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Guidelines for Investigating Chemical Process Incidents 2nd Edition [Kõva köide]

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  • Formaat: Hardback, 480 pages, kõrgus x laius x paksus: 236x166x31 mm, kaal: 812 g
  • Ilmumisaeg: 15-Mar-2003
  • Kirjastus: American Institute of Chemical Engineers
  • ISBN-10: 0816908974
  • ISBN-13: 9780816908974
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Guidelines for Investigating Chemical Process Incidents 2nd EditionSuurem pilt
  • Formaat: Hardback, 480 pages, kõrgus x laius x paksus: 236x166x31 mm, kaal: 812 g
  • Ilmumisaeg: 15-Mar-2003
  • Kirjastus: American Institute of Chemical Engineers
  • ISBN-10: 0816908974
  • ISBN-13: 9780816908974
Teised raamatud teemal:
Püsilink: https://www.kriso.ee/db/9780816908974.html
This book provides a valuable reference tool for technical and management personnel who lead or are a part of incident investigation teams. This second edition focuses on investigating process-related incidents with real or potential catastrophic consequences. It presents on-the-job information, techniques, and examples that support successful investigations. The methodologies, tools, and techniques described in this book can also be applied when investigating other types of events such as reliability, quality, occupational health, and safety incidents. The accompanying CD-ROM contains the text of the book for portability as well as additional supporting tools for on-site reference and trouble shooting.
Preface xv
Acknowledgments xvii
1 Introduction
1(8)
1.1. Building on the Past
1(3)
1.2. Who Should Read This Book?
4(1)
1.3. The Guideline's Objectives
4(4)
1.4. The Continuing Evolution of Incident Investigation
8(1)
2 Designing an Incident Investigation Management System
9(24)
2.1. Preplanning Considerations
10(7)
2.1.1. An Organization's Responsibilities
10(4)
2.1.2. The Benefits of Management's Commitment
14(1)
2.1.3. The Role of the Developers
15(1)
2.1.4. Integration with Other Functions and Teams
15(1)
2.1.5. Regulatory and Legal Issues
16(1)
2.2. Typical Management System Topics
17(10)
2.2.1. Classifying Incidents
17(2)
2.2.2. Other Options for Establishing Classification Criteria
19(1)
2.2.3. Specifying Documentation
20(1)
2.2.4. Describing Team Organization and Functions
20(2)
2.2.5. Setting Training Requirements
22(1)
2.2.6. Emphasizing Root Causes
23(1)
2.2.7. Developing Recommendations
24(1)
2.2.8. Fostering a Blame-Free Policy
24(1)
2.2.9. Implementing the Recommendations and Follow-up Activities
25(1)
2.2.10. Resuming Normal Operation and Establishing Restart Criteria
25(1)
2.2.11. Providing a Template for Formal Reports
26(1)
2.2.12. Review and Approval
27(1)
2.2.13. Planning for Continuous Improvement
27(1)
2.3. Implementing the Management System
27(5)
2.3.1. Initial Implementation-Training
28(1)
2.3.2. Initial Implementation Data Management System
28(4)
References
32(1)
3 An Overview of Incident Causation Theories
33(10)
3.1. Stages of a Process-Related Incident
33(3)
3.1.1. Three Phases of Process-Related Incidents
34(1)
3.1.2. The Importance of Latent Failures
35(1)
3.2. Theories of Incident Causation
36(3)
3.2.1. Domino Theory of Causation
37(1)
3.2.2. System Theory
37(1)
3.2.3. Hazard-Barrier-Target Theory
38(1)
3.3. Investigation's Place in Controlling Risk
39(1)
3.4. Relationship between Near Misses and Incidents
40(1)
Endnotes
41(2)
4 An Overview of Investigation Methodologies
43(18)
4.1. Historical Approach
43(1)
4.2. Modern Structured Approach
44(1)
4.3. Methodologies Used by CCPS Members
45(2)
4.4. Description of Tools
47(9)
4.4.1. Brainstorming
47(1)
4.4.2. Timelines
48(1)
4.4.3. Sequence Diagrams
49(1)
4.4.4. Causal Factor Identification
50(1)
4.4.5. Checklists
50(1)
4.4.6. Predefined Trees
51(1)
4.4.7. Team-Developed Logic Trees
52(4)
4.5. Selecting an Appropriate Methodology
56(1)
Endnotes
57(4)
5 Reporting and Investigating Near Misses
61(14)
5.1. Defining a Near Miss
5.2. Obstacles to Near Miss Reporting and Recommended Solutions
63(10)
5.2.1. Fear of Disciplinary Action
64(2)
5.2.2. Fear of Embarrassment
66(1)
