Process Disasters — Are we learning from them?

Learning the lessons of previous process disasters is an important goal for process engineers working in heavy industry. When dealing with high temperatures, pressures and volatile and often toxic substances things can go wrong quickly. It is important that the lessons of others are applied so that history doesn’t repeat. There are many informative sources of information online such as the US Chemical Safety Board or the Disaster Cast podcast.

Texas City Explosion (CSB)

One of the major industrial disasters in Australia was the 1998 explosion at Esso’s Longford facility in Victoria. There are many lessons that have been drawn from this disaster as a result of the scrutiny it received under the Royal Commission established to investigate it. Broadly the main lessons relevant to loss prevention are:

• Safety Management System — incomplete implementation
• Knowledge Stewardship — insufficient on old plant
• Management of Change — organisational change not scrutinised
• Audit and Review — inadequate attention to detail

A more detailed summary of Andrew Hopkins book “Lessons from Longford” can be found here and in this paper also by Hopkins:

1. Operator error is not an adequate explanation for major accidents.
2. Systematic hazard identification is vital for accident prevention.
3. Auditing must be good enough to identify the bad news and ensure it gets to the top.
4. Reliance on lost time injury data in major hazard industries is itself a major hazard.
5. Good reporting systems must specify relevant warning signs. They must provide feedback to reporters and an opportunity for reporters to comment on feedback.
6. Alarm systems must be carefully designed so that warnings of trouble do not get dismissed as normal (normalised).
7. Senior management must accept responsibility for the management of hazardous processes.
8. A safety case regime should apply to all major hazard facilities.

This Disaster Cast podcast focus’s in some detail on the accident with a slightly different perspective on the lessons that can be drawn from it.

A couple of other interesting items worth consideration through the various reports include:

• Is your workplace adequately tracking Process safety metrics? These are not to be confused with personal safety and require seperate reporting and monitoring. The following sites have useful links to developing process safety metrics:
• Bakers report composite process safety measure
• Process safety leading and lagging metrics
• Developing process safety indicators
• Piper Alpha Appleton BBC — YouTube
• The Rule of Three to manage ambiguous or emerging process safety conditions. With decisions when situations are not clearly dangerous in their own right but when combined with 2 or more other borderline or sub standard conditions add up to a situation that can clearly spiral out of control and should trigger a review or stop. This comes from the Shell Hearts and Minds safety program and more details can be found in this paper.

Many of the lessons from Longford have been repeated in subsequent process industry disasters, notably the BP Texas City explosion.

Deepwater Disaster

You might also like:

• Boundaries of failure — Rasmussen’s model of how accidents happen.
• System of Profound Knowledge — Deming developed his system of profound knowledge to describe the work of organisations.
• Building a culture of full disclosure — How does a work place culture allow people to speak up, highlight important issues and opportunities to improve?