Driving Continuous Process Safety Improvement From Investigated Incidents

Acronyms and Abbreviations xv
 
Acknowledgements xvii
 
Glossary xix
 
Foreword xxi
 
Executive Summary xxiii
 
Applicability of this Book xxvii
 
1 Introduction 1
 
1.1 The Focus of this Book 2
 
1.2 Why Should We Learn from Incidents? 4
 
1.2.1 The Theory of Root Cause Correction 6
 
1.2.2 Acting on Learning from High Potential Near-misses 7
 
1.2.3 Learning from Other Companies' (External) Incidents 8
 
1.2.4 Societal Expectations and the Business Case 8
 
1.3 References 10
 
2 Learning Opportunities 13
 
2.1 Think Broadly 13
 
2.1.1 Look Beyond the Specific Circumstances 13
 
2.1.2 Learn from Other Industries 15
 
2.1.3 Learn from Regulatory Standards and Beyond 17
 
2.2 Resources for Learning 18
 
2.2.1 Process Safety Boards 18
 
2.2.2 Databases 18
 
2.2.3 Publications 19
 
2.2.4 Events and Proceedings 21
 
2.2.5 Other Resources 22
 
2.3 References 22
 
3 Obstacles to Learning 27
 
3.1 The Impact of Individuals 28
 
3.2 The Impact of Company Culture 31
 
3.3 Obstacles Common to Individuals and Companies 34
 
3.4 Consequences of Not Learning from Incidents 35
 
3.5 References 36
 
4 Examples of Failure to Learn 39
 
4.1 Process Safety Culture 40
 
4.2 Facility Siting 42
 
4.3 Maintenance of Barriers/Barrier Integrity 44
 
4.4 Chemical Reactivity Hazards 48
 
4.5 Asphyxiation Hazards in Confined Spaces 49
 
4.6 Hot Work Hazards 50
 
4.7 References 51
 
5 Learning Models 55
 
5.1 Learning Model Requirements 55
 
5.2 Learning Models for Individuals 57
 
5.2.1 Multiple Intelligences and Learning Styles Model 57
 
5.2.2 Career Architect Model 58
 
5.2.3 Dynamic Learning 59
 
5.2.4 Ancient Sanskrit 59
 
5.2.5 Guiding Principles for Learning

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.