Events lessons learned

Sokol, S. L, Tsang, R, Aggarwal, V., Melamed, M. L., Srinivas, V. S. 2011. Vitamin D status and risk of cardiovascular events Lessons learned via systematic review and metaanalysis. Cardiol Rev, 19 192-201. 

A large portion of these common events can be linked to less than adequate follow-up of recommendations from previous incident investigations. The earlier investigation teams may have properly identified underlying root causes, submitted suggested preventive actions, and attempted to share results yet the repeat occurrences continue due to incomplete implementation of recommendations or ineffective sharing of lessons learned between potentially affected parties. 

One of the lessons learned is that validation is not cheap there is no way industry can gain assurance that a process will always be under control with just a single event. Validation, by definition, requires multiple events to fully deliver the confidence that the validated item will perform as expected. Equally important are the preliminary trials leading up to the validation activity. 

Prior to the mid-1980s the chemical industry experienced some upheavals of which the thalidomide tragedy of the early 1960s and the Bhopal catastrophe in 1984 are two major examples. However, the lessons learned from such sad events led to a spectacular improvement during the 1990s in the safety record of the industry in the Western world. 

The lessons learned from the Texas City Disaster event from health and safety viewpoint are ... 

The accidental contamination of chicken feed with dioxin contaminated fat in Europe shows how food exposure could occur. Because dioxin does not cause immediate symptoms, authorities did not discover the contamination for months in 1999, and Europeans probably consumed the dioxin in chicken meat and eggs sold that year. One lesson learned from this event is that physicians and public health officials need to recognize and report unusual or suspicious health problems in animals as well as humans (1). The 1999 West Nile virus epidemic in birds and humans in New York City reinforced this lesson. Fortunately, biological and chemical contamination of public water supplies will usually pose little risk due to dilution by the large volume of water. 

Where does all this little bit of history lead us It is certainly not just to say that some materials called "alumina" can catalyze the dehydration of ethanol to produce ethylene. It is to say that product distributions with the various dumina preparations were different, and changed in different ways as the time of operation increased. In the long run the lesson learned fi om this work was to recognize, however imperfectly that catalysts are materials, they undergo solid state transformations, they are subject to chemical attack fi om feed stream impurities, they suffer thermal stress, maybe they are susceptible to cancer - at any event, most of them eventually die. It s like a medical history why and how ... 

The paper reports some of the initiatives undertaken in the field of chemical accidents of industrial origin. The accent was on the necessity to share available information between countries about the occurrence of the events and lessons learned. It is recognized that there is still the need to improve the harmonization of reporting tools towards the homogenization of data collection. The issue of possible transboundary effects of chemical accidents has not been covered in this report. However, a number of reporting and alert systems have been established in Conventions signed by representatives of several countries in Europe and world-wide. 

Lessons-learned programs are not the only way of capturing deviant conditions and potential solutions. Accident and incident reports are useful in themselves even though many form the basis for lessons learned. They alert people to potential safety issues so that the same adverse event is not repeated inadvertently. Near-miss reporting systems can be even more proactive as they allow personnel to avoid potential events as well as actual events. 

Training. These events underscore the importance for chemical worker training to include hazard information and lessons learned from accidents, previous studies, and similar events involving the same chemicals and chemical work practices... 

Design of liquid metal cooled fast reactors (LMFRs) is still in evolution, and only a small number of LMFRs are in operation aroirnd the world. Specialists operating these LMFRs have gained valuable experience from incidents, failures, and other events that took plaee in the reactors. These unusual occurrences, lessons learned and measures to prevent recurrences are often either not reported in literature, or reported only briefly and without sufficient detail. Hence there is a need for specialists designing and operating LMFRs to share their knowledge on unusual occurrences. 

The management systems used to control these different types of risk have much in common. But they are not identical, particularly when it comes to the prevention of catastrophic events. One of the lessons learned from the Texas City refinery event of 2005 is that the management was not using the proper types of SMS. 

This example is loosely based on an actual event that occurred at a process facility. Fortunately, the incident did not result in a major loss, but it does provide some opportunities for lessons learned. 

Every company operates within an industrial community that creates and administers rules and regulations, and that also creates consensus standards written by organizations such as API, ASME, and IEEE. The lessons learned from industrial events— particularly large accidents—help that community improve those regulations and standards. 

Once the facts have been established and an understanding of the event has been established, a root cause analysis can be carried out in order to apply lessons learned to a broader set of circumstances. There are four types of root cause analysis ... 

Following the initial investigation, management wdl evaluate the seriousness of the incident and assess the potential it provides for lessons learned. Management must also decide as to how detailed the investigation should be. This means that a method for evaluating the seriousness of events—particularly near misses and potential incidents— has to be selected. 

Many people use stories to develop root causes by analogy. They examine incidents that have occurred elsewhere and develop lessons that can be used in the current situation. Indeed, many companies encourage the dissemination of incident stories in order to create a lessons learned culture, and some professional organizations publish information to do with incidents that can be used by other companies. For example, the journal Chemical Engineering Progress routinely publishes descriptions of actual events. 

The Process Safety Beacon is a regular news bulletin issued by the American Institute of Chemical Engineers in their Chemical Engineering Progress magazine. The Beacon reports on actual events show how they occurred and highlight lessons learned. 

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