Guidelines for Investigating Process Safety Incidents

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• Publisher: Wiley-AIChE
• Year: 2019
• Print ISBN: 9781119529071
• eBook ISBN: 9781119529125
• Edition: 3
• Topic: Technology & Engineering
• Subtopic: Industrial Health & Safety
• Index: Technology & Engineering

This book provides a comprehensive treatment of investing chemical processing incidents. It presents on-the-job information, techniques, and examples that support successful investigations. Issues related to identification and classification of incidents (including near misses), notifications and initial response, assignment of an investigation team, preservation and control of an incident scene, collecting and documenting evidence, interviewing witnesses, determining what happened, identifying root causes, developing recommendations, effectively implementing recommendation, communicating investigation findings, and improving the investigation process are addressed in the third edition.

While the focus of the book is investigating process safety incidents the methodologies, tools, and techniques described can also be applied when investigating other types of events such as reliability, quality, occupational health, and safety incidents.

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INTRODUCTION

1.1 BUILDING ON THE PAST

Flixborough, Bhopal, Piper Alpha, Deepwater Horizon, Buncefield— all are now synonyms for catastrophe. These names are inextricably linked with images of death, suffering, environmental damage and disastrous loss tied to the production of chemicals, fuels, or oils. An objective review of the world’s industrial history reveals a story punctuated with infrequent yet similarly tragic incidents. Invariably, in the wake of such tragedy, companies, industries, and governments work together to learn the causes. Their ultimate goal is to implement the knowledge acquired through diligent investigation, which in turn can help prevent recurrence or mitigate consequences.

Investigations into catastrophic events have revealed something of major significance—the key to preventing disaster first lies in recognizing leading indicators rather than the lagging indicators. Leading indicators exist, and therefore can be uncovered, in incidents that are much less than catastrophic. They can even be seen in so-called near-misses that may have no discernable impact on routine operation. By examining abnormal/upset operations, near-misses, and lower-consequence higher-frequency occurrences, companies may identify deficiencies that, if left uncorrected, could eventually result in serious or even catastrophic events.

The two most significant roles incident investigations can play in comprehensive process safety programs are:

1. Preventing disasters by consistently examining and learning from near-misses (inclusive of abnormal operations, minor events, etc.) and;
2. Preventing disasters by consistently examining and learning from more serious accidents.

The Center for Chemical Process Safety (CCPS) of the American Institute of Chemical Engineers (AIChE) recognized the role of incident investigation when it published the original Guidelines for Investigating Chemical Process Incidents in 1992.

The first edition provided a timely treatment of incident investigation including:

• a detailed examination of the role of incident investigation in a process safety management system,
• guidance on implementing an incident investigation system, and
• in-depth information on conducting incident investigations, including the tools and techniques most useful in understanding the underlying causes.

The second edition, released in 2003, built on the first text’s solid foundation. The goal was to retain the knowledge base provided in the original book while simultaneously updating and expanding upon it to reflect the latest thinking. That edition presented techniques used by the world’s leading practitioners in the science of process safety incident investigation.

This third edition is a further enhancement of the second edition. Specific emphasis has been placed on updating investigation techniques and analytical methodologies, and applying them to example case studies where possible. Expanded topics include scientific validation of hypotheses, rigorous physical evidence documentation and examination, scientific analysis, hypothesis rejection and substantiation, learnings from repeat incidents, and means to institutionalize learnings within an organization.

1.2 INVESTIGATION BASICS

Successful investigations are dependent on preplanning, documented procedures, appropriate investigator training and experience, appropriate support from leadership, and necessary resources (personnel, time, and materials), to conduct a thorough investigation. It is imperative that operating organizations conduct careful and comprehensive investigations that are factual and defensible. Developing and following written procedures allows organizations to consistently respond promptly and effectively, establishes the basis for continuous improvement, and helps preserve a company’s “license to operate”.

1.2.1 The First Step in conducting a successful incident investigation is to recognize when an incident has occurred so that an Incident Management System (Chapter 4) can be activated. Linked with incident recognition are Initial Notification, Classification, and Investigation (Chapter 5).

It is important to use standard terminology when referring to incident investigation so that those investigating an occurrence all share a common language that efficiently and accurately supports their investigation objectives. Some investigators may define the terms presented below slightly differently or use other descriptive terms that have the same meaning. Some organizations may desire to further sub-divide these terms into different levels. Within the scope of this book, the following definitions for key terms will apply throughout:

1.2.1.1 Incident—an unusual, unplanned, or unexpected occurrence that either resulted in, or had the potential to result in harm to people, damage to the environment, or asset/business losses, or loss of public trust or stakeholder confidence in a company’s reputation. Some examples are:

• process upset with potential process excursions beyond operating limits,
• release of energy or materials,
• challenges to a protective barrier,
• loss of product quality control,
• etc.

