Process Safety Management (PSM) programs are expected to reduce the probability and severity of hazardous incidents. This paper presents a real life incident that occurred in a plan before a PSM program was put in place. A detailed description of the incident is provided with appropriate discussions of noncompliance with the PSM rule. Finally, the paper provides a theoretical scenario where a fully operational PSM program would have prevented the incident. The case history and discussion provided in this paper also reinforces the concept of maintaining process and equipment integrity through multiple barriers of safety. A fully operational PSM program represents such a multiple barrier safety systems.

The incident occurred in a high temperature boiler in a process plant. The incident was caused by a sequence of four occurrences that combined to cause the boiler to lose water level and have serious internal and tube damage. The problem was not detected until a mechanic who was going to work on the feed pump realized that there was flames coming out of the boiler stack. The mechanic told the operator about the problem and the boiler was manually tripped. The boiler feedwater pump was not blocked in until 30 minutes after the incident was over. If this pump was started during or directly after the incident, the addition of boiler feedwater to the over-heated boiler would have caused an explosion. At the time the incident was reported there were 8–10 employees in the area of the boilers.