In response to a gap analysis performed of the Baker Panel Report on Texas Cityrn(2006), a large Midwest refinery implemented a matrix of event-related lagging PSMrnmetrics starting in January 2007. This effort was coupled with a PSM awarenessrntraining program, as well as tracking performance on a number of leading keyrnperformance indicators (KPIs). Two years and more than 350 PSM near miss andrnincident investigations later, the refinery is in a much improved state for PSM. Thisrnpaper outlines the path, the results, and the lessons of this effort.
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