1.2.1.1(a) Accident—an incident that results in a significant consequence involving:

• human impact,
• detrimental impact on the community or environment,
• property damage, material loss,
• disruption of a company’s ability to continue doing business or achieve its business goals, (e.g. loss of operating license, operational interruption, product contamination, etc.).

1.2.1.1(b) Near-miss—an incident in which an adverse consequence could potentially have resulted if circumstances (weather conditions, process safeguard response, adherence to procedure, etc.) had been slightly different.

For most occurrences, protective barriers prevent a resultant adverse consequence. Such occurrences are often referred to as near-hits, near-misses, or close calls. For every incident labeled a near-miss, more subtle precursors exist that, if investigated and understood, could provide valuable insights into factors that could be applied to mitigating or preventing other incidents.

1.2.2 The Second Step in conducting a thorough investigation is to assemble a qualified team (Chapter 6) that will determine and analyze the facts of the incident. This team’s charter is to apply appropriate investigation tools and methodologies (Chapter 3) that will lead to the identification of the latent causes and application of remedies that could have prevented the incident or mitigated its consequence.

1.2.3 The Third Step in incident investigation is to gather information, separate facts from suppositions, analyze data, and determine what happened. Before conducting a cause analysis, a comprehensive and accurate understanding of what happened must first be completed. Witness management (Chapter 7), evidence management Chapter 8), and evidence analysis and hypothesis testing (Chapter 9) are key concepts to be employed during the investigation process.

1.2.4 The Fourth step in incident investigation is to determine root causes for the failure(s) that initiated or failed to prevent the incident. Note that root cause is being used in this book in the traditional sense, i.e.:

Root Cause - A fundamental, underlying, system-related reason why an incident occurred that identifies a correctable failure(s) in management systems.

By this definition, a root cause is the most fundamental level in the cause determination, and there is no more fundamental level. Recommendations can be developed for root causes that will prevent, lessen the likelihood, and/or consequence, of the same and similar incidents from occurring. Whereas, causal factors are invariably contributory in nature and, for the purposes of this book, are defined as:

Causal Factor - A major unplanned, unintended contributor to an incident (a negative event or und...

Table of contents

• Cover
• Title Page
• Title Page
• Copyright
• PREFACE
• ACKNOWLEDGMENTS
• ACRONYMS AND ABBREVIATIONS
• 1 INTRODUCTION
• 2 OVERVIEW OF CHEMICAL PROCESS INCIDENT CAUSATION
• 3 AN OVERVIEW OF INVESTIGATION METHODOLOGIES
• 4 DESIGNING AN INCIDENT INVESTIGATION MANAGEMENT SYSTEM
• 5 INITIAL NOTIFICATION, CLASSIFICATION AND INVESTIGATION OF PROCESS SAFETY INCIDENTS
• 6 BUILDING AND LEADING AN INCIDENT INVESTIGATION TEAM
• 7 WITNESS MANAGEMENT
• 8 EVIDENCE IDENTIFICATION, COLLECTION AND MANAGEMENT
• 9 EVIDENCE ANALYSIS AND CAUSAL FACTOR DETERMINATION
• 10 DETERMINING ROOT CAUSES—STRUCTURED APPROACHES
• 11 THE IMPACT OF HUMAN FACTORS
• 12 DEVELOPING EFFECTIVE RECOMMENDATIONS
• 13 PREPARING THE FINAL REPORT
• 14 IMPLEMENTING RECOMMENDATIONS
• 15 CONTINUOUS IMPROVEMENT FOR THE INCIDENT INVESTIGATION SYSTEM
• 16 LESSONS LEARNED
• APPENDIX A.PHOTOGRAPHY GUIDELINES FOR MAXIMUM RESULTS
• APPENDIX B. EXAMPLE PROTOCOL – CHECKING POSITION OF A CHAIN VALVE
• APPENDIX C.PROCESS SAFETY EVENTS LEVELING CRITERIA
• APPENDIX D.EXAMPLE CASE STUDY
• APPENDIX E. QUICK CHECKLIST FOR INVESTIGATORS
• APPENDIX F. EVIDENCE PRESERVATION CHECKLIST – PRIOR TO ARRIVAL OF THE INVESTIGATION TEAM
• APPENDIX G. GUIDANCE ON CLASSIFYING POTENTIAL SEVERITY OF A LOSS OF PRIMARY CONTAINMENT
• GLOSSARY
• REFERENCES
• INDEX
• WILEY END USER LICENSE AGREEMENT