5.2.3. Lack of Understanding: Near Miss versus Nonincident
66(3)
5.2.4. Lack of Management Commitment and Follow-through
69(1)
5.2.5. High Level of Effort to Report and Investigate
70(1)
5.2.6. Disincentives for Reporting Near Misses
71(1)
5.2.7. Not Knowing Which Investigation System to Use
72(1)
5.3. Legal Aspects
73(1)
Endnotes
74(1)
6 The Impact of Human Factors
75(22)
6.1. Defining Human Factors
76(1)
6.2. Human Factors Concepts
77(9)
6.2.1. Skills-Rules-Knowledge Model
82(2)
6.2.2. Human Behavior
84(2)
6.3. Incorporating Human Factors into the Incident Investigation Process
86(3)
6.3.1. Finding the Causes
88(1)
6.4. How an Incident Evolves
89(4)
6.4.1. Organizational Factors
90(1)
6.4.2. Unsafe Supervision,
91(1)
6.4.3. Preconditions for Unsafe Acts
91(1)
6.4.4. Unsafe Acts
92(1)
6.5. Checklists and Flowcharts
93(1)
Endnotes
93(4)
7 Building and Leading an Incident Investigation Team
97(18)
7.1. Team Approach
97(1)
7.2. Advantages of the Team Approach
98(1)
7.3. Leading a Process Safety Incident Investigation Team
98(2)
7.4. Potential Team Composition
100(3)
7.5. Training Potential Team Members and Support Personnel
103(2)
7.6. Building a Team for a Specific Incident
105(3)
7.6.1. Minor Incidents
106(1)
7.6.2. Limited Impact Incidents
106(1)
7.6.3. Significant Incidents
107(1)
7.6.4. High Potential Incidents
107(1)
7.6.5. Catastrophic Incidents
107(1)
7.7. Developing a Specific Investigation Plan
108(2)
7.8. Team Operations
110(2)
7.9. Setting Criteria for Resuming Normal Operations
112(3)
8 Gathering and Analyzing Evidence
115(64)
8.1. Overview
116(6)
8.1.1. Developing a Specific Plan
116(2)
8.1.2. Investigation Environment Following a Major Occurrence
118(1)
8.1.3. Priorities for Managing an Incident Investigation Team
119(3)
8.2. Sources of Evidence
122(17)
8.2.1. Types of Sources
122(6)
8.2.2. Information from People
128(4)
8.2.3. Physical Evidence and Data
132(1)
8.2.4. Paper Evidence and Data
133(2)
8.2.5. Electronic Evidence and Data
135(1)
8.2.6. Position Evidence and Data
136(3)
8.3. Evidence Gathering
139(22)
8.3.1. Initial Site Visit
139(2)
8.3.2. Evidence Management
141(1)
8.3.3. Tools and Supplies
142(2)
8.3.4. Photography and Video
144(4)
8.3.5. Witness Interviews
148(13)
8.4. Evidence Analysis
161(16)
8.4.1. Basic Steps in Failure Analysis
161(10)
8.4.2. Aids for Studying Evidence
171(3)
8.4.3. New Challenges in Interpreting Evidence
174(1)
8.4.4. Evidence Analysis Methods
175(1)
8.4.5. The Use of Test Plans
176(1)
Endnotes
177(2)
9 Determining Root Causes-Structured Approaches
179(2)
9.1. The Management System's Role
181(2)
9.2. Structured Root Cause Determination
183(2)
9.3. Organizing Data with a Timeline
185
9.3.1. Developing a Timeline
185(4)
9.3.2. Determining Conditions at the Time of Failure
189(1)
9.4. Organizing Data with Sequence Diagrams
190(7)
9.5. Root Cause Determination Using Logic Trees-Method A
197(1)
9.5.1. Gather Evidence and List Facts
197(1)
9.5.2. Timeline Development
198(1)
9.5.3. Logic Tree Development
198(3)
9.6. Logic Trees
201(1)
9.6.1. Choosing the Top Event
202(1)
9.6.2. Logic Tree Basics
203(6)
9.6.3. Example-Chemical Spray Injury
209(5)
9.6.4. What to Do If the Process Stalls
214(1)
9.6.5. Guidelines for Stopping Tree Development
214(2)
9.7. Fact/Hypothesis Matrix
216(2)
9.7.1. Application of Fact/Hypothesis Matrix
218(1)
9.8. Case Histories and Example Applications
219(1)
9.8.1. Fire and Explosion Incident-Fault Tree
219(4)
9.8.2. Data Driven Cause Analysis
223(1)
9.9. Root Cause Determination Using Predefined Trees Method B
224(1)
9.9.1. Evidence Gathering
225(1)
9.9.2. Timeline Development
226(1)
9.3.3. Scenario Determination
226(1)
9.9.4. Causal Factors
226(1)
9.9.5. Predefined Tree
227(1)
9.10. Causal Factor Identification
228(5)
9.10.1. Identifying Causal Factors
228(2)
9.10.2. Barrier Analysis
230(1)
9.10.3. Change Analysis
231(1)
9.10.4. Quality Assurance
232(1)
9.10.5. Causal Factor Summary
233(1)
9.11. Predefined Trees
233(12)
9.11.1. Background MORT
234(1)
9.11.2. Using Predefined Trees
235(2)
9.11.3. Example-Environmental Incident
237(7)
9.11.4. Quality Assurance
244(1)
9.11.5. Predefined Tree Summary
245(1)
9.12. Checklists
