Incident Causes

Listed below are safety practices aimed at minimizing the incidents caused by process chemistry issues. 

Other incidents caused by the sudden vaporization of water are described in Sections 12.2 and 12.4.5. 

Detailed methods for incident analysis are described in Chapter 6. The methods described in this chapter provide the basis for a psychological analysis of incident causes. 

Incidents causing shutdown. This group covers (a) Incidents where shutdown has occurred at some stage, either from damage repair or in anticipation of damage occurring, and (b) incidents where serious damage has occurred. 

Incidents causing immediate shutdown, (a) This group covers all incidents where any discharge from a pipe occurred. (b) Faults in pipe laying which were not immediately found and repaired, are included. 

Peng MM. Jick H A population-based study of the incidence, cause, and severity of anaphylaxis in the United Kingdom. Arch Intern Med 2004 164 317-319. Bohlke K, Davis RL, DeStefano F. et al Vaccine Safety Datalink Team. Epidemiology of anaphylaxis among children and adolescents enrolled in a health maintenance organization. J Allergy Clin Immunol 2004 113 536-542. 

Record accident/incident causes and corrective actions and other operating experience for future guidance... 

OSHA IMIS Records of workplace inspections, including those prompted by accidents where a worker is injured 1984-Present Information from OSHA field inspections, a third party More accurate description of impacts on employees and contractors Keyword indexing allows for easy search and retrieval Not comprehensive, limited to incidents selected by OSHA Inspections without abstracts cannot be keyword searched causal information unavailable Designed to assist compliance enforcement, not to report on incident causes Limited information from State-Plan states Not designed to be a lessons-leamed database... 

On July 9, 1976, in Meda, Italy, near Seveso, a chemical reactor incident caused a release of dioxin (TCDD), which is a highly toxic chemical. The regulatory requirements developed as a result of this incident are referred to as the Seveso Directive. 

As the result of a number of recent incidents caused by inappropriate handling of reactive chemicals, CCPS initiated a project in 2001 to develop additional management guidelines for reactive hazards. A CCPS technical steering committee documented the urgent need for... 

The four potential contributors to the incident causes in all three phases are ... 

Using structured approaches such as those presented in the preceding chapter, an investigation team identifies the multiple system-related incident causes. These approaches provide the mechanism for understanding the interaction and impact of management system deficiencies. When the investigators understand what happened, how it happened, and why it happened, they can develop recommendations to correct immediate, contributing, and root causes. 

In July 2002, the safety supervisor presented an overview of the incident, causes, and corrective actions to a safety meeting sponsored by the regional chemical industry council. 

Bottles of Tylenol , a common pain reliever, were found to contain sodium cyanide that had purposely been placed there. Seven deaths occurred in Chicago. The murderer has never been found. This incident caused stricter packaging guidelines for the pharmaceutical industry. Most drugs now are sealed into their containers with a plastic or metal wrapping that cannot be removed without it being noticed. 

Some cancers are caused by exposure to the sun or to naturally occurring radioactive isotopes. The estimated cancer incidence caused by these combined exposures is approximately 0.5 to 1.0 percent during a lifetime, with two-thirds of the exposure stemming from radon alone (Kocher and Hoffman 1991,1989 National Council on Radiation Protection and Measurement 1987,15,53 International Commission on Radiological Protection 1991, 188). 

The safety of the medication system is the primary concern of every hospital pharmacist. Recently published reports of the incidence, causes, and cost of injury resulting from medication errors have led many hospitals to critically evaluate their quality assurance systems (Bates et al., 1996, 1997 Classen et al., 1997 Kohn, Corrigan, and Donaldson, 1999 Leape et al., 1991, 1995 Poon et al., 2006 Stelfox, et al., 2006). Written incident reports were once the standard for gathering information about medication misadventures. This method is now believed to lack sufficient completeness and reliability for identifying weaknesses in a medication system (Classen et al., 1991 Cullen et al., 1995 Leape, 1994, 2002 Leape et al., 1995). 

Dowell, Art M. Ill and Dennis C. Hendershot, No Good Deed Goes Unpunished Case Studies of Incidents and Potential Incidents Caused by Protective Systems, Process Safety Progress 16, no. 3, Fall 1997 pp. 150-53. 

It just does not intuitively seem clear that if what appears as only bracket bolts are removed, the valve stem will be ejected by pressure within the piping. The proper procedure is very clear to me now, but I did not identify the problem at first. I have heard two other reports in the late 1970s or early 1980s within Louisiana of incidents caused by improper valve actuator removal complete with ejecting of the stem that did not result in as serious situations. 

The incident caused a flood of media coverage and a criminal investigation followed with the help of the local and Dutch Health Inspectorate. Thereafter, the prosecutor dismissed the case and held that the intoxication was caused by... 

Number of incidents caused by a lack of self-checking or peer-checking X ... 

Studies established to identify tlie incidence, causes, and comphcations of CKD have largely focused on advanced disease and Iddney failure. Data obtained from epidemiological surveys have been compromised by the lack of consistent surrogate markers of kidney function to identify established disease. For example, plasma creatinine, calculated creatinine clearance, and measured creatinine clearance have variously been used. The NKF-K/DOQI - has published a definition of CKD in an effort to identify its early stages. Early identification is essential so that adverse outcomes of CKD can be prevented or treated. CKD is... 

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