Using Incident Reporting to Integrate Hazard Analysis and Risk Assessment into the Unit Operations Lab

Since 2017, instructors from six universities have collaborated to better understand and improve the integration of process safety into chemical engineering unit operations (UO) laboratories. While past studies by the team have focused on assessing the state of UO lab safety education, the current study aims to implement new strategies for improving process safety education in the UO labs. By examining the Safety and Chemical Engineering (SAChE) process safety learning outcomes, hazard analysis and risk assessment were identified as the first priority for integration into these university labs, as they are most relevant to a laboratory setting and not heavily covered elsewhere in these university chemical engineering curricula. For integration, a safety incident reporting structure was developed to allow students to report safety incidents and assess hazards and risk levels. Students were asked to categorize the incidents as being related to personal, process, or environmental safety, and were then asked to assess risk levels. The goals of the reporting structure were to increase student awareness of these topics, improve safety culture, and develop an understanding of actual risk frequencies in the undergraduate teaching labs. After development, four of the six universities were able to implement the reporting structure in their UO labs, although specific data could only be reported from three due to timing of IRB approval. Risk and frequencies were determined by analyzing over 400 incidents or near-misses from these three universities, showing that 62% of safety incidents were related to personal safety, whereas 18% were process-related and 20% were environment-related. Of those incidents, 45% were characterized as near-miss incidents where students were able to prevent the hazard from escalating to a level requiring intervention. Prior to implementing this system, very little or no documentation on safety incidents was kept; often, only incidents requiring medical attention were reported to the instructor and/or lab manager. Preand post-tests were also utilized to understand the impact of the incident reporting on process safety-related learning outcomes. From the pre-test data (approximately 200 total students) at the start of the semester, students had a stronger understanding of personal safety than they did process or environmental safety. When comparing preand post-survey data, selfreported knowledge levels were significantly improved for understanding of consequence, frequency, process safety and environmental safety. Interestingly, improvements in self-reported understanding and knowledge gains were stronger for those students who had never completed an industrial internship. To date, all instructors have observed that the incident reporting structure has resulted in a positive change to the safety culture of the laboratories. These results alone show the positive effect of integrating incident reporting into the UO laboratories. Background and Motivation Over the past few years, a group of instructors from six universities has been collaborating to better understand how process safety concepts can be integrated into the chemical engineering unit operations (UO) laboratory. Past work has detailed available process safety resources relevant to the UO lab [1], as well as an assessment of how well the six institutions teach the Safety and Chemical Engineering (SAChE) process safety learning outcomes [2] as part of UO and the entire curriculum [3]. The former work identified a lack of UO-specific active learning activities that could be easily integrated into a course, and the latter identified that risk assessment and hazard identification were not only highly relevant to UO courses but were inadequately covered or not taught at all at the six institutions. Furthermore, the authors could find no data that quantified the frequency of incidents, near-misses, or positive observations within a UO laboratory course. This kind of data is commonly collected in industrial settings to help benchmark frequencies, create risk matrices, and identify areas for improvement [4]. The current work aims to address all of these shortcomings via the development and implementation of an incident reporting structure that focuses on hazard identification and risk assessment. The project has several overarching goals: 1. To teach students about risk assessment 2. To have students practice hazard identification and reporting of good safety practices, near misses, and incidents 3. To quantitatively benchmark the hazards and frequencies of events in the lab courses so targeted improvements can be made in the courses’ overall safety 4. To improve safety culture in the lab To assess risk and teach students about risk assessment, a semi-quantitative risk matrix may be used [5]. The risk matrix consists of consequences and frequencies (probability of incident occurring) (Figure 1). Both of these variables need to be defined and quantified in order for the risk to be assessed. Consequences can be categorized into different types based on who or what is affected, such as personal, process, or environmental. Personal consequences are defined as harm to individuals, process consequences focus on the equipment and the chemical process system, and environmental consequences focus on the effect to the surroundings of the chemical process system. Each type of consequence should be rated for severity by using a numerical scale with definitions for each number on the scale. Levels of severity may include a near-miss (nothing happened, but there was a potential for harm) at the lower level up to a catastrophic event (death or irreversible damage) at the higher level. The quantitative values assigned to these severity levels may, for example, range from 0-4, with 0 assigned to a near-miss and 4 assigned to irreversible damage (Figure 1). The frequency component of the risk matrix assigns a numerical value based on the probability of a consequence occurring. For example, a consequence that is very unlikely to occur because current control measures are effective may be assigned a value of 1, while a consequence that is likely to occur due to inadequate or nonexistent control measures may be assigned a value of 4 (Figure 1). Multiplying the value for the consequence and the frequency results in the “Risk Product” that can be used to analyze the level of risk. To teach UO laboratory students about the frequency component of the risk matrix, an incident reporting system was designed and implemented. An example of the system can be viewed at the link provided at the end of this paper. This system was based on reporting systems used in industry, which serve several purposes [7,8], including (1) quantifying the number of new occurrences to identify potential incidents, (2) quantifying the number of repeating occurrences to enable the company to address the most frequent and highest risk incidents, and (3) maintaining awareness of safety and developing a safety culture [9]. Utilizing the incident reporting system enables the university UO lab instructors to collect data similar to that collected for industrial purposes (which could be used to benchmark future course safety), while also helping the students understand how frequency data is acquired. In order to assess student learning, pre-semester and post-semester surveys were used to measure changes in awareness and knowledge level of risk, consequence, frequency, and differences between personal, process, and environmental safety. Figure 1. Risk matrix for university UO laboratories [6] Methods Study participants were engineering students enrolled in UO at four medium-to-large R1 universities: University of Kentucky (89 enrolled), University of Michigan (64 enrolled), University of Minnesota (109 enrolled), and Washington University in St. Louis (42 enrolled). While implementation structure was maintained across programs as much as possible, slight modifications were made at each university to obtain Institutional Review Board (IRB) approval. All four universities implemented the incident reporting structure in their courses, although due to the timing of IRB approval, incident reporting data from the University of Kentucky could not be reported in this study. Prior to the start of incident reporting and after the conclusion of the semester, students were asked to complete preand post-surveys to assess understanding of key process safety related concepts and learning gains. IRB approval for this data was obtained for all four universities and is presented here. Participation in the preand post-tests was voluntary and anonymous. At the start of the survey, students were shown an IRB-approved cover letter and asked to consent to participation in the study. To control for process safety related knowledge due to prior internship and research experience, students were first asked to identify if they participated in a single internship, multiple internships, or lab research experience. If participation was identified, they were asked to describe how safety was integrated into that experience. Students were then asked to rate their understanding of the following concepts: risk assessment, consequence, frequency, personal safety, process safety, and environmental safety. Understanding was ranked using the following categories: “I don’t know what this term means” (0), “Not well at all” (1), “Slightly well” (2), “Moderately well” (3), “Very well” (4), or “Extremely well” (5). For the post-survey, an additional question was added where students were asked to rate the extent to which they made gains as a result of the UO course for the following concepts: risk assessment, consequence, frequency, personal safety, process safety, and environmental safety. Gains were categorized using the following categories: “None at all” (0), “A little, (1), “A moderate amount” (2), “A lot” (3) or “A great deal” (4). Because pre