Guidelines for investigating chemical process incidents 2nd ed

Contents Preface xv Acknowledgments xvii 1 Introduction 1 1.1. Building on the Past 1 1.2. Who Should Read This Book? 4 1.3. The Guideline’s Objectives 4 1.4. The Continuing Evolution of Incident Investigation 8 2 Designing an Incident Investigation Management System 9 2.1. Preplanning Considerations 10 2.1.1. An Organization’s Responsibilities 10 2.1.2. The Benefits of Management’s Commitment 14 2.1.3. The Role of the Developers 15 2.1.4. Integration with Other Functions and Teams 15 2.1.5. Regulatory and Legal Issues 16 2.2. Typical Management System Topics 17 2.2.1. Classifying Incidents 17 2.2.2. Other Options for Establishing Classification Criteria 19 2.2.3. Specifying Documentation 20 2.2.4. Describing Team Organization and Functions 20 2.2.5. Setting Training Requirements 22 2.2.6. Emphasizing Root Causes 23 2.2.7. Developing Recommendations 24 2.2.8. Fostering a Blame-Free Policy 24 2.2.9. Implementing the Recommendations and Follow-up Activities 25 2.2.10. Resuming Normal Operation and Establishing Restart Criteria 25 2.2.11. Providing a Template for Formal Reports 26 2.2.12. Review and Approval 27 2.2.13. Planning for Continuous Improvement 27 2.3. Implementing the Management System 27 2.3.1. Initial Implementation—Training 28 2.3.2. Initial Implementation—Data Management System 28 References 32 3 An Overview of Incident Causation Theories 33 3.1. Stages of a Process-Related Incident 33 3.1.1. Three Phases of Process-Related Incidents 34 3.1.2. The Importance of Latent Failures 35 3.2. Theories of Incident Causation 36 3.2.1. Domino Theory of Causation 37 3.2.2. System Theory 37 3.2.3. Hazard–Barrier–Target Theory 38 3.3. Investigation’s Place in Controlling Risk 39 3.4. Relationship between Near Misses and Incidents 40 Endnotes 41 4 An Overview of Investigation Methodologies 43 4.1. Historical Approach 43 4.2. Modern Structured Approach 44 4.3. Methodologies Used by CCPS Members 45 4.4. Description of Tools 47 4.4.1. Brainstorming 47 4.4.2. Timelines 48 4.4.3. Sequence Diagrams 49 4.4.4. Causal Factor Identification 50 4.4.5. Checklists 50 vi Guidelines for Investigating Chemical Process Incidents 4.4.6. Predefined Trees 51 4.4.7. Team-Developed Logic Trees 52 4.5. Selecting an Appropriate Methodology 56 Endnotes 57 5 Reporting and Investigating Near Misses 61 5.1. Defining a Near Miss 61 5.2. Obstacles to Near Miss Reporting and Recommended Solutions 63 5.2.1. Fear of Disciplinary Action 64 5.2.2. Fear of Embarrassment 66 5.2.3. Lack of Understanding: Near Miss versus Nonincident 66 5.2.4. Lack of Management Commitment and Follow-through 69 5.2.5. High Level of Effort to Report and Investigate 70 5.2.6. Disincentives for Reporting NearMisses 71 5.2.7. Not Knowing Which Investigation System to Use 72 5.3. Legal Aspects 73 Endnotes 74 6 The Impact of Human Factors 75 6.1. Defining Human Factors 76 6.2. Human Factors Concepts 77 6.2.1. Skills–Rules–Knowledge Model 82 6.2.2. Human Behavior 84 6.3. Incorporating Human Factors into the Incident Investigation Process 86 6.3.1. Finding the Causes 88 6.4. How an Incident Evolves 89 6.4.1. Organizational Factors 90 6.4.2. Unsafe Supervision 91 6.4.3. Preconditions for Unsafe Acts 91 6.4.4. Unsafe Acts 92 6.5. Checklists and Flowcharts 93 Endnotes 93 Contents vii 7 Building and Leading an Incident Investigation Team 97 7.1. Team Approach 97 7.2. Advantages of the Team Approach 98 7.3. Leading a Process Safety Incident Investigation Team 98 7.4. Potential Team Composition 100 7.5. Training Potential Team Members and Support Personnel 103 7.6. Building a Team for a Specific Incident 105 7.6.1. Minor Incidents 106 7.6.2. Limited Impact Incidents 106 7.6.3. Significant Incidents 107 7.6.4. High