New perspectives on how to successfully drive changes in companies’ process safety management systems
Simply learning from process safety incidents has proven to be insufficient to drive performance improvements. To truly change, organizations must seek out & embed learnings in their programs & systems. This book picks up from previous CCPS books, Incidents That Define Process Safety and Investigating Process Safety Incidents.
This important book:
- Offers guidelines for improving process safety performance by embedding the lessons learned from publicly available investigations
- Recommends a continuous improvement learning model focused on organizational learning
- Provides examples for using the model’s techniques to drive continuous improvements
Contains an index of more than 400 investigated incidents and introduces the concept of Drilldown to help find lessons that might not have been mentioned before.
Written for safety professionals and process safety consultants, Driving Continuous Process Safety Improvement from Investigated Incidents is a hands-on guide for adopting a model for successfully driving the learnings from process safety incident investigations.
Table of Contents
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 60
5.3 Corporate Change Models 61
5.3.1 Lewin 61
5.3.2 McKinzie 7-S® 62
5.3.3 Kotter 63
5.3.4 ADKAR® 63
5.3.5 IOGP 64
5.4 The Recalling Experiences and Applied Learning (REAL) Model 65
5.5 References 67
6 Implementing the REAL Model 69
6.1 Focus 71
6.1.1 Identify High Potential Impact Learning Opportunities 71
6.1.2 76
6.2 Seek Learnings 79
6.3 Understand 80
6.4 Drilldown 80
6.5 Internalize 82
6.6 Prepare 83
6.7 Implement 85
6.8 Embed and Refresh 86
6.9 References 86
7 Keep Learnings Fresh 89
7.1 Musical Intelligence 91
7.2 Visual-Spatial Intelligence 93
7.3 Verbal-Linguistic Intelligence 95
7.4 Logical-Mathematical Intelligence 97
7.5 Kinesthetic Intelligence 98
7.6 Interpersonal Intelligence 99
7.7 Intrapersonal Intelligence 100
7.8 Naturalistic Intelligence 101
7.9 Summary 102
7.10 References 102
8 Landmark Incidents that Everyone Should Learn From 105
8.1 Flixborough, North Lincolnshire, UK, 1974 106
8.2 Bhopal, Madhya Pradesh, India, 1984 108
8.3 Piper Alpha, North Sea off Aberdeen, Scotland, 1988 110
8.4 Texas City, TX, USA, 2005 111
8.5 Buncefield, Hertfordshire, UK, 2005 113
8.6 West, TX, USA, 2013 113
8.7 NASA Space Shuttles Challenger, 1986, and Columbia, 2003 115
8.8 Fukushima Daiichi, Japan, 2011 117
8.9 Summary 118
8.10 References 118
9 REAL Model Scenario: Chemical Reactivity Hazards 121
9.1 Focus 121
9.2 Seek Learnings 122
9.3 Understand 124
9.4 Drilldown 125
9.5 Internalize 126
9.6 Prepare 127
9.7 Implement 128
9.8 Embed and Refresh 129
9.9 References 130
10 REAL Model Scenario: Leaking Hoses and Unexpected Impacts of Change 131
10.1 Focus 132
10.2 Seek Learnings 132
10.3 Understand 135
10.4 Drilldown 135
10.5 Internalize 137
10.6 Prepare 138
10.7 Implement 139
10.8 Embed and Refresh 140
10.9 References 141
11 REAL Model Scenario: Culture Regression 143
11.1 Focus 144
11.2 Seek Learnings 145
11.3 Understand 148
11.4 Drilldown 149
11.5 Internalize 149
11.6 Prepare 150
11.7 Implement 152
11.8 Embed and Refresh 153
11.9 References 154
12 REAL Model Scenario: Overfilling 155
12.1 Focus 156
12.2 Seek Learnings 157
12.3 Understand 159
12.4 Drilldown 160
12.5 Internalize 161
12.6 Prepare 164
12.7 Implement 166
12.8 Embed and Refresh 167
12.9 References 167
13 REAL Model Scenario: Internalizing a High-Profile Incident 169
13.1 Focus 169
13.2 Seek Learnings 170
13.3 Understand 173
13.4 Drilldown 174
13.5 Internalize 175
13.6 Prepare 175
13.7 Implement 176
13.8 Embed and Refresh 176
13.9 References 178
14 REAL Model Scenario: Population Encroachment 179
14.1 Focus 180
14.2 Seek Learnings 181
14.3 Understand 184
14.4 Drilldown 184
14.5 Internalize 185
14.6 Prepare 186
14.7 Implement 187
14.8 Embed and Refresh 188
14.9 References 189
15 Conclusion 191
15.1 References 194
Appendix: Index of Publicly Evaluated Incidents 195
A.1 Introduction 195
A.2 How to Use this Index 196
A.3 Index of Publicly Evaluated Incidents 197
A.4 Report References 211
A.5 References 236
Index 239
