Lest We Forget

I'm afraid to say that March 23rd passed by this year and this is the first time I didn't think of Texas City. It's now 13 years ago and since then we've had other devasting & dramatic incidents - I'm sure that every day must be an anniversary of some terrible process industry event somewhere, however there is no excuse for not remembering and honouring those lost & injured. Any loss of containment is one release too many and we must remain vigilant to the potential for equipment failures, control malfunctions, human error or external influences.

Trevor Kletz quoted a variation of Ecclesiastes Chapter 1 in "What Went Wrong?":

"Only that shall happen, which has happened, Only that occur, which has occurred; There is nothing new beneath the sun..."

The (in)famous Rumsfeld quote puts it into more modern (but no less vexing) language:

"..there are KNOWN KNOWNS ... there are KNOWN UNKNOWNS ... there are also UNKNOWN UNKNOWNS ... it is the latter category that tend to be the difficult ones"

A key challenge to the design & operation of a process is to consider what incidents have happened before and if they can happen (again) at the location. What are we doing about the things we should know about ?

Ultimately we should aim to operate in safe, stable & successful environment inspired by Radiohead with ...

"No Alarms and No Surprises Please"

So, are we not learning or are we learning but not applying ?

Dare I ask...

· Are we teaching the right people ?

· Are the right people teaching ?

· Are we teaching the right things ?

· Are we teaching the things right ?

We're definitely not short of material (or inspiration)

Maybe the "macro-messages" about Management of Change (Flixborough), Permit to Work Systems (Piper Alpha) are acknowledged but not applied. If you don't operate an isomerization unit or handle methyl isocyanate then maybe Texas City & Bhopal don't stay with you long after the training or briefing has passed.

The CSB develop & share invaluable incident information and Marsh regularly publish their 100 largest losses report - but what if your industry has had incidents (or near misses) that haven't been publicised ?

I tried, in my own small way, to keep on top of the incidents by developing a timeline:

And a map:

But it's a full time job to capture & communicate these (you can tell how out of date this already is) - perhaps professional institutions (ISC, CCPS, MKOPSC etc) would like to pick this up and run with it.

Big messages (the key components of Process Safety Management systems) are still vital to inform and engage duty holders and stakeholders.

I previously posted 'Pushing the Envelope of Pushing your Luck' which referenced a CCPS publication which offered 60 Loss of Containment Causes in the Chemical Industry (I'd still like to hear from anybody who knows of an incident (type) that isn't in Appendix A of the CCPS Guidelines for Chemical Process Quantitative Risk Analysis).

We know what can go wrong and believe we know what protection measures we need to prevent or mitigate the outcomes, so how can we more efficiently capture incidents and effectively communicate the lessons learned to prevent the same incident arising or avoid a similar incident occurring ?

Scenario based Incident Registration (SIR) is one method of gathering valuable contextual information and sharing it across the enterprise (or even industry if the commercial, legal & cultural fears could be allayed). Familiar scenarios can be interactively developed in an empowering environment and then if/when (god forbid) an incident occurs, the outcome can be compared to the anticipated effects and the barriers (organisational & technical measures) enhanced or supplemented as appropriate. We don't need to re-invent the wheel every time something predictable (and arguably avoidable) occurs.

Otherwise, unfortunately ...

Those that cannot remember the past are condemned to repeat it