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Catastrophic incidents, while common in the world, are rare events to any single facility or even company. Were anyone to count catastrophic incidents to measure Process Safety performance, it is likely the facility would be gone before they counted to two. We look instead to Near Miss incidents as one measure of Process Safety performance. We count them and measure their frequency. We implement corrective actions to prevent reoccurrence. We look beyond the specific incident to apply the lessons in other areas. Most importantly, we look for faults in our management systems that permitted the near miss to occur. Defining near misses, identifying their occurrence, and fully learning the lessons they can teach us can be a difficult undertaking. Simple communication of these incidents can be problematic. And, learning lessons from an incident occurring at another facility can challenge even the broadest-minded people. This article will describe the learning process that has evolved at one specialty chemical company. It will include definitions of specific types of near misses, how data are gathered and communicated, and information on the number and type of incidents occurring. The reader will gain ideas on how to classify and collect data on specific near miss incidents, and ways to communicate the information throughout a company. © 2015 American Institute of Chemical Engineers Process Saf Prog, 2015

The learning from operational incidents plays a key role in improving the performance and safety of the chemical process plants. In this article, the incidents occurred during January 2011 to April 2012 in different sections, that is, Ammonia, Urea, and Utility Units of fertilizer sector in Pakistan have been analyzed using Why Tree analysis. The aim is to identify the failures in the safety management system to prevent the incidents. One thousand and fifteen, root and contributing causes identified in investigations strongly assert that improvement in safety management systems could have prevented or mitigated the intensity of many of the occurred incidents/accidents. The flaws in mechanical integrity, maintenance procedures and operating procedures, and job risk assessment are the most common recurrent as root cause failures of safety management system. © 2014 American Institute of Chemical Engineers Process Saf Prog 33: 399–404, 2014

A key mission of the US Chemical Safety and Hazard Investigation Board (CSB) is to determine the root causes of incidents, report the findings, and issue recommendations to prevent similar incidents from occurring. CSB investigators respond to a variety of events occurring in a wide range of workplaces, from chemical plants and refineries to food-flavoring factories and steel mills. The details of each investigation are unique and the root causes are pertinent to each specific case. However, a common thread that emerges in CSB investigations is the inadequacy of management systems that might have prevented the incident from occurring. Examples of the systemic issues identified in CSB reports are: Lack of hazard review to predict and prevent incidents Insufficient investigation and follow-up after previous incidents Inadequate training of staff Failure to implement effective mechanical integrity programs These issues are well recognized as elements of a process safety management (PSM) program, although many incidents investigated by the CSB occurred at facilities that are not regulated by OSHA's process safety management rule.1 Indeed, a number of these incidents occurred at facilities that are well outside society's definition of “chemical plants.” Please note that the opinions and conclusions expressed in this paper are those of the author, and do not necessarily represent the opinions of the Chemical Safety and Hazard Investigation Board. © 2004 American Institute of Chemical Engineers Process Saf Prog, 2004

In the course of chemical process and plant design, engineers identify potential hazardous incidents. These potential incidents may be identified through special hazard analysis reviews and procedures, or by the design team in the course of design activities. To manage and control those hazards, the team will modify the initial design, often by adding on additional protective devices and systems—alarms, interlocks or active protective systems. However, any change in a system, even a change intended to prevent or mitigate a potential hazardous incident, also has the potential to introduce new hazards, or new mechanisms by which existing hazards can result in an incident. A number of case studies illustrating this point are reviewed. The examples illustrate the importance of a management of change program, which must consider all changes including the addition of safety devices and systems, and which must throughly consider all potential effects on the system.

This paper presents some case histories of power-and control-based process safety incidents and near misses involving the Procter & Gamble Company and its affiliates. A key part of our Process Safety Program is to learn from the incidents that we and others experience. Incidents in our facilities are investigated for basic cause, and the learnings are shared with other plants. In some cases it is necessary to change our design practices and standards. We believe that thorough incident investigation is a major tool in our continuous improvement efforts. Each of these events had the potential to cause serious personnel injury and/or major production losses. Fortunately, these incidents did not produce any reportable personnel injuries. We are sharing these case histories of process safety incidents and near misses here so others can learn from them. The six incidents reviewed in this paper all resulted from the failure of a power or control system. We will review what happened, what we learned, and make recommendations to avoid future incidents like them. We hope that this will help avoid similar, possibly more serious, incidents in other facilities.