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2008 epsc - accident avoidance

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Presented at the European Process Safety Centre seminar.
How to avoid accidents by learning from others.

Publié dans : Ingénierie
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2008 epsc - accident avoidance

  1. 1. Tel: +44 1492 879813 Mob: +44 7984 284642 andy.brazier@gmail.com www.andybrazier.co.uk Accident Avoidance
  2. 2. Learning about accidents Companies cannot learn everything from their own accidents and incidents Not many significant events Limited resources to investigate Internal mindset Look at one incident at a time But don’t always learn from others’ misfortune Different hazard, equipment, controls etc. Skim through the headlines only Focus on the last big one.
  3. 3. BP Texas City Process industry has, quite rightly, looked carefully at this accident It seemed as if, to some people, the causes were novel and unheard of in the industry I believe the reports actually reflect the current consensus of what causes major accidents.
  4. 4. Previous study Analysis of major accident reports PhD in mid 90’s Published inquiries go far beyond in-house investigations Recurring findings One or more ‘fatal errors’ Conditions that made the error likely System failures contributing to the accident’s likelihood and consequence All accidents preceded by similar near misses Management did not recognise the warning signs.
  5. 5. My aim here Not look at accidents in isolation Identify recurring themes Select accidents that provide the best illustration of an issue Provide a list of factors that all organisations should look out for.
  6. 6. Piper Alpha Permit to work failures Well established system Compliant Not working in practice
  7. 7. Procedures are essential but… It is easy to be reassured that written systems and procedures are being used No news is good news? People think they are following the procedure but have not actually understood what is required People think the procedure is only a guide People daren’t say they don’t follow the procedure Assume people will adapt & take short cuts Audit what people do, not just the paper.
  8. 8. Chernobyl Communication failures Management secretive about design weaknesses Operators did not challenge instructions.
  9. 9. Error is a natural part of communication It is not what you say, it is what people think you mean Some messages are taken literally Other times people ‘read between the lines’ If people are not told about problems They will make the wrong decisions Will not understand why they need to follow procedures More/better communication is required when unusual events are happening.
  10. 10. Clapham Junction Technician errors Highly trained Experienced.
  11. 11. Training ≠ Competence Training courses have limited impact Most learning is achieved ‘on the job’ Needs to be planned Trainees need to be supervised Time served does not replace the need for competence assessment Competent people still make mistakes Given more complex and demanding tasks Indispensable means less able to take a break.
  12. 12. Herald of Free Enterprise Door left open Ship’s Master did not know Vulnerable design
  13. 13. Layers of protection Understand How many? Are they independent? Don’t assume they will work Always obtain positive indications of operation Make sure people understand their safety responsibilities Learn from near misses Not just failures, but also what prevented an accident If you don’t act, people will assume all is safe.
  14. 14. Bhopal Methyl Isocyante Runaway reaction Unable to contain vapours
  15. 15. Reduced throughput does not mean reduced risk Delaying maintenance Reduced budget or staff People get used to systems being inoperable People are more interested in plants that make money High rate is more likely to be steady state.
  16. 16. Mexico City Fractured pipe Slow response Too late to prevent escalation
  17. 17. Detect → Diagnose → Respond Have to succeed in all three stages AND not OR gate logic Prompt alarms Competent people Plant knowledge and understanding Decision making Resources People Equipment.
  18. 18. BP Texas City People in the wrong place at the wrong time Trailers in plant area Area not cleared during start up Slow to raise the alarm A good safety record has its downside.
  19. 19. Generic Learning Big accidents start small Accidents occur most during unusual circumstances If you haven’t got it, it can’t hurt you Keep people away from hazards Written systems & procedures provide poor risk control Most learning is on the job Error is a natural part of communication People who are tired make more mistakes Safety devices can create complacency Don’t assume safety devices are working.
  20. 20. Generic Learning (cont.) Everyone needs to act if they know something is unsafe You need to challenge your emergency arrangements People must be prepared to raise the alarm Anyone who may have to deal with the consequences of an accident has to know what they are dealing with Make sure you learn from near misses All incidents have multiple causes and this should be seen in your investigations Don’t overlook sabotage Non-operational parts of the business can be hazardous Don’t believe your safety is good (enough).
  21. 21. Conclusions Before major accidents most managers didn’t have particular concerns about safety Not perfect, but did not foresee the risk Reassured that systems were in place without having good evidence that they were effective Only heard or listened to good news The biggest risks occur because of the errors and poor judgements made by those managers High reliability organisations expect failuresHigh reliability organisations expect failures and so work hard to avoid themand so work hard to avoid them