Driving Continuous Process Safety Improvement from Investigated Incidents

ISBN-13: 9781119768661 / Angielski / Twarda / 2021 / 288 str.

CCPS (Center for Chemical Process Safety)

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Acronyms and Abbreviations xvAcknowledgements xviiGlossary xixForeword xxiExecutive Summary xxiiiApplicability of this Book xxvii1 Introduction 11.1 The Focus of this Book 21.2 Why Should We Learn from Incidents? 41.2.1 The Theory of Root Cause Correction 61.2.2 Acting on Learning from High Potential Near-misses 71.2.3 Learning from Other Companies' (External) Incidents 81.2.4 Societal Expectations and the Business Case 81.3 References 102 Learning Opportunities 132.1 Think Broadly 132.1.1 Look Beyond the Specific Circumstances 132.1.2 Learn from Other Industries 152.1.3 Learn from Regulatory Standards and Beyond 172.2 Resources for Learning 182.2.1 Process Safety Boards 182.2.2 Databases 182.2.3 Publications 192.2.4 Events and Proceedings 212.2.5 Other Resources 222.3 References 223 Obstacles to Learning 273.1 The Impact of Individuals 283.2 The Impact of Company Culture 313.3 Obstacles Common to Individuals and Companies 343.4 Consequences of Not Learning from Incidents 353.5 References 364 Examples of Failure to Learn 394.1 Process Safety Culture 404.2 Facility Siting 424.3 Maintenance of Barriers/Barrier Integrity 444.4 Chemical Reactivity Hazards 484.5 Asphyxiation Hazards in Confined Spaces 494.6 Hot Work Hazards 504.7 References 515 Learning Models 555.1 Learning Model Requirements 555.2 Learning Models for Individuals 575.2.1 Multiple Intelligences and Learning Styles Model 575.2.2 Career Architect Model 585.2.3 Dynamic Learning 595.2.4 Ancient Sanskrit 595.2.5 Guiding Principles for Learning 605.3 Corporate Change Models 615.3.1 Lewin 615.3.2 McKinzie 7-S(r) 625.3.3 Kotter 635.3.4 ADKAR(r) 635.3.5 IOGP 645.4 The Recalling Experiences and Applied Learning (REAL) Model 655.5 References 676 Implementing the REAL Model 696.1 Focus 716.1.1 Identify High Potential Impact Learning Opportunities 716.1.2 766.2 Seek Learnings 796.3 Understand 806.4 Drilldown 806.5 Internalize 826.6 Prepare 836.7 Implement 856.8 Embed and Refresh 866.9 References 867 Keep Learnings Fresh 897.1 Musical Intelligence 917.2 Visual-Spatial Intelligence 937.3 Verbal-Linguistic Intelligence 957.4 Logical-Mathematical Intelligence 977.5 Kinesthetic Intelligence 987.6 Interpersonal Intelligence 997.7 Intrapersonal Intelligence 1007.8 Naturalistic Intelligence 1017.9 Summary 1027.10 References 1028 Landmark Incidents that Everyone Should Learn From 1058.1 Flixborough, North Lincolnshire, UK, 1974 1068.2 Bhopal, Madhya Pradesh, India, 1984 1088.3 Piper Alpha, North Sea off Aberdeen, Scotland, 1988 1108.4 Texas City, TX, USA, 2005 1118.5 Buncefield, Hertfordshire, UK, 2005 1138.6 West, TX, USA, 2013 1138.7 NASA Space Shuttles Challenger, 1986, and Columbia, 2003 1158.8 Fukushima Daiichi, Japan, 2011 1178.9 Summary 1188.10 References 1189 REAL Model Scenario: Chemical Reactivity Hazards 1219.1 Focus 1219.2 Seek Learnings 1229.3 Understand 1249.4 Drilldown 1259.5 Internalize 1269.6 Prepare 1279.7 Implement 1289.8 Embed and Refresh 1299.9 References 13010 REAL Model Scenario: Leaking Hoses and Unexpected Impacts of Change 13110.1 Focus 13210.2 Seek Learnings 13210.3 Understand 13510.4 Drilldown 13510.5 Internalize 13710.6 Prepare 13810.7 Implement 13910.8 Embed and Refresh 14010.9 References 14111 REAL Model Scenario: Culture Regression 14311.1 Focus 14411.2 Seek Learnings 14511.3 Understand 14811.4 Drilldown 14911.5 Internalize 14911.6 Prepare 15011.7 Implement 15211.8 Embed and Refresh 15311.9 References 15412 REAL Model Scenario: Overfilling 15512.1 Focus 15612.2 Seek Learnings 15712.3 Understand 15912.4 Drilldown 16012.5 Internalize 16112.6 Prepare 16412.7 Implement 16612.8 Embed and Refresh 16712.9 References 16713 REAL Model Scenario: Internalizing a High-Profile Incident 16913.1 Focus 16913.2 Seek Learnings 17013.3 Understand 17313.4 Drilldown 17413.5 Internalize 17513.6 Prepare 17513.7 Implement 17613.8 Embed and Refresh 17613.9 References 17814 REAL Model Scenario: Population Encroachment 17914.1 Focus 18014.2 Seek Learnings 18114.3 Understand 18414.4 Drilldown 18414.5 Internalize 18514.6 Prepare 18614.7 Implement 18714.8 Embed and Refresh 18814.9 References 18915 Conclusion 19115.1 References 194Appendix: Index of Publicly Evaluated Incidents 195A.1 Introduction 195A.2 How to Use this Index 196A.3 Index of Publicly Evaluated Incidents 197A.4 Report References 211A.5 References 236Index 239

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The Center for Chemical Process Safety (CCPS), an industry technology alliance of the American Institute of Chemical Engineers, has been the world leader in developing and disseminating information on process safety management and technology since 1985. CCPS has published over 100 books in its process safety guidelines and process safety concepts series, and over 30 training modules through its Safety in Chemical Engineering Education (SAChE) series. CCPS is supported by the contributions and voluntary participation of more than 220 companies globally.