Enhancing Safety and Sustainability of Malaysian Refineries

The Vital Role of Human Factors and Safety Culture
by Alvin Chin and Prof. Najmedin Meshkati

Knowing the importance of human factors and cultivating strong safety culture in any industries, especially oil refining industry, are vital to ensure sustainable success with positive and safe working environment. We can achieve that by:

  • Investing sufficient resources in safety-related factors
  • Instilling high awareness in risk management
  • Paying heightened attention to human factors of startup
  • Learning from the cohorts and industry’s previous failures and accidents that occurred globally
  • Assessing safety performance in a timely manner
Illustration by Kong Yink Heay

Illustration by Kong Yink Heay

Malaysia is one of the most important oil exporters in Southeast Asia. There are six operating oil refineries in the states of Negeri Sembilan, Melaka, Terengganu and Sarawak. Oil refineries are typically large industrial complexes with extensive complicated piping and huge chemical processing units. The safety measurements involved in maintaining the complexes are of critical importance to ensure the safety and well-being of employees and the community surrounding these facilities. Despite a good safety standard developed through ages of practices, oil refinery accidents still occur in this 21st century. Even though, in recent years, there have been no major oil refinery hazards causing serious casualties reported in Malaysia, there are safety issues which Malaysian oil refinery management should be cautious about.

By investigating the root causes of two overseas major oil refinery accidents – the BP refinery explosion in Texas City, USA on March 23, 2005 and Amuay refinery explosion in Falcon, Venezuela on August 25, 2012, some important but neglected factors of safety culture in oil refinery industry were derived. These two accidents which killed and injured more than 55 and 250 people, respectively, received high exposure via international media and reflected the underlying issues regarding oil refinery safety standard.

In terms of technical findings, we found that the root causes were primarily due to faulty refinery design, lack of safety and maintenance standard, and inadequately skilled technical and managerial personnel. Faulty refinery design refers to the compromised safety regarding the refinery’s proximity to the local community and its placement of buildings (temporary/ permanent). For example, fatalities in the BP Texas refinery explosion occurred in or around a temporary working trailers which were “sited too close to a process unit handling highly hazardous materials” [1]. Lack of safety and maintenance standard conforms to the violation of internationally set standard, resulting in inadequate safety measurements, lack of contingency response and faulty equipment. For example, the Amuay refinery has been reported to have problems regarding “broken pipes and a lack of spare parts [2].

Inadequately skilled technical and managerial personnel and their oversight resulted in less comprehensive supervision and execution of the operations, eventually compromising the safety parameters involved. In the 2005 BP Texas refinery explosion, the management “did not effectively implement their pre-startup safety review policy” [1] which resulted in compromised safety of the refinery workers.  The importance of paying heightened attention to human and organisational factors affecting the safety of startup, as well as risks of deviations from the standard operating procedures during the startup, are corroborated by several studies (e.g., BP Process Safety Series: Safe Ups and Downs for Process Units [3]), as, “it is a well-known fact that unit startup is an especially hazardous time in a refinery” [4]).

On the other hand, most important organisational findings include lack of investment, disconnectivity between management and employee, lack of learning culture and lack of routine safety assessment. Insufficient funds invested in refineries could result in under-maintained equipment, as resources are required to repair damaged parts. In the case of Amuay refinery explosion, there were nine scheduled maintenance shutdowns but “only two were conducted because of lack of parts” [5]. Disconnectivity between management and employee is also another organisational failure: lack of response and considerations from the leadership expose the refinery to vulnerable threats such as accidents and worker dissatisfaction. In the BP Texas refinery explosion case, their personnel “were not encouraged to report safety problems and some feared retaliation for doing so” [1]. A poor learning culture could also lead to the management’s inability to analyse and learn from previous accidents so that valuable lessons can be applied towards improving the well-being of the refinery. The management of the BP Texas refinery in the 2005 explosion did not incorporate “important relevant safety lessons from a British government investigation of incidents at BP’s Grangemouth, Scotland refinery” [1]. Lastly, infrequent routine safety assessment on the company’s policies, organisational management, and safety protocol could result in the failure to form effective management leadership to keep up with the latest safety applications. These were the other factors leading to the BP Texas refinery explosion, whereby the management “did not effectively assess changes involving people, policies, or the organisation that could impact process safety” [1].

