Lessons

In part, continuous improvement can be achieved by learning and recording the lessons from those who have done similar work in the past. Note that many are repeats of previous lessons. They are listed because of their significance and the need not to repeat any correctible shortcomings of the past. Such lessons from process hazard analysis activities are  

The PSM rule tends to ensure that sites are operated in a safe manner by imposing a set of rules that may be interpreted as burdensome. Even properly implemented, the rules do not guarantee an accident-free site. Nevertheless, in order not have to comply with the burdensome rule, some owners divide the quantity of chemicals that would normally trigger compliance with the rule into amounts under the threshold quantity. As an example, the threshold 

Proper implementation of process safety requirements is key to safety assurance at covered process sites. In this chapter we attempted to identify actions prior to and during the implementation of the PSM and RMP process safety programs. Specific actions for each of the 14 PSM elements were highlighted as well as a section on RMP implementation. Finally, a section on lessons learned and information regarding implementation evasion was presented. 

Prior to undertaking the details of process safety implementation what actions are needed  

Name five recognized organizations that promulgate standards for design. 

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Successful companies use military strategy to win. Barrie James shows how - and draws some vital lessons for today s manager. 

Japanese industrial success owes much to Japanese management techniques, which we in the West neglect at our peril. The lessons are set out in this important book. 

It is good practice to reviewa project on completion and record the reasons for departure between planned and actual performance. Where lessons can be learned, or opportunities exploited, they should be incorporated into project management guidelines. Some companies hold post project sessions with their contractors to explore better ways of handling particular issues, especially when there is an expectation of additional shared activities. 

R. A. Murgatroyd, G.M. Worrall, und S. Crutzen Lessons leamt from the RISC 111 study of the influence of human factors on inspection reliability. 6 European Conference on Nondestructive Te.sting, Nice. 1994, Vol. 2, p 989-993... 

A new approach of partnership between client and inspection service organisations has been established primarily for the North Sea but increasingly finding application elsewhere Benefits accrue to all parties and the technical and commercial lessons learnt in the process have relevance to a wide range of other industries. 

The take-home lesson is that the vast majority of high-pressure studies are on solids or other rigid media and are not done under hydrostatic conditions. The stresses and stress-related properties may vary throughout the sample. Unless the probes are very local and focus on a small region of the sample, measurements are averages over a range of, often uncharacterized, conditions. 

Brenner S E, C Chothia and T ] P Hubbard 1997. Population Statistics of Protein Structures Lessons from Structural Classifications. Current Opinion in Structural Biology 7 369-376. 

Niels Bohr was frequently quoted to have said, you must be prepared for a surprise, but at the same time you must also understand what your findings mean and what they can be used for. To me, this is the lesson of the norbornyl ion controversy. I strongly believe it was not a waste of effort to pursue it, and eventually it greatly helped to advance chemistry to new areas of significance that are still emerging. 

The NFS shear successfully processed irradiated LWR fuel between 1966 and 1972. Among the lessons learned were that the chute that channeled sheared fuel pieces to the dissolver basket was susceptible to bridging, the gag drives required a disproportionate amount of maintenance, and insufficient throat clearance led to jamming of chopped fuel. 

R. T. Jenkyn and D. J. Goodwih, "Silo Failures Lessons to be Learned," Eng. Digest (Sept. 1987). 

After the incident, an investigation team determined that the first operator had not added the initiator when required earlier in the process. When the relief operator added the initiator, the entire monomer mass was in the reactor and the reaction was too energetic for the cooling system to handle. Errors by both operators contributed to the runaway. Both operators were performing many tasks. The initiator should have been added much earlier in the process when much smaller quantities of monomer were present. There was also no procedure to require supervision review if residual monomers were detected. The lesson learned was that operators need thorough training and need to be made aware of significant hazardous scenarios that could develop. 

