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The American Institute of Chemical
Engineers (AIChE) has a 30-year history of involvement with process safety
and loss control for chemical and petrochemical plants. Through its
ties with process designers, builders and operators, safety processionals
and academia, the AIChE has enhanced communications and fostered
improvement in the high safety standards of this industry. Its
publications and symposia have become an information resource for the chemical
engineering profession on the causes of incidents and means of prevention.
The Center for Chemical Process Safety
(CCPS), a directorate of the AIChE, was established in 1985 to intensity
development and dissemination of the latest scientific and engineering
practices for prevention and mitigation of catastrophic incidents
involving hazardous materials: advance the state-of-the-art of
engineering practices through research: and develop and encourage the use
of undergraduate curricula that will improve the safety knowledge and consciousness
of engineers.
Over 80 corporations from all segments of
the chemical and hydrocarbon process industries support the Center.
They select CCPS's projects relevant to improved process safety, they
furnish the processionals who give the Center's works technical direction
and substance, and they help fund the center. Since its founding,
CCPS has cosponsored several international, technical symposia, developed
training courses, undertaken research projects and published nine volumes
in it Guidelines series, the proceedings of five technical meetings
and teaching materials to help integrate process safety into undergraduate
chemical engineering programs. CCPS research projects now in
progress will yield new data for improved process safety.
Most CCPS books in print are written for
engineers in plant design and operations and address scientific techniques
and engineering practices. Some of the new books embody the philosophy
that successful process safety programs result from the committed and
active participation of managers at all levels and a systematic approach
to press safety that is an integral part of operations management.
The first of these, Guidelines for Technical Management of Chemical
Process Safety, is based on the best safety management systems in use
within industry and was written for middle and top managers. It
explains the twelve elements that must be considered in an effective
program to manage chemical process safety. The next in this series
of publications, Plant Guidelines for Technical Management of Chemical
Process Safety, is designed to be used by plant mangers and their
staff, and it provides more detail and examples of useful management
systems in these twelve elements.
One of the twelve elements in a process
safety management program is the investigation of incidents, the subject
of this book. The target audience for the book is a cross-section of
mid-level managers, engineering professionals, and production supervisors
who will lead, manage, or participate on an investigation team. For
them, this book in the Guideline series presents techniques for
investigating incidents of a serious nature, whether they result in
accidents or not, whether they have in-plant or off-plant consequences, or
whether they are characterized by actual or potential loss of life and/or property
or damage to the environment. Guidance is also provided for initial
establishment of an investigation team and establishment and evaluation of
a management system for incident investigation. Lastly an annotated bibliography
is included for safety processionals who may wish to refer to many books
available on incident investigation.
The major components in the investigation
of an incident are:
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Identify the root causes.
-
Determine recommendations necessary to
prevent a recurrence.
-
Ensure that action is taken on the
recommendations.
In many older approaches to investigation
of a process incident, the investigation frequently ended when one or two
direct or intermediate causes of an incident were identified. New
technology has demonstrated that incidents and accidents are the end result
of several failures which contribute tot he event. The new
approaches have proven successful in their application and results.
This book is based upon the new approaches and covers state-of-the-art
technology and practices in use for thoroughly investigating an incident.
Consequently, the major principals around
which this book was written include the following:
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Every process incident is a symptom
of a system failure. Successful operation of a process plant
results from multiple elements (process, equipment, employees,
management practices, and policies) working together as a complete
system. No process incident occurs as a reuslt of any one cause,
but is the result of a combination of featrues and/or failures of
various system elements. To prevent accidents, we must,
therefore, address system causes, not just direct or immediate causes
of incidents.
-
Few, if any process incidents, occur
as a result of a single cause.
-
Process incident investigations
should follow formal logical methodologies. The reason for
an investigation is to prevent another incident by taking steps to
remedy all the system causes. An investigation is too important
for hit-or-miss methods that may overlook significant causes or
potential causes.
-
To prevent accidents all of the
groups in the system (managers, designers, supervisors, maintainers,
operators, engineers, etc) have to work together as a team.
The most significant concept in this book is that all groups involved
with a process have a shared responsibility for success and failure in
preventing a process incident. All groups must work together as
a team through the life cycle of a plant to minimize incidents.
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Communication of key learning's from
process incident investigations is essential. Sharing of lessons
learned among plants, sites, and companies can help prevent recurrence
of similar incidents. However, there can be legal difficulties
in communicating the details of process incident
investigations., Some groups are exploring means to work around
these constraints and communicate necessary incident information.
This Guidelines is an effort to
present currently used state-of-the-art information on process incident
investigation in a manner that would be most useful to managers and
engineers in the chemical and hydrocarbon processing industries. We
look forward to the day when there will be news and even better
investigation techniques and systems, and a second edition of this book
will be a necessity.
Finally, the cornerstone of a successful
investigation is the investigator's commitment to excellence.
Excellence requires finding all the system causes, developing workable and
innovative solutions to failures found and to problems encountered,
testing new ideas, and continuing to look for better methods, techniques,
and remedies. The reward of excellence is the prevention of accidents
and better protection of employees, neighbors, and the environment.
