How we can learn important safety lessons from success as well as failure
COMPARE these headlines for two articles on the current pandemic: COVID-19 a ‘failure of early warning’ for Canada, intelligence expert says,1 and As governments fumbled their coronavirus response, these four got it right. Here’s how.2 Which article would you prefer to read first? Perhaps your decision would be based on what best motivates you to learn – stories about failure, or stories about success.
Process safety researchers and practitioners often find themselves living in a world of things that have gone wrong: designs, components, equipment, and procedures that have failed. At no point in my career was this clearer to me than when I was completing the sixth edition of What Went Wrong? Case Histories of Process Plant Disasters and How They Could Have Been Avoided.3 After more than a year of working on the classic treatment by Trevor Kletz, I could not help but wonder if anything ever went right in our quest to keep hazardous materials contained and thus prevent process fires, explosions, and toxic releases. The answer, of course, is a resounding yes.4,5 The fact remains, though, that one of our key tools for reducing process risk is to study incident case histories and learn lessons that enable us to avoid having things go wrong in our own plant.
So why do there seem to be more reports of process failure than success in the research, conference, and trade literature? Perhaps because it’s true that failure is a better teacher than success; that learning from past failure will more effectively lead to future success.6 Or perhaps because advances in process safety occur largely through after-the-fact changes brought about by major accidents.7 Maybe because of the view that if nothing bad happens, it is because there are no hazards, and if there are no hazards, then there is no need to take preventive measures.7 I also wonder if a story without tragic loss is seen as not being compelling enough to adequately convey a meaningful process safety lesson.
Regardless of the reasons for studying failure, there remains a need to learn from success in taking proactive process safety measures. There also remains a need to incorporate these lessons into our hazard analyses, risk assessments, and incident investigations. Major loss-producing events rightfully give us pause to consider whether our current techniques are adequate for today’s processing demands being made on aging process plants. (Who involved in the production of fertiliser-grade ammonium nitrate is not reviewing their inventory sizes, storage arrangements, and safety procedures following the devastating explosion in Beirut?) On the other hand, Clay’s analysis published in the Loss Prevention Bulletin8 shows that hazard identification methods practised in the process industries can have significant crossover value for the power generation industry. He writes (with bold added for emphasis):8 Intelligent use of these techniques, appropriately selected and competently executed, may help power engineers to deploy exciting new power technologies safely and efficiently. A recent partnership between the IChemE Safety Centre (ISC) and the Mary Kay O’Connor Process Safety Center, Process Safety for the 21st Century and Beyond,9 has identified competency as a key process safety challenge for academia, regulators, industry, and society. The ISC subsequently published a competency guidance document10 – essentially a roadmap for process safety success. Proficiency in identifying opportunities and assessing costs/benefits for implementing risk reduction controls10 would clearly necessitate an examination of how often those controls are successful in achieving their intended function. Likewise, studying success as well as failure would seem critical in developing an understanding of the hierarchy of controls and how control effectiveness is measured.10
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