Drogaris, G. 1993. Major Accident Reporting System Lessons Learned from Accidents Notified. Elesevier Science Publishers,B.V., Amsterdam. 

The main lessons learned from the workshop were (with some 5-year old... 

Phase 3 - Implementation. This phase is often called the post-experimental stage. It is about acting on the results and communicating the lessons learnt. Some points on the process are given below ... 

Communicate lessons learnt through the business and included in training programmes. 

Nicholson, C. E., Heyes, P. F. and Wilson, C. 1993 Common Lessons to be Learned from the Investigations of Failures in a Broad Range of Industries. In Rossmanith, H. P. (ed.). Structural Eailure, Product Liability and Technical Insurance. Elsevier. 

The simple lesson to be learnt from these experiments is that critical amino acid residues can have pleiotropic roles in determining a protein s structure and therefore its function. 

Important novel information has thus been obtained for the specific biological function of those molecules, but disappointingly few general lessons have been learned that are relevant for other membrane-bound proteins with different biological functions. In that respect the situation is similar to the failure of the structure of myoglobin to provide general principles for the construction of soluble protein molecules as described in Chapter 2. 

The most important general lesson is that there are hydrophobic transmembrane helices, the positions of which within the amino acid sequence can be predicted with reasonable accuracy. This applies both to the single transmembrane-spanning helix within the H polypeptide chain of the reaction center and the five transmembrane helices of the L and M chains that... 

Cowan, S.W. Bacterial porins lessons from three high-resolution structures. Curr. Opin. Struct. Biol. 

The sequence just outlined provides a salutary lesson in the nature of explanation in materials science. At first the process was a pure mystery. Then the relationship to the shape of the solid-solubility curve was uncovered that was a partial explanation. Next it was found that the microstructural process that leads to age-hardening involves a succession of intermediate phases, none of them in equilibrium (a very common situation in materials science as we now know). An understanding of how these intermediate phases interact with dislocations was a further stage in explanation. Then came an nnderstanding of the shape of the GP zones (planar in some alloys, globniar in others). Next, the kinetics of the hardening needed to be... 

A close study of the chronology of this episode teaches another lesson. The early observation on irradiation-induced growth of uranium was purely phenomeno-... 

The evolution of superalloys has been splendidly mapped by an Ameriean metallurgist, Sims (1966, 1984), while the more restrieted tale of the British side of this development has been told by Pfeil (1963). I have analysed (Cahn 1973) some of the lessons to be drawn from the early stages of this story in the eontext of the methods of alloy design it really is an evolutionary tale... the survival of the fittest, over and over again. The present status of superalloy metallurgy is eoneisely presented by MeLean (1996). 

The key innovations in turning optical waveguides (fibres) into a successful commercial product were made by R.D. Maurer in the research laboratories of the Corning Glass Company in New York State. This company was also responsible for introducing another family of products, crystalline ceramics made from glass precursors - glass-ceramics. The story of this development carries many lessons for... 

Colloidal crystals . At the end of Section 2.1.4, there is a brief account of regular, crystal-like structures formed spontaneously by two differently sized populations of hard (polymeric) spheres, typically near 0.5 nm in diameter, depositing out of a colloidal solution. Binary superlattices of composition AB2 and ABn are found. Experiment has allowed phase diagrams to be constructed, showing the crystal structures formed for a fixed radius ratio of the two populations but for variable volume fractions in solution of the two populations, and a computer simulation (Eldridge et al. 1995) has been used to examine how nearly theory and experiment match up. The agreement is not bad, but there are some unexpected differences from which lessons were learned. 

The lesson in these figures is that the qualitative concepts of chemical structures can be given a pictorial representation based on the quantitative application of the principles of quantum chemistry. Various, indeed all, molecular properties can, in principle, be calculated from the electronic distribution these pictures represent. 

Kletz, T.A. (1993) Lessons from Disasters How Organisations Have No Memory and Accidents Recur, Institutional Chemical Engineers, Rugby. 

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