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Introduction
The relation of incident investigation to
management of process safety.
The needs for and benefits of incident
investigation.
Incident classification and definitions.
Concepts for process incident
investigation.
Objectives of this book.
Arrangement of this book.
References.
Basic Incident Investigation Techniques
Philosophy for process incident
investigation.
Anatomy of the process-related incident.
Theories of incident causation.
Human factors considerations in incident
causation.
Techniques for incident investigation.
Review of analytical techniques.
Validity and user-friendliness.
Some observations.
Application of PSH techniques.
Incident data bases.
Types and sources of historical data.
General considerations of data base
structures.
References.
Investigating Process Safety Incidents.
Management responsibilities.
Near-miss incidents.
Classification.
Activating the investigation team.
The process safety incident investigation
team.
Purpose and general concepts.
Team leader.
Team composition.
Development of specific plan for
investigating a specific incident.
Team operations.
Resumption of normal operation and
restart criteria.
Team training.
Practical Investigation
Considerations: Gathering Evidence
Legal and credibility Concerns
On-site investigation overview.
CCPS approach.
Specific plan.
Priorities for the PSII team.
Initial site visit.
Sources of information.
Field investigation tools / equipment /
supplies.
Personal equipment.
Protective gear.
PSII team supplies.
Witness interviews.
Identifying witnesses.
Human characteristics related to
interviews.
General guidelines for collecting
information from witnesses.
Conducting the interview.
Common avoidable mistakes.
Physical evidence.
General considerations.
Preservation.
Identification.
Document control.
Photography.
Overview.
Guidelines for maximum results.
Third-party information.
Aids of studying evidence.
Sources of information.
Analyzing physical evidence.
Laboratory testing in support of
failure analysis.
Chemical analysis.
Mechanical testing.
New challenges in interpretation of
evidence.
References.
Multiple
Cause Determination
Introduction.
Concept of multiple causes.
Multiple cause analysis.
Illustrative case histories.
Type 3 approach.
Tool kit for multiple cause
determination.
Logic tree diagram.
Fault tree analysis.
Guidelines for stopping tree
development.
Human factors applications.
Fact / hypothesis matrix.
Simulations and re-creations.
Determining conditions at the time of
failure.
Severity of consequences.
Flowchart for multiple cause
determination.
Introduction.
Develop chronology of events.
List facts.
Develop logic tree.
Review and confirm logic against facts.
Completeness test.
Systems causes test.
Overall review test.
Iterative loop.
Case history, example applications.
Logic tree development.
Three-truck incident.
Fire and explosion incident fault-tree.
Data driven cause analysis.
Conclusion.
References.
Recommendations and Follow-Through
Major Concepts
Development of recommendations
Responsibilities
Attributes of good recommendations
Types of recommendations
Inherent safety
Hierarchies and layers of
recommendations
Disciplinary action/commendation
The "No-Action"
recommendation
Expanded Flowchart Discussion
Select one cause
Develop and examine preventative action
Management of change
Completeness test
Restart/resumption of operations
Establish and prepare to present
recommendations for preventative action
Review recommendations with management
Documentation of recommendation
decisions
Implementation of recommendations and
follow-up action
Management system for follow-through
Reports and Communication
References
Formal Reports and Communication Issues
Initial notification
Interim reports
For written report
General
Abstract
Background
Narrative description of the incident
Root causes
Recommendations
Other
Criteria for restart
Capturing lessons learned
Internal
External
Sample reports
Quality assurance
Check list
Good practices to avoid common mistakes
References
Development and Implementation
Developing the initial management system
Commitment by management
Incident reporting system
Incident classification system
Formation of the team
Team organization
PSII team operations
Identifying root causes
Recommendations and findings
Formal reports
Implementation of recommendations
Process safety incident investigation
documentation
Integration with other functions and
teams
Process safety incident investigation
critique mechanism
Review and approval
Implementation
Initial training
Team training
References
Appendix A: Relevant organizations
Appendix B: Annotated bibliography
Appendix C: Selected sampling of
Type 3 deductive investigation methods
Rhone Poulenc -- Description of the
Causal Tree Method
MCSOII: Rohm and Haas Texas Inc.
Incident investigation guidelines
Appendix D: Actual incidents
Phillips 66 Company Houston Chemical
complex
Piper Alpha
Bhopal, India
Pemex
Three Mile Island
Sevesco
Feyzin
Other recent major incidents
Appendix E: Excerpts from
regulations on investigation of process safety incidents
Appendix F: Example case
study: Fictitious NDF incident
Appendix G: Sample applications of
various root cause determinations
Multiple-cause-systems-oriented incident
investigation applied to NDF hypothetical incident in Appendix F.
Flashback from waste gas incinerator into
air supply piping
More bang for the buck: Getting the
most from accident investigations
Failure of synthesis gas compressor
Appendix H: Sources of information
about incident investigation techniques listed in table 2-1
Glossary
Acronyms and abbreviations
Index
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