Potential Incidents 107 7.6.5. Catastrophic Incidents 107 7.7. Developing a Specific Investigation Plan 108 7.8. Team Operations 110 7.9. Setting Criteria for Resuming Normal Operations 112 8 Gathering and Analyzing Evidence 115 8.1. Overview 116 8.1.1. Developing a Specific Plan 116 8.1.2. Investigation Environment Following aMajor Occurrence 118 8.1.3. Priorities for Managing an Incident Investigation Team 119 8.2. Sources of Evidence 122 8.2.1. Types of Sources 122 8.2.2. Information from People 128 8.2.3. Physical Evidence and Data 132 8.2.4. Paper Evidence and Data 133 8.2.5. Electronic Evidence and Data 135 8.2.6. Position Evidence and Data 136 8.3. Evidence Gathering 139 8.3.1. Initial Site Visit 139 8.3.2. Evidence Management 141 8.3.3. Tools and Supplies 142 8.3.4. Photography and Video 144 8.3.5. Witness Interviews 148 8.4. Evidence Analysis 161 viii Guidelines for Investigating Chemical Process Incidents 8.4.1. Basic Steps in Failure Analysis 161 8.4.2. Aids for Studying Evidence 171 8.4.3. New Challenges in Interpreting Evidence 174 8.4.4. Evidence Analysis Methods 175 8.4.5. The Use of Test Plans 176 Endnotes 177 9 Determining Root Causes—Structured Approaches 179 9.1. The Management System’s Role 181 9.2. Structured Root Cause Determination 183 9.3. Organizing Data with a Timeline 185 9.3.1. Developing a Timeline 185 9.3.2. Determining Conditions at the Time of Failure 189 9.4. Organizing Data with Sequence Diagrams 190 9.5. Root Cause Determination Using Logic Trees—Method A 197 9.5.1. Gather Evidence and List Facts 197 9.5.2. Timeline Development 198 9.5.3. Logic Tree Development 198 9.6. Logic Trees 201 9.6.1. Choosing the Top Event 202 9.6.2. Logic Tree Basics 203 9.6.3. Example—Chemical Spray Injury 209 9.6.4. What to Do If the Process Stalls 214 9.6.5. Guidelines for Stopping Tree Development 214 9.7. Fact/Hypothesis Matrix 216 9.7.1. Application of Fact/HypothesisMatrix 218 9.8. Case Histories and Example Applications 219 9.8.1. Fire and Explosion Incident—Fault Tree 219 9.8.2. Data Driven Cause Analysis 223 9.9. Root Cause Determination Using Predefined Trees— Method B 224 9.9.1. Evidence Gathering 225 9.9.2. Timeline Development 226 9.3.3. Scenario Determination 226 9.9.4. Causal Factors 226 9.9.5. Predefined Tree 227 9.10. Causal Factor Identification 228 Contents ix 9.10.1. Identifying Causal Factors 228 9.10.2. Barrier Analysis 230 9.10.3. Change Analysis 231 9.10.4. Quality Assurance 232 9.10.5. Causal Factor Summary 233 9.11. Predefined Trees 233 9.11.1. Background—MORT 234 9.11.2. Using Predefined Trees 235 9.11.3. Example—Environmental Incident 237 9.11.4. Quality Assurance 244 9.11.5. Predefined Tree Summary 245 9.12. Checklists 245 9.12.1. Use of Checklists 246 9.12.2. Checklist Summary 246 9.13. Human Factors Applications 247 9.14. Conclusion 247 Endnotes 248 10 Developing Effective Recommendations 251 10.1. Major Issues 251 10.2. Developing Effective Recommendations 253 10.2.1. Team Responsibilities 253 10.2.2. Attributes of Good Recommendations 253 10.3. Types of Recommendations 255 10.3.1. Inherent Safety 255 10.3.2. Hierarchies and Layers of Recommendations 256 10.3.3. Commendation /Disciplinary Action 259 10.3.4. The “No-Action” Recommendation 259 10.3.5. The IncompletelyWorded Recommendation 259 10.4. The Recommendation Process 260 10.4.1. Select One Cause 260 10.4.2. Develop and Examine Preventive Actions 260 10.4.3. Perform a Completeness Test 262 10.4.4. Establish Criteria to Resume Operations 262 10.4.5. Prepare to Present Recommendations 263 10.4.6. Review Recommendations with Management 264 10.5. Reports and Communications 264 Endnotes 265 x Guidelines for Investigating Chemical Process Incidents 11 Communication Issues and Preparing the Final Report 267 