Moreover, according to a seminal review research article by two investigators of the US Chemical Safety Board (CSB), “all too often the CSB finds that companies who suffer a devastating incident had experienced similar incidents or near misses in the past that could have had the same results, had just one or two things gone differently”. The BP Texas City explosion, which is briefly discussed earlier in this article, is one such additional example. There were eight serious isomerisation unit blowdown drum incidents that preceded the 2005 explosion” [3].

Previously, Shaluf et al. [6] concluded that technical and operational errors eventually led to a fire at a refinery in West Malaysia on 28th April 1999. This fire, which lasted 7 hours, caused a unit downtime of 24 hours and an estimated RM15.21 million in damages. The article concluded that “poor project management, poor design, modifications, poor operation procedure, poor communication and coordination” [6] led to this accident. These findings, which share similar elements with the explored root causes, show that oil industries in different countries also suffer from similar safety culture problems. As such, common recommendations conceiving safety culture improvement can be applied to the oil industry, regardless of its geographical and cultural background. The following are extracted and adopted from the suggested recommendations:

  • Train employees to learn proper safety procedures and raise the safety awareness in refinery.
  • Flatten the organisational structure through elimination of unnecessary positions especially in the operational management.
  • Maintain equipment in a timely manner; damaged equipment should be repaired immediately.
  • Instill awareness about risk management in all managerial and operational levels.
  • Form a task force group to analyse previous accidents including major and minor ones.
  • Allocate sufficient resources to the safety and maintenance of the refinery.
  • Hire an independent and reputable firm to audit safety performance (which should include human factors and culture considerations).

Our research pointed out that there remains flaws in the safety standard even in well known refineries. Although many refineries may have established high standard of safety, it is critical to constantly evaluate and improve procedural and operational safety measurements to ensure the safety of workers and that the surrounding of the refinery are protected at all times. Safety culture and human factors consideration should be given more emphasis and weightage in the operation of an oil refinery. Neglecting these factors may result in tragedies involving loss of lives and huge economical loss.

“…common recommendations conceiving safety culture improvement can be applied to the oil industry, regardless of its geographical and cultural background. ”

In a recent lessons-learned review article concerning Process Hazard Analysis (PHA), a senior CSB investigator has concluded and recommended that, “recently completed PHAs should be checked to ensure that all regulatory required PHA elements have been addressed. Specific attention should be given to facility siting; human factors; ensuring that all credible scenarios have been reviewed; and that controls and safeguards are sufficient to address the severity of the hazards” [7].

The latest example of a refinery accident which can directly be attributed to the human factors and safety culture issues is the Chevron Richmond Refinery fire of August 6, 2012 which resulted in a large plume of particulates and vapor travelling across the Richmond, California area and caused approximately 15,000 people from the surrounding area to seek medical treatment due to exposure.  According to U.S. Chemical Safety and Hazard Investigation Board’s report [8], in the ten years prior to incident, there were at least six specific recommendations by Chevron personnel to fix the problem which “were not implemented by Chevron management” [8].  This serious fire led Chevron management to acknowledge and declare a year later that, “we will also soon begin discussions with Contra CostaHealth Services in preparation for a proposed review of the Refinery’s safety culture, process safety management systems, and human factors associated with our operations” [9].  The vital role of human factors and safety culture in refinery safety has been further emphasised in a most recent report by the Interagency Working Group on Refinery Safety [10] where two of its major recommendations include to “require refineries to perform periodic safety culture assessments” and to “require refineries to explicitly account for human factors”.

More importantly, a corrective risk management mindset must be instilled in the refining industry to include supervisors, managers and senior executives of any oil company running a refinery so that each decision or evaluation is made critically without any deluded perceptions or biased method. They must be encouraged “to cultivate a questioning attitude and a rigorous and prudent approach to all aspects of their jobs, and set up necessary open communication between line workers and mid- and upper management” [11].

