(67b) Systematic Analysis and Learning from Process Safety Incidents

Numerous incidents have occurred in the process industries and caused hundreds of fatalities and injuries. The US Chemical Safety Board (CSB) has conducted incident investigations as one element of the Process Safety Management (PSM) program and provided final reports for over 75 incidents. This paper is to look into all those final reports and summarize the findings. The type of accidents is identified as vapor explosion, dust explosion, reactive chemical explosion, and toxic chemical release. The main type of accidents is found to be vapor explosion that resulted in about 40% of all the types of accidents. Through the comprehensive analysis of PSM violations, the results show that mechanical integrity, process safety information, and process hazard analysis are the top three types of violations while about 20% of the PSM violations are due to mechanical integrity. The results also show that about 80% of these incidents are somehow due to human error. Detailed human error analysis for all these incidents is performed and the results show that lack of training is the main contribution to incidents. Recommendations are given to each type of incident that occurred based on the analysis results. This research is supported by the National Science Foundation (NSF) through OK-LSAMP to develop learning from incidents and therefore to improve process safety.