11.1. Interim Reports 267 11.2. Writing the Formal Report 269 11.2.1. General Guidance 269 11.3. Sample Report Format 272 11.3.1. Executive Summary 272 11.3.2. Introduction 273 11.3.3. Background 274 11.3.4. Sequence of Events and Description of the Incident 274 11.3.5. Evidence and Cause Analysis 275 11.3.6. Findings and Recommendations 275 11.3.7. Noncontributory Factors 278 11.3.8. Attachments or Appendices 278 11.3.9. Criteria for Restart 279 11.4. Capturing Lessons Learned 279 11.4.1. Internal 279 11.4.2. External 283 11.5. Tools for Assessing Report Quality 286 11.5.1. Checklist 286 11.5.2. Avoiding CommonMistakes 286 Endnotes 288 12 Legal Issues and Considerations 289 12.1. Seeking Legal Guidance in Preparing Documentation 290 12.1.1. Use and Limits of Attorney–Client Privilege 290 12.1.2. Recording the Facts 291 12.2. The Importance of Document Management 292 12.3. Communications and Credibility 293 12.4. The Challenges and Rewards of Sharing New Knowledge 294 12.5. Employee Interviews and Personal Liability Concerns 295 12.6. Gathering and Preserving Evidence 297 12.7. Inspection and Investigation by Regulatory and Other Agencies 298 12.8. Legal Issues Related To “Postinvestigation” 300 12.9. Summary 302 Endnotes 303 Contents xi 13 Implementing the Team’s Recommendations 305 13.1. Three Major Concepts 306 13.2. What Happens When There Is Inadequate Follow-up? 307 13.2.1. Nuclear Plant Incident 307 13.2.2. Aircraft Incident 308 13.2.3. Petrochemical Plant Incident 308 13.2.4. Challenger Space Shuttle Incident 308 13.2.5. Typical Plant Incidents 309 13.3. Management System Considerations for Follow-up 309 13.3.1. Understanding Responsibilities 310 13.3.2. Formally Accepting Recommendations 311 13.3.3. Assigning a Responsible Individual 312 13.3.4. Determining Action Item Priority 312 13.3.5. Implementing the Action Items 312 13.3.6. Documenting Recommendation Decisions— the Audit Trail 314 13.3.7. Tracking Action Items 314 13.3.8. Revising the Incident InvestigationManagement System 315 13.4. Sharing Lessons Learned 316 13.4.1. Performing the Follow-Up Audit 316 13.4.2. Internal Sharing 316 13.4.3. External Sharing 318 13.5. Analyzing Incident Trends 320 Endnotes 321 14 Continuous Improvement for the Incident Investigation System 323 14.1. Regulatory Compliance Review 324 14.2. Investigation Quality Assessment 325 14.3. Recommendations Review 326 14.4. Potential Optimization Options 326 14.4.1. Follow Up 326 14.4.2. Causal Category Analysis 326 Endnotes 331 xii Guidelines for Investigating Chemical Process Incidents 15 Lessons Learned 333 15.1. Learning Lessons from Within Your Organization 333 15.2. Learning Lessons from Others 334 15.3. Cross-Industry Lessons 335 15.4. Trends and Statistics 337 15.5. Management Application 337 15.6. Case Studies 337 15.6.1. Esso Longford Gas Plant Explosion 338 15.6.2. Union Carbide Bhopal Toxic Gas Release 340 15.6.3. NASA Challenger Space Shuttle Disaster 342 15.6.4. Tosco Avon Oil Refinery Fire 343 15.6.5. Shell Deer Park Olefins Plant Explosion 345 15.6.6. Texas Utilities Concrete Stack Collapse 346 15.6.7. ThreeMile Island Nuclear Accident 349 15.6.8. Concorde Air Crash 350 15.7. Sharing Lessons Learned 351 References 353 Appendix A Relevant Organizations 355 Appendix B Professional Assistance Directory 359 Appendix C Photography Guidelines for Maximum Results 361 Appendix D Example Case Study—Fictitious NDF Company Incident 365 Appendix E Example Case Study—More Bang for the Buck: Getting the Most from Accident Investigations 395 Contents xiii Appendix F Selected OSHA and EPA Incident Investigation Regulations 415 Appendix G Quick Checklist for Investigators 419 Appendix H Additional Resources 425 Appendix I Contents of CD-ROM 431 Glossary 433 Index 443