Finally, an overall paradigm shift in dealing with the design, construction, operation, and regulatory oversight of Malaysian refineries is required.  In order to improve the safety of these refineries, the safety culture of this industry should be improved and human and organisational-related factors need to be proactively addressed. A total system analysis of our plants’ system by concentrating on its three main composing sub-systems: human, organisational, and technological needs to be done.  To keep Malaysian refinery workers and citizens safe, a genuine interdisciplinary cooperation among all private stakeholders, as well as with, cognizant Malaysian governmental agencies is needed.

About the Authors

Prof. Najmedin Meshkati is a professor of civil/environmental and industrial and systems engineering at the Viterbi School of Engineering at the University of Southern California (USC). He conducts research on the safety of complex, large-scale technological systems and created USC’s Process Safety Management Program in 1992.  He collaborated with the U.S. Chemical Safety and Hazard Investigation Board (CSB), as an expert advisor in human factors and safety culture, on the investigation of the BP Refinery explosion in Texas City (2005).  Most recently, he was a member of the National Academy of Engineering/National Research Council’s Committee on the Analysis of Causes of the BP Deepwater Horizon Explosion, Fire, and Oil Spill to Identify Measures to Prevent Similar Accidents in the Future (2010-2011) which produced the Macondo Well Deepwater Horizon Blowout: Lessons Learned for Improving Offshore Drilling Safety (published by the National Academies Press, 2012). He can be contacted at [email protected]

Alvin Chin is a junior currently majoring in industrial and systems engineering at the Viterbi School of Engineering at the University of Southern California. This article is adopted from Alvin’s research paper under Professor Meshkati’s supervision. Alvin can be contacted at [email protected] Find out more about Alvin by visiting his Scientific Malaysian profile at http://www.scientificmalaysian.com/members/alvinchin/.


[1] U.S. Chemical Safety And Hazard Investigation Board. (2007). Refinery Explosion and Fire. Texas City: U.S. Chemical Safety And Hazard Investigation Board. http://www.csb.gov/bp-america-refinery-explosion/

[2] Oil refinery blast kills 26 in Venezuela, dozens hurt. (2012, August 25). http://www.foxnews.com/world/2012/08/25/venezuela-refinery-explosion-kills-at-least-7-injures-dozens

[3] Institute of Chemical Engineers (2005).  BP Process Safety Series: Safe Ups and Downs for Process Units. Rugby, UK: Institute of Chemical Engineers.

[4] Mackenzie, C. and Holmstron, D. (2009, March).  Investigating beyond the human machinery: A closer look at accident causation in high hazard industries.  Process Safety Progress, Vol. 28, No. 1, 84-89.

[5] Lopez, V. (2012, August 27). Venezuela oil refinery explosion: Chávez denies warnings were ignored. http://www.guardian.co.uk/world/2012/aug/27/venezuela-oil-refinery-explosion-chavez

[6] Ibrahim M. Shaluf, Fakhrul-Razi Ahmadun, Aini Mat Said. (2003). Fire incident at a refinery in West Malaysia: the causes and lessons learned. Journal of Loss Prevention in the Process Industries, 16: 297-303.

[7] Kaszniak, M. (2010, September).  Oversights and omissions in process hazard analysis: Lessons learned from CSB investigations.  Process Safety Progress, Vol. 29, No. 3, 264-269.

[8] U.S. Chemical Safety and Hazard Investigation Board (CSB) (2013, April 15). Interim Investigation Report: Chevron Richmond Refinery Fire. http://www.csb.gov/assets/1/19/Chevron_Interim_Report_Final_2013-04-17.pdf 

[9]Chevron Richmond Refinery Incident Response: Update and Information on the Aug. 2012 Fire (2013, April 19). Press Release. http://www.tombutt.com/pdf/chevron%20csb%20response.pdf

[10] Interagency Working Group on Refinery Safety – Governor Jerry Brown (2013, July). Improving Public and Worker Safety at Oil Refineries http://www.calepa.ca.gov/Publications/Reports/2013/Refineries.pdf

[11] Meshkati, N. (2007, January 23th). How refineries can create strong ‘safety culture’. Houston Chronicle, B9.