COMMONLESSONSLEARNEDFROMANANALYSISOFMULTIPLECASEHISTORIESXiaoleYang,LinhDinh,DianaCastellanos,CarmenOsorio,DedyNgandM.SamMannanMaryKayO’ConnorProcessSafetyCenter,ArtieMcFerrinDepartmentofChemicalEngineering,TexasA&MUniversitySystem,CollegeStation,Texas77843-3122,USA;Tel:(979)862-3985,e-mail:mannan@tamu.eduInrecentyearstherehasbeenincreasedemphasisonprocesssafetyasaresultofmajorchemicalincidentsinvolvinggasreleases,majorexplosions,andenvironmentalincidents.Topreventtherecurrenceofincidents,theapplicationofmostadvancedtechnologiesisstronglyurgedforoptim-izationofdesigns,operations,managements,controls,andemergencyresponse.Ontheotherhand,spendingsometimetofixoureyesonthehistoricalcatastrophesofindustrialprocessesisextre-melynecessaryforprocesssafetyimprovement.Whileeachcasehistorypresentsanimportantfoundationforunderstanding,identifying,andeliminatingrootcauses,inordertopreventrecurrenceoftheseincidentsthereisaneedtoidentifythecommonlessonslearned.Rootcausesareusuallydeficienciesinsafetymanagementsystems,butcanbeanyfactorthatwouldhavepreventedtheincidentifthatfactorhadnotoccurred.Inthispaper,multiplecasehistorieswereanalyzedtounderstandthecommonsimilaritiesbetweenprocessincidents.Theobjectiveofthispaperistofocusonlearningsomecommonlessonsfromthehistoricalincidentsinordertopreventrecurrencesofsimilarincidents.INTRODUCTIONRecentadvancesinscienceandtechnologyhaverevolu-tionizedthechemicalproductioninprocessindustry.Consequently,ithasalsogeneratedarapidgrowthoftech-nologicalrisks,whichhasbeenassociatedwithchemicalincidentsinthepastdecade.Chemicalincidentsmayresultinfire,explosions,andreleasesofhazardousmaterials.Theseincidentscouldpossiblyoccurduringpro-duction,handling,storage,andtransportationofchemicalandpetrochemicalproducts.Reportsofhazardousmaterialsspillsandreleaseshavebecomeincreasinglycommonplaceinrecentyears.InMexicoCity(1984)incident,aseriesofexplosionsintheLPGterminalresultedin500fatalitiesanddestructionofthewholefacilityandsurroundingresidentialarea(Pietersen,1988).InwhatisconsideredtheworstindustrialdisasterinBhopal(1984),thetoxicgaswasreleasedbecauseoftheintroductionofwaterinthestoragetankcontainingmethylisocyanate(MIC)andresultedin4,000fatalities(Joseph,2005).Asaresultofmajorincidentsatrefineriesandchemicalplants,manylegislationsandregulationshavebeencreatedtoeliminateorminimizethepotentialforsuchevents.Forinstance,theOccupationalSafetyandHealthAdministration(OSHA)published“thePSMrule,”entitledProcessSafetyManagementofHighlyHazardousChemicals,ExplosiveandBlastingAgents,whichbecamepartofOSHA’sregulationsas29CFRPart1910.119(OSHA,2008).TheEnvironmentalProtec-tionAgency(EPA)requiredtheimplementationofRiskManagementProgramregulations(40CFRPart68)intheindustriesinordertopreventmajorchemicalincidentsthatcouldharmworkers,thepublic,andtheenvironment(CFR,1996).TheAmericanInstituteofChemicalEngin-eersformedaseparatebranch–theCenterforChemicalProcessSafety(CCPS)todisseminateprocesssafetyresources,informationandguidelinesforsaferprocessdesign.AnotherentitycreatedundertheCleanAirActAmendmentsof1990istheChemicalSafetyandHazardInvestigationBoard(CSB),anindependentUSfederalagencychargedwithinvestigatingindustrialchemicalinci-dents.Allthesetypeofentitieshavegeneratedsignificantreductionofincidents;accordingtotheUSOccupationalSafetyandHealthAdministration,since1992onsitefata...
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