INCIDENTALLY

Hindsight & Insight

Exactly a year ago, on 1st July 2020, I started publishing Incident Anniversaries on Social Media. These were intended to remind Duty Holders & Owner/Operators that their facilities are vulnerable and their protection systems are fallible.

The feedback has been humbling - particularly from those with first-hand accounts. Many thanks to those who took the time to comment.

Since then, there have been numerous Major Accidents with significant loss of life - I can't tell you how many incidents, fatalities & injuries and, to be honest, it doesn't matter because 1 accident or casualty is 1 too many.

It is disappointing that, in the 21st year of the 21st century, despite better technology and bigger data, we are still experiencing these events.

The only thing that we learn from history is that we learn nothing from history

Please take time to watch this short CSB video - not your usual familiar incident animation, but a tribute to the late, great Trevor Kletz.

As usual, he cuts to the chase with the reasons why we are still failing to "keep it in the pipe" with the following stark reminders ...

After an accident, managers often say "I didn't know this was happening or not happening, as the case may be. If I'd known, I'd have stopped it" - Now this is bad management. It's the manager's job to know what is going on. And he (she) can do that by going round and by keeping his (her) eyes open and reading the accident reports in detail.

And it's also in human nature, there's a tendency to say "Oh, gosh. That was a near one; I'm glad that leak didn't catch fire. Let's forget about it and get on with the job" .

The major problem with the chemical industry and indeed, with other industries, is that the way accidents are investigated; reports are written, circulated, read, filed away and then forgotten. And then ten years later, even in the same company, the accident happens again.

There is a saying that organisations have no memory; only people have memory. Once they leave the plant, the accident that occurred there is forgotten about.

I created Process Safety Events as single source of knowledge (to develop operational wisdom from information) where the existing Investigations (e.g. CSB ), Databases (e.g. ARIA ) & Bulletins (e.g. LPB , CCPS & EPSC ) could be collated, connected & communicated to time-poor responsible parties who could use this to prevent these (or similar/equivalent) events from happening at their sites.

It's not practical for an individual to curate these on an ongoing basis and therefore I'm now leaving this to the "professionals" i.e. institutions, professional bodies etc who I know are working to develop & deploy a consistent taxonomy to classify incidents and identify trends & patterns to be addressed to avoid the (inevitable ?) next event, or to make the next event less serious.

I encourage everyone to contribute to the Process Safety Incidents group (although let's pray there are less & less posts) and the Process Safety Events group (let's hope there are more & more posts in this community). Don't rely on me for content - I've simply created the space for you to share your experience & wisdom.

I also encourage you to visit the IChemE Safety Centre video channel where they are doing great work to remind us of previous incidents.

Please also visit the IChemE Lessons Learned Database where they produce 1-page summaries of familiar (and less well known) major accidents.

Insight & Foresight

Frontline personnel - those who may (unintentionally) contribute to and/or be impacted by these events - do not have the time/tools that "specialists" (like you & I and pretty much the majority of folks reading this article) have to interrogate & interpret incidents, therefore I'm moving from being 'wise after the event' to be 'wise before the event' to put the same knowledge (e.g. Lessons & Topics ) that I developed for Process Safety Events into their hands in a familiar, accessible and memorable format.

For example, QR codes on the front of the cards can now direct the 'Players' to relevant resources - we call that Process Safety Intelligence.

We'll be developing and rebranding the portfolio to be simply Work Safety Cards to cover a wide variety of Assets & Activities and although you'll continue to see updates here, we recognise that LinkedIn appeals to a certain 'technical' demographic and that other 'casual' platforms are perhaps best for sharing these ideas.

Please bear with us while we transition to this new brand and look out for forthcoming media from @WorkSafetyCards on your favourite apps.

The cards themselves are not the 'smart' bit (they are simply a reminder of WHAT can go wrong) they simply create awareness and direct the 'players' to visual scenarios which summarise (in bowtie format) WHY events happen (potential Threats), HOW they are prevented (appropriate Barriers) and WHO contributes to avoiding them (barrier responsibility/accountability) and, as part of the Work Safety Cards portfolio, we will be creating relationships with Subject Matter Experts who can help us develop bowties for the following industries:

• Agricultural
• Aviation
• Construction
• Drilling
• Manufacturing
• Maritime
• Mining
• Rail
• Road

Please contact me to find out how you can contribute to, or benefit from, these low-tech but high-impact learning aids.

#ProcessSafety #LearningFromIncidents #WorkSafety