defined by the CCPS (Center for Chemical Process Safety), which are:
Process Safety Culture
Compliance
Competence
Workforce Involvement
Stakeholder Outreach
Knowledge Management
Hazard Identification and Risk Management
Operating Procedures
Safe Work Practices
Asset Integrity / Reliability
Contractor Management
Training / Performance
Management of Change
Operational Readiness
Conduct of Operations
Emergency Management
Incident Investigation
Measurement and Metrics
Auditing
Management Review
In the case of this incident, three elements have been highlighted.
The first is Safe Work Practices. PPE falls into this category. But so does awareness that creating an opening to a pressurized line containing hazardous chemicals is always a risk. Some form of double block and bleed could have prevented this event.
The second highlighted element is Asset Integrity / Reliability ― what OSHA refers to as Mechanical Integrity. In this situation, we are told that the first block valve was ‘visibly broken’. This statement opens up two questions, ‘Why was it broken, and why was it not repaired?’ The response to these questions will generate further questions to do with the maintenance and inspection programs. The equipment condition was known, yet no corrective action had been taken.
The second mechanical integrity concern is to with blockage in the pressure gauge piping, as shown in the second image at the head of this post.
The third selected element is Hazard Management. While the task described in this Beacon does not justify a formal hazards analysis, a short ‘tool box meeting’ could have helped. As one veteran operator put it, ‘If a man’s not there, he can’t be killed’ — a reminder that minimizing personnel exposure is a fundamental hazard control strategy.
If a man’s not there, he can’t be killed.
Did four people need to be present? If the task could have been carried out by just one person, then he or she would have been the only person affected by the release.
Conclusion
This incident underscores the fact that PPE is a last line of defense. When isolation, inspection, and work authorization systems fail, even minor maintenance tasks can escalate into serious events. Effective mechanical integrity and hazard management programs are what keep routine work from becoming the next Process Safety Beacon.
