Recognizing Catastrophic Incident Warning Signs in the Process Industries - American Institute of Chemical Engineers [2012, PDF]

Language: english
Author: American Institute of Chemical Engineers
Genre: Reference book
Publisher: Wiley
Edition: 1
ISBN: 978-0-470-76774-0
Format: PDF
Quality: eBook
Pages count: 242
Description: Recognizing Catastrophic Incident Warning Signs in the Process Industries Warning signs are indicators that something is wrong or about to go wrong. When we recognize and act on these indicators, a loss may be prevented. Of course, this will only happen when we know what to look for and are willing to take the
initiative to do something about it. A review of significant incidents in the process industries suggests that most if not all incidents were preceded by warning signs.
Some of these signs were clearly visible but not acted upon because their significance was not understood. Other warning signs were less obvious, but observant personnel may have detected them. This book is about warning signs that have preceded or contributed to past incidents. There is one common characteristic shared by the incident warning signs presented here:
The organization does not perceive or recognize them. An incident warning sign is a subtle indicator of a problem that could lead to an incident. Some minor incidents might have the potential to escalate to a catastrophic level. There are warning signs of a physical or tangible nature, and there are warning signs related to the management practices of an organization. Some warning signs may be problems in themselves while others may be symptoms of potential problems or incidents. Every sign provides a clue that may be an early warning of catastrophe. These clues give us an opportunity to do things differently to reduce the risk of a catastrophe.
It is common for an organization that experiences a major catastrophic incident to respond initially with shock and surprise. Somehow, facility workers and their pervisors may have developed the impression that catastrophic incidents only happen elsewhere and are the result of gross misconduct or total system breakdown. As the organization or local facility may have sustained itself without a catastrophic incident for many years, managers, technical staff, and facility workers often hold the sentiment... We must be doing things right. In many cases, this is a misguided perception. Consider taking a closer look at possible warning signs at your facility to avoid this experience.
Additional info: The oil spill from the Macondo well in the Gulf of Mexico in 2010 was a classic example of the thesis of this book. In the lead up to the accident there were numerous warning signs, some subtle, but some utterly unambiguous. Most strikingly, in the hours immediately before the blowout, the well was giving
unmistakable signs that it had not been properly sealed. These were either missed, because people had stopped paying attention in the rush to get the job finished, or
dismissed, because ways were found to normalize them. Hours earlier there were a number of other anomalies. The meaning of these anomalies was less clear at the
time, but in retrospect were probably signs that something was wrong. These were passed over without adequate thought as to their implications.
Warning signs can sometimes be used as the basis for safety indicators. For instance, a well instability event (often called a kick) is a warning of danger, and the
number of such events could possibly be used as the basis for a safety indicator. However, well integrity was not considered a safety matter in the Gulf of Mexico
and so no such safety indicators had been developed. Safety with respect to major hazards depends on developing such indicators and incorporating them into
management systems. This book catalogs a large range of warning signs that are worthy of attention. It is an extremely useful source for people seeking to develop key performance indicators (KPIs) for how well major hazard safety is being managed. The book also discusses some of the reasons why these signs are passed over so often and what needs to be done to ensure that we pay them proper attention. As such, it is a valuable addition to safety literature in hazardous industries.
Andrew Hopkins
Emeritus Professor of Sociology, Australian National University
March 2011