Serious Incident Prevention: How to Sustain Accident-Free Operations in Your Plant or Company

1 The Improvement Challenge......Page 14
1.1 Serious Incidents of the Past......Page 16
1.2 References......Page 31
2 The Barriers to Improvement......Page 34
2.2 Limited Employee Involvement......Page 35
2.3 Inadequate Measurement and Feedback......Page 36
2.4 Inadequate Recognition......Page 37
2.6 Limited Personal Experience......Page 38
2.7 Misguided Optimism......Page 39
2.8 Overcoming the Barriers......Page 40
2.9 References......Page 41
3 A Proven Process Improvement Model......Page 42
3.1 Process Model For Serious Incident Prevention......Page 45
3.2 References......Page 49
4 Management Commitment and Leadership......Page 50
4.1 Achieving and Sustaining Effective Leadership......Page 53
4.2 Achieving a Common Focus......Page 55
4.4 Knowledge of Results......Page 56
4.6 Decisions Consistent with Objectives......Page 57
4.7 Commitment and Leadership - Closing Thoughts......Page 59
4.8 References......Page 60
5 Employee Involvement......Page 61
5.1 Synergy......Page 63
5.2 Prison Break Exercise......Page 65
5.3 Teamwork......Page 66
5.3 An OSHA Perspective on Employee Participation......Page 67
5.4 Leveraging the Power of Employee Involvement......Page 68
5.5 References......Page 72
6.1 Employee Involvement on Teams......Page 73
6.2 Effective Teamwork Techniques......Page 74
6.3 References......Page 80
7 Understanding the Risks......Page 81
7.1 Do Managers Understand the Risks?......Page 82
7.2 Small Boat Operation: An Illustration of Risks......Page 84
7.3 Understanding More Complex Risks......Page 85
7.4 A Systematic Process of Risk Identification......Page 87
7.5 Understanding the Role of Human Error......Page 89
7.6 Classifying and Prioritizing Risks......Page 91
7.7 Understanding the Risks - A Prerequisite for Success......Page 94
7.8 References......Page 95
8.1 Managing Similar Risks with Varying Levels of Success......Page 96
8.2 Beyond Regulatory Compliance......Page 99
8.3 Identifying Critical Work......Page 100
8.4 Causal Factors for Serious Incidents......Page 101
8.5 Critical Work for a Tank Car Loading Operation......Page 102
8.6 Sustaining Performance......Page 104
8.7 A Systematic, Knowledge-Based Approach......Page 106
8.8 Process Safety Management Standard......Page 107
8.9 References......Page 108
9 Identifying the Critical Work - Management of Change......Page 109
9.1 Unplanned Changes......Page 110
9.2 Planned Changes......Page 112
9.3 Management of Change in the Serious Incident Prevention Process......Page 114
9.4 References......Page 115
10 Establishing Performance Standards......Page 116
10.1 Corporate/Company Standards......Page 118
10.2 Facility/Operating Level Standards......Page 119
10.3 Explicit and Implicit Standards......Page 121
10.4 Standards - A Prerequisite for Measurement, Feedback, and Accountability......Page 122
10.5 References......Page 123
11 Measurement and Feedback......Page 124
11.2 Performance Measurement for Critical Work......Page 126
11.3 Feedback and Its Linkage to Reinforcement......Page 133
11.4 Elevating the Visibility of Critical Work......Page 134
11.6 Measurement Systems......Page 135
11.7 Feedback Systems......Page 136
11.9 Safety Performance Indexing......Page 137
11.11 References......Page 138
12 Measurement and Feedback - Safety Performance Indexing......Page 139
12.1 Establishing a Safety Performance Index for Prevention of Serious Incidents......Page 140
12.2 References......Page 153
13.1 Reinforcement......Page 154
13.3 Addressing Causal Factors......Page 161
13.4 Responding to Red Flags......Page 162
13.5 References......Page 165
14 Improving and Updating the Process......Page 166
14.1 Shared Vision......Page 168
14.3 Employee Involvement......Page 169
14.4 Transforming Concepts to Actions......Page 170
14.5 References......Page 171
15.1 Management Commitment and Leadership......Page 172
15.2 Implementing Other Process Elements......Page 174
15.3 Chemical Handling Department Team......Page 175
15.4 Chemical Handling Department Pipeline Operations......Page 180
15.5 Chemical Handling Department: Tank Storage Operations......Page 191
15.6 Chemical Handling Department: Warehouse Operations Team......Page 192
15.7 Manufacturing Department - Serious Incident Prevention Processes......Page 195
15.8 HSE - Serious Incident Prevention Processes......Page 196
15.9 QMI Site Management Team: Serious Incident Prevention......Page 200
15.11 References......Page 202
16 Responding to the Challenge......Page 203
16.1 Keys for Successful Implementation......Page 205
16.2 Taking the Step Forward......Page 207
16.3 References......Page 208
Index......Page 210