LEARNING FROM PROCESS SAFETY INCIDENTS

摘要

The process industry and the health and safety regulator both have a need to learn the lessons from process safety incidents. In the UK, the Health and Safety Laboratory is undertaking operational research and analysis of data from process industry incidents to inform the Health and Safety Executive's decision-making, prioritization and trend analysis. Sources of data are discussed. A preliminary incident analysis is provided: Process industry dangerous occurrences are reviewed for 2008 with explosive manufacturing having most incidents followed by oil refining. For a sample of 19 incidents from 2006 and 2007 direct causes, underlying causes, safety management failings and "mitigation against escalation" are all discussed. Inadequate isolation was the most prominent direct cause. Operating procedures and hazard analysis/risk assessment were significant underlying causes. Planning and implementation followed by organising/competence were significant safety management failings. Process stopped and none/unknown were the most frequent "mitigation against escalations". Ways to improve the HSE incident data recording system are identified.