This book provides a comprehensive treatment of investing chemical processing incidents. It presents on-the-job information, techniques, and examples that support successful investigations. Issues related to identification and classification of incidents (including near misses), notifications and initial response, assignment of an investigation team, preservation and control of an incident scene, collecting and documenting evidence, interviewing witnesses, determining what happened, identifying root causes, developing recommendations, effectively implementing recommendation, communicating…mehr
This book provides a comprehensive treatment of investing chemical processing incidents. It presents on-the-job information, techniques, and examples that support successful investigations. Issues related to identification and classification of incidents (including near misses), notifications and initial response, assignment of an investigation team, preservation and control of an incident scene, collecting and documenting evidence, interviewing witnesses, determining what happened, identifying root causes, developing recommendations, effectively implementing recommendation, communicating investigation findings, and improving the investigation process are addressed in the third edition. While the focus of the book is investigating process safety incidents the methodologies, tools, and techniques described can also be applied when investigating other types of events such as reliability, quality, occupational health, and safety incidents.Hinweis: Dieser Artikel kann nur an eine deutsche Lieferadresse ausgeliefert werden.
The Center for Chemical Process Safety (CCPS) was founded in 1985 to develop technology and management practices that mitigate or eliminate process safety incidents in the chemical and petrochemical industries. Since that time, CCPS has published more than 100 books and held dozens of international conferences, each representing the most advanced thinking in process safety. CCPS is supported by the contributions and voluntary participation of more than 200 companies globally. CCPS is also the world's largest provider of undergraduate engineering curriculum materials through its SAChE program, with more than 160 universities participating from around the world.
Inhaltsangabe
Preface xxv
Acknowledgments xxvii
Acronyms and Abbreviations xxix
1 Introduction 1
1.1 Building on the Past 1
1.2 Investigation Basics 2
1.2.1 The First Step 2
1.2.2 The Second Step 4
1.2.3 The Third Step 4
1.2.4 The Fourth step 4
1.2.5 The Fifth Step 5
1.2.6 The Sixth Step 5
1.3 Who Should Read This Book? 5
1.4 The Guideline's Objectives 6
1.5 The Guideline's Content and Organization 6
1.6 The Continuing Evolution of Incident Investigation 11
2 Overview of Chemical Process Incident Causation 13
2.1 Stages of a Process-Related Incident 14
2.1.1 Three Phase Model of Process-Related Incidents 14
2.1.2 Event Tree 14
2.1.3 Swiss Cheese Model 16
2.1.4 Importance of Latent Failures 17
2.2 Key Causation Concepts 18
2.2.1 Loss of Containment or Energy 18
2.2.2 Management System Failure 20
2.2.3 Human Factors 21
2.2.4 Multiple Causation 22
2.2.5 Events vs Root Causes 22
2.2.6 Controlling Risk 23
2.3 Summary 24
3 An Overview of Investigation Methodologies 26
3.1 History of Investigation Methodologies and Tools 29
3.1.1 One-on-One Interview 29
3.1.2 Brainstorming 29
3.1.3 What If Analysis 30
3.1.4 5-Whys 30
3.1.5 Process of Elimination 31
3.1.6 Timelines 31
3.1.7 Sequence Diagrams 31
3.1.8 Predefined Trees 33
3.2 Tools for Use in Preparation for Root Cause Analysis 34
3.2.1 Timelines 34
3.2.2 Sequence Diagrams 35
3.2.3 Scientific Method 35
3.2.4 Causal Factor Identification 36
3.3 Structured Root Cause Analysis Methodologies 37
3.3.1 Checklists 37
3.3.2 Predefined Trees 38
3.3.3 Team-Developed Logic Trees 39
3.4 Selecting an Appropriate Methodology 43
3.4.1 Methodologies Used by CCPS Members 46
4 Designing An Incident Investigation Management System 47
4.1 System Considerations 49
4.1.1 An Organization's Responsibilities 49
4.1.2 Workforce Responsibilities 51
4.1.3 Role of the Management System Developers 53
4.1.4 Integration with Other Functions and Teams 54
4.1.5 Involvement by Regulatory Agencies 55
4.2 Typical Management System Topics 58
4.2.1 Classifying Incidents 58
4.2.2 Specifying and Managing Documentation 59
4.2.3 Legal Considerations 60
4.2.4 Describing Team Organization and Functions 63
4.2.5 Electronic Process Data and Control Systems 64
4.2.6 Defining Training Requirements 65
4.2.7 Emphasizing Root Causes 69
4.2.8 Fostering a Blame-Free Policy 70
4.2.9 Developing Recommendations 70
4.2.10 Recommendation Responsibilities 71
4.2.11 Implementing the Recommendations and Follow-up Activities 72
4.2.12 Providing a Template for Formal Reports 73
4.2.13 Management System Review and Approval 73
4.2.14 Planning for Continuous Improvement 73
4.3 Management System 74
4.3.1 Initial Implementation-- Training 75
4.3.2 Developing a Specific Investigation Plan 75
5 Initial Notification, Classification and Investigation of Process Safety Incidents 79
