Accidents in "normal" operation - Can you see them coming?

作者：Sonnemans P J M^*; Korvers P M W; Pasman H J

来源：Journal of Loss Prevention in the Process Industries, 2010, 23(2): 351-366.

DOI：10.1016/j.jlp.2010.01.001

• Process safety
• Risk
• Accident prevention
• Analysis protocol
• Precursor
• Resilient engineering

Despite the increased understanding of how accidents occur in the chemical process industry, today's safety measures and indicators do not prevent these accidents from occurring. Finding a way to better, proactively, identifying precursors to imminent safety risks, could help organizations to focus their limited resources. The protocol proposed and demonstrated in this paper shows a way to do this. Basis is to examine usually low consequence, high likelihood reoccurring disruptions or deviations in the process (e.g. defects, disturbances, anomalies) for their relevance to process safety and define those possibly leading to accidents as 'precursors'. As a next step ineffective supervising and managerial control processes and their underlying latent conditions, causing the persistence of these precursors, are identified and it was shown how these cause safety barriers to become ineffective and to open the way to accidents. In conclusion, this paper demonstrates that the proposed 7-stage protocol developed to this end can explicitly and proactively indicate safety risks, and find the controlling latent conditions causing the trouble. It will help organizations to direct their resources to improve safety, which will include their control structure and their normal way of working and will yield higher efficiency as a side benefit.

• 出版日期2010-3