Case Histories of Incidents

Previous sections of this book have emphasized that incidents occur due to (Section 1)  

They have also emphasized that, in order to minimize the likelihood of an incident occurring or to minimize the consequences, it is necessary to  

To indicate what can happen if appropriate procedures, as outlined above and described in more detail in the preceding sections of the book, are not followed, 1(X) brief case histories (with acknowledgement to HSE for the use of edited extracts from Reference 134) are presented below under headings which reflect the outline given above. 

The intention is to emphasize some of the main points made in the text by using examples of actual incidents, by way of illustration. It is not the intention to give blow-by-blow accounts of the incidents, but merely to draw out their principal features. 

Cross-references are given to appropriate sections and sub-sections of 

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Davie, F.M., etal., Case histories of incidents in heated bitumen storage tanks, J. Loss Prev. Process Ind., 7, No. 3, 217-221, 1994. 

Case histories of incidents can be interesting and informative, and a selection is given in Appendix 1. An unique case history is given in Appendix 6 which demonstrates that problems with mnaway exothermic reactions have been with us for some time. The interested reader is referred also to the UK Institution of Chemical Engineers Loss Prevention Bulletin in which, over the years, many accounts of incidents have appeared, and to the IChemE interactive training package. Control of Exothermic Reactions, developed in conjunction with the UK Health and Safety Executive (HSE) and including the HSE video Control of Exothermic Chemical Reactions, which includes some case histories. 

W. B. Howard, Case Histories of Two Incidents Following Process Safety Reviews, Proceedings of the Thirty-first Annual Loss Prevention Symposium, AIChE, New York, 1997. 

Appendices contain case histories of chemical reactivity incidents, a sample inherently safer process checklist, and the Executive Summary of the CSB hazard investigation report on "Improving Reactive Hazard Management (CSB 2002b). 

Case histories of chemical reactivity incidents, such as those in Appendix A-l, are useful in getting needed attention and priority for a chemical reactivity hazard management system. Other companies programs, such as the ones shared on the CD-ROM accompanying this publication, can be... 

Morrison 1, Sprague P. 1976. Kerosene pneumonia Its incidence in Perth and case history of a recent fatality. Australas Radiol 20(2) 118-121. 

Although most explosive incidents have involved mixtures of the chlorate with combustible materials, the exothermic decomposition of the chlorate to chloride and oxygen can accelerate to explosion if a sufficient quantity and powerful enough heating are involved. A case history of a fire-heated explosion of a store of 80 t of chlorate is given. The more stable sodium chlorate will also explode under similar... 

Here is another case history of a compressed air system that was modified to near disaster. Details of this incident are unavailable, but some years ago a chemical plant or refinery with multiple reciprocating air compressors and pneumatic instruments systems decided to modernize. The modernization project replaced the air supply system. Economics favored one large centrifugal air compressor, and no backup air supply was installed. 

What Went Wrong Case Histories of Process Plant Disasters examines the causes and aftermaths of numerous incidents that provide learning opportunities for those involved with chemical plants and refineries. Look for more information at Butterworth-Heinemann s website, http //www.bh.com/engineering. What Went Wrong Case Histories of Process Plant Disasters is published by Gulf Publishing, which is an imprint of Butterworth-Heinemann, and it sells for 60. 

The fundamentals of the occasionally destmctive, harsh nature of water, and steam within a chemical plant or petroleum refinery will be discussed and illustrated via case histories. Eight incidents will be reviewed. Five incidents resulted in bruised egos and property damages. One incident resulted in injuries. Sadly, two other incidents resulted in a total of seven deaths of chemical plant workers. 

Case histories of the twenty-first centuiy are focused on in this chapter and the next. However, case histories both past and present provide us with a timeless awareness resource. Incidents from the 1960s, 1970s, 1980s, and 1990s can be equally informative as tomorrow s incident when reviewing the technical causes. In all cases we must try to see the respect for or the lack of a positive safety culmre. 

Let s apply the concept of shared responsibility to an incident found earlier in Chapter 8. See A Furnace Temperature Safeguard is Altered, in Chapter 8, to see the entire incident and the six supporting photos. The case history first appeared in Monday Morning Quarterbacking Applying PSM Methods to Case Histories of Yesteryear [7]. ... 

NIDDM is a much more common disease than IDDM, accounting for about 85—90% of all cases of diabetes meUitus. Whereas NIDDM may be present at any age, the incidence increases dramatically with advanced age over 10% of the population reaching 70 years of age has NIDDM. Patients with NIDDM do not require insulin treatment to maintain life or prevent the spontaneous occurrence of diabetic ketoacidosis. Therefore, NIDDM is frequendy asymptomatic and unrecognized, and diagnosis requires screening for elevations in blood or urinary sugar. Most forms of NIDDM are associated with a family history of the disease, and NIDDM is commonly associated with and exacerbated by obesity. The causes of NIDDM are not well understood and there may be many molecular defects which lead to NIDDM. 

To determine which jobs you should analyze first, review your injury and illness reports such as the OSHA 200 log, your medical case histories, your first-aid cases, and workers compensation claims. First, you should conduct a JHA for jobs with the highest rates of disabling injuries and illnesses. Do not forget jobs in which you have had close calls or near hits. You should give these incidents a high priority. Analyses of new jobs and jobs in which changes have been made in processes and procedures should be the next priority. 

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