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PT Notes

Causes of Process Safety Incidents

PT Notes is a series of topical technical notes on process safety provided periodically by Primatech for your benefit. Please feel free to provide feedback.

Important insights can be obtained by analyzing a large set of process safety incidents. Trends and commonalities are illuminated and learning opportunities are provided that go beyond what can be learned from the causes of any one individual incident. Such an analysis is important because major incidents continue to occur despite the widespread adoption of process safety practices. Knowledge of the omissions and deficiencies in process safety programs that have actually resulted in process safety incidents is essential to help prevent further incidents.

A recent study analyzed 68 incidents that have been investigated by the Chemical Safety Board (CSB). About 40% of the incidents occurred in processes covered by the Occupational Safety and Health Administration’s (OSHA’s) process safety management (PSM) regulations. A detailed statistical analysis was performed on the contributing causes for all 68 incidents.

The top issues were with abnormal / non-routine work, process safeguards, stationary source siting, and procedures. Issues with standards and practices compliance, maintenance, process changes, previous incidents, and emergency preparedness and response came next. They were followed by issues with design, standards, compliance with regulations, normalization of deviance, facility siting, and audits. The lowest percentage of incidents for any of the issues was 13% and the highest was 64%. This is poor process safety performance. Time trend analysis indicates that the trend is for virtually all issues to continue.

Most incidents involved multiple issues. There was an average of 5 issues per incident and as many as 13. It is likely that the underlying reason for multiple issues being present for the majority of incidents is a systemic problem with process safety management systems. Details of the analysis are contained in the recent article:

Insights into process safety incidents from an analysis of CSB investigations, Journal of Loss Prevention in the Process Industries, DOI: 10.1016/j.jlp.2016.07.002.

The article can be accessed for free on ScienceDirect until November 1, 2016 by clicking on the link below. No sign up or registration is needed.


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