The Use and Storage of Methyl Isocyanate (MIC) at Bayer CropScience (2012) / Chapter Skim
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8 Post-Incident Retrospective Process Assessment
8 Post-Incident Retrospective Process Assessment
Pages 141-152
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From page 141... ...
This chapter also provides information regarding emergency response systems and discusses how ISP assessments could be used to improve and support effective emergency planning and response. INCIDENT INVESTIGATION -- AN ESSENTIAL COMPONENT OF A SAFETY MANAGEMENT SYSTEM As noted in Chapter 7, incident investigation is not a one-time, stand-alone event, but instead a necessary element within a functioning process safety man agement (PSM)
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Relationship Between A Priori and Post-Facto Assessment Although advance preparation is essential, incident investigations are con ducted after the fact -- that is, after a loss-producing event or a near-miss has occurred. In conducting a post-incident process assessment, it is important to avoid the problem of hindsight bias.
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For example, commitment to a strong process safety culture will undoubtedly affect all remaining PSM elements as previously discussed in Chapter 7. It is difficult to envisage senior managers searching for PSM system deficiencies during an incident investigation without those same managers being fully committed to ensuring a sound safety culture; Sutton (2008)
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SUBSTITUTE Is this hazardous process/product necessary? Is it possible to completely eliminate hazardous raw materials, process intermediates, or by-products by using an alternative process or chemistry?
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to motivate incident investigators and investigation teams to think of less obvious ways of preventing process incidents. These questions, given below in adapted form, raise issues similar to the checklist questions listed in Table 8.1: • What is the purpose of the operation involved in the incident?
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. necessary to make full use of all opportunities at the conceptual stages of process development and design to reduce the frequency of accidents in the chemical process industries." This is essentially a call for early ISP consideration and an examination of the effectiveness of preincident ISP assessments based on the findings of post-incident investigations.
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The final item in particular, which was first introduced to the process safety community by Professor Trevor Kletz, is critical to the integration of ISP within the investigation protocol. As described previously in this chapter, it should be well-understood that the root causes of process incidents are typically management system deficiencies; this accounts for the third layer of recommendations shown in Figure 8.1.
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148 USE AND STORAGE OF METHYL ISOCYANATE (MIC) AT BAYER CROPSCIENCE FIGURE 8.1 Inherent safety-based incident investigation methodology.
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gives the example of additional training being provided to air traffic controllers who had made procedural errors, as opposed to removing hazards by making changes to the computer software running the air traffic control consoles, which had been identified as the root-cause source of error. Such system-wide improvements to the underlying technology, although resourceintensive and requiring comprehensive risk assessment, remain the best response to hazards identified during an incident investigation (Hopkins, 2009)
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CONCLUSIONS This chapter has provided a review of incident investigation from both a general perspective as a key element of a PSM system and with specific ISP considerations in mind. Incident investigations are most useful in the process industries when they are conducted with the objective of determining root causes.
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2007. Incorporation of inherent safety principles in process safety management.
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2008. Use root cause analysis to understand and improve process safety culture.
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