Safety and Loss Prevention

E-Book: Learning Lessons from Major Incidents

E-Book: Learning Lessons from Major Incidents

1st June 2022

Excellence in process safety performance is no accident. It requires competence, diligence and good communication across multiple disciplines. If personnel at an operating plant are not aware of the hazards present in commissioning, startup, operation, maintenance, shutdown and decommissioning of their plant, they cannot be expected to manage those risks by ensuring appropriate safeguards are provided. If an accident happens in your plant or in a similar plant at a different location, it should be thoroughly investigated to ensure the underlying technical and organisational root causes are understood and appropriate corrective action is taken. Everyone associated with operating and maintaining a plant has a part to play in ensuring its integrity and taking responsibility for their own and their colleagues’ safety, regardless of their role or seniority within the organisation.

The IChemE Safety and Loss Prevention Special Interest Group has compiled a series of 52 one-page summaries of major incidents from a variety of process industry sectors into a free-to-download e-book. The purpose of the book is to raise awareness of these incidents, to explain what happened and to share key root causes and lessons learned for each incident. The 1-page format enables the information to be easily shared not just with process safety professionals, but with colleagues at all levels in an organisation from plant technicians and engineers to line management and senior executives. The summaries can be used as handouts in university classrooms, posters in plant offices and control rooms, attachments to process hazard analysis or business case documentation to help justify investment in process safety improvement initiatives etc.  We hope you find it useful.

The book is available here.  Note that this file uses internal links for navigation and also contains links to publicly-available incident investigation reports for those looking for more detailed information.


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