Learning from Incidents - A Personal Journey over Decades of Manufacturing Hazardous Substances

摘要

The author spent 32 years primarily in the manufacturing of hazardous chemicals. These ranged from peroxides, ammonia, acids, ammonium nitrate and the full range of explosives and blasting accessories. The author was involved in several process safety incidents over this period. By using a selection of 6 of these the author will outline the nature of the incident, the causes and the lessons learnt at the time. The incidents to be described / analysed are: 1. A runaway exothermic reaction involving hydrogen peroxide (1970); 2. A dangerous start-up of a standby boiler feed pump for a waste heat boiler (1972); 3. The hazardous entry into a mist precipitator to remove a star-wire which had shorted out (1973); 4. Installation of an inline filter on an ammonium nitrate lien - unexpected explosion (1980); 5. Modification on a nitro glycerine separator leading to a major explosion with 8 fatalities (1982); 6. As Director, dealing with the aftermath of a major nitro glycerine explosion with 7 fatalities (1994). The author will put them into the context of the period and environment in which they occurred (pre- Process Safety). The incidents will then be reviewed in terms of the modern thinking and practices of good process safety. Appropriate actions with today's knowledge and practices will be tabled. Lessons learnt at the time and in the modern context will be drawn out. Hopefully, these will be of value to others. The period over which the incidents took place (late 60's to the end of the 90s) also saw the development of the fundamentals of process safety management although the terminology was loss prevention rather than process safety. The author will link the incidents to the state of play in process safety at the time. The author will illustrate the parallel between the development of process safety knowledge in industry to the growth in his personal development in the safety field. It will illustrate that both experience and continuous learning is required to understand process safety and be able to teach / influence others.