Lessons-learned information

F. Bellifemine, G. Caire, A. Poggi, G. Rimassa, JADE A software framework for developing multi-agent applications. Lessons learned. Information and Software Technology. 50 (2008) 10-21. 

Collect the necessary input documents and reference resources, including applicable codes, standards, and regulations, list of consultants, lessons learned information, examples of ETBAs on similar projects, other analyses and/or a PHL on this project, and other materials that may aid in the ETBA effort). List the types of energy associated with this project, which may include... 

Lessons learned provide valuable information for managing health and safety programs. This information addresses conditions to be avoided or recommended practices. Lessons learned typically have the potential for wide-ranging application. Effective identification of lessons learned requires an awareness of emerging practices, programs, and technologies related to hazardous waste activities [3]. 

The authors believe that although the following information is speeifie to superfund sites, the general findings are universal. As you review this information, you will notiee some areas of bold print. Within these bolded areas, the authors have added their own analysis, eomments, and lessons learned while performing field aetivities at sites of all sizes that deal with hazardous materials. 

An important lesson learned from the studies of naphtazarin [2], benzoylacetone [8] and nitromalonamide has been that the detailed structure of these types of compounds can only be reliably determined by introducing results of low-temperature neutron diffraction studies in the analysis of the low-temperature X-ray diffraction data. Furthermore it has been found that information about the bonding of the enol hydrogen can be extracted from the thermal parameters of the enol hydrogen. This underlines the importance of the neutron diffraction study in these cases. 

Information related to broader industry issues, newly recognized hazards, and lessons learned from near misses and actual incidents can also be shared with customers and users as part of product stewardship. Trade, professional, and other cooperative organizations such as universities and local emergency planning committees (LEPCs) can be effective vehicles for information sharing, in addition to individual company initiatives. 

It is difficult to identify causes and lessons learned in existing sources of process safety incident data because industry associations, government agencies, and academia generally do not collect this information. 

Only one publicly available database is designed to provide such information. The Accident Database from the Institution of Chemical Engineers (IChemE) contains lessons learned for one-fourth of the 12,000 incidents in the database. 

IChemE Accident Database Reports about chemical incidents around the world from official government sources, the news media, and company reports 1980-Present Scope is beyond incidents reported to or investigated by regulatory agencies or first responders Contains lessons learned from 3,000 incidents Only one-fourth of the 12,000 incidents in the database contain lessonsdeamed information... 

U.S. Fire Administration NFIRS Response data submitted by local fire departments 1980-Present Includes fire and explosion incidents with no/little release, incidents resulting in property damage only, and near-misses if fire department was called Limited state participation Represents limited information available to fire department at time of response Checklist approach limits respondent choices Not designed to be a lessons-learned database... 

Are reassessments of vulnerabilities made after incidents, and are lessons learned and other relevant information incorporated into security practices ... 

This chapter focuses on the value of critically analyzing incident information and discusses the benefits of using databases to evaluate lessons learned. The power of both internal databases and industry-wide incident databases can help organizations improve their performance in process safety and environmental responsibility. 

Historical incident recording and communicating in useful form has several beneficial results. This information suggests precautions for other facilities, allows lessons learned to be taken into account in future design, and helps identify trends not apparent from single incidents. Because... 

Sharing the information and lessons learned with other companies and organizations. 

Communicate lessons learned in a user-friendly method with enough information for the intended audience. Include what happened, why, and how it can be prevented. 

Include the knowledge from the lessons learned in training, orientation, process safety information, and written procedures for employees. 

A simple reminder or jogger that an operation is vulnerable or that an existing standard or practice is critical. The effectiveness of such a reminder depends on the background of the reader. For those with considerable technical and operations experience, lessons learned will drive a quest for more information. Ultimately, this... 

The following references provide information on techniques for sharing of lessons learned as well as additional information on some of the case studies that were highlighted in this chapter. Other significant incidents are also cross-referenced in some of these documents. It is important to recognize that some of these publications have heen written from a nontechnical perspective and may not have recognized the concepts or methods covered in this text. 

The following individuals and companies are acknowledged for their contributions Patrick Foley (Senior Environmental Engineer, U.S. EPA), for his input and permission to use information and data. EPA ECC Technical Team Members, for team participation and willingness to share lessons learned in Consent Decree implementation. 

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