Connecting the Dots – Managing the Little Things That Lead to Big Accidents

摘要

Major accidents often result from a failure to attend to seemingly little details. Examples mightinclude an improperly designed injection point; a procedure that is mostly, but not completelyfollowed; a small part with the wrong metallurgy; or other design, maintenance or operatingdiscrepancies. In many cases, system flaws can exist for extended periods of time, detected orundetected, with little or no consequence. However, on occasion, and with the right initiatingevent, they can combine with other system flaws, allowing an unforeseen chain of events topropagate into a major accident.This paper will review aggregated information from a range of process safety incidents,including "subtle" accidents resulting from a series of "little" failures. It will highlight themanagement system breakdowns that contributed to the incidents, and examine the complexinteractions among people, process safety systems, and equipment as orchestrated by the overallorganizational culture. The paper will reinforce the concept that an effective process safetyculture is key to "connecting the dots" that, if unchecked, can result in a major accident.