245(2)
9.12.1. Use of Checklists
246(1)
9.12.2. Checklist Summary
246(1)
9.13. Human Factors Applications
247(4)
9.14. Conclusion
247(1)
Endnotes
248(3)
10 Developing Effective Recommendations 251(16)
10.1. Major Issues
251(2)
10.2. Developing Effective Recommendations
253(2)
10.2.1. Team Responsibilities
253(1)
10.2.2. Attributes of Good Recommendations
253(2)
10.3. Types of Recommendations
255(5)
10.3.1. Inherent Safety
255(1)
10.3.2. Hierarchies and Layers of Recommendations
256(3)
10.3.3. Commendation/Disciplinary Action
259(1)
10.3.4. The "No-Action" Recommendation
259(1)
10.3.5. The Incompletely Worded Recommendation
259(1)
10.4. The Recommendation Process
260(4)
10.4.1. Select One Cause
260(1)
10.4.2. Develop and Examine Preventive Actions
260(2)
10.4.3. Perform a Completeness Test
262(1)
10.4.4. Establish Criteria to Resume Operations
262(1)
10.4.5. Prepare to Present Recommendations
263(1)
10.4.6. Review Recommendations with Management
264(1)
10.5. Reports and Communications
264(1)
Endnotes
265(2)
11 Communication Issues and Preparing the Final Report 267(22)
11.1. Interim Reports
267(2)
11.2. Writing the Formal Report
269(3)
11.2.1. General Guidance
269(3)
11.3. Sample Report Format
272(7)
11.3.1. Executive Summary
272(1)
11.3.2. Introduction
273(1)
11.3.3. Background
274(1)
11.3.4. Sequence of Events and Description of the Incident
274(1)
11.3.5. Evidence and Cause Analysis
275(1)
11.3.6. Findings and Recommendations
275(3)
11.3.7. Noncontributory Factors
278(1)
11.3.8. Attachments or Appendices
278(1)
11.3.9. Criteria for Restart
279(1)
11.4. Capturing Lessons Learned
279(7)
11.4.1. Internal
279(4)
11.4.2. External
283(3)
11.5. Tools for Assessing Report Quality
286(2)
11.5.1. Checklist
286(1)
11.5.2. Avoiding Common Mistakes
286(2)
Endnotes
288(1)
12 Legal Issues and Considerations 289(16)
12.1. Seeking Legal Guidance in Preparing Documentation
290(2)
12.1.1. Use and Limits of Attorney-Client Privilege
290(1)
12.1.2. Recording the Facts
291(1)
12.2. The Importance of Document Management
292(1)
12.3. Communications and Credibility
293(1)
12.4. The Challenges and Rewards of Sharing New Knowledge
294(1)
12.5. Employee Interviews and Personal Liability Concerns
295(2)
12.6. Gathering and Preserving Evidence
297(1)
12.7. Inspection and Investigation by Regulatory and Other Agencies
298(2)
12.8. Legal Issues Related To "Postinvestigation"
300(2)
12.9. Summary
302(1)
Endnotes
303(2)
13 Implementing the Team's Recommendations 305(18)
13.1. Three Major Concepts
306(1)
13.2. What Happens When There Is Inadequate Follow-up?
307(2)
13.2.1. Nuclear Plant Incident
307(1)
13.2.2. Aircraft Incident
308(1)
13.2.3. Petrochemical Plant Incident
308(1)
13.2.4. Challenger Space Shuttle Incident
308(1)
13.2.5. Typical Plant Incidents
309(1)
13.3. Management System Considerations for Follow-up
309(7)
13.3.1. Understanding Responsibilities
310(1)
13.3.2. Formally Accepting Recommendations
311(1)
13.3.3. Assigning a Responsible Individual
312(1)
13.3.4. Determining Action Item Priority
312(1)
13.3.5. Implementing the Action Items
312(2)
13.3.6. Documenting Recommendation Decisions the Audit Trail
314(1)
13.3.7. Tracking Action Items
314(1)
13.3.8. Revising the Incident Investigation Management System
315(1)
13.4. Sharing Lessons Learned
316(4)
13.4.1. Performing the Follow-Up Audit
316(1)
13.4.2. Internal Sharing
316(2)
13.4.3. External Sharing
318(2)
13.5. Analyzing Incident Trends
320(1)
Endnotes
321(2)
14 Continuous Improvement for the Incident Investigation System 323(10)
14.1. Regulatory Compliance Review
324(1)
14.2. Investigation Quality Assessment
325(1)
14.3. Recommendations Review
326(1)
14.4. Potential Optimization Options
326(5)
14.4.1. Follow Up
326(1)
14.4.2. Causal Category Analysis
326(5)
Endnotes
331(2)
15 Lessons Learned 333(22)
15.1. Learning Lessons from Within Your Organization
333(1)
15.2. Learning Lessons from Others
334(1)
15.3. Cross-Industry Lessons
335(2)
15.4. Trends and Statistics
337(1)
15.5. Management Application
337(1)
15.6. Case Studies
337(14)
15.6.1. Esso Longford Gas Plant Explosion
338(2)
15.6.2. Union Carbide Bhopal Toxic Gas Release
340(2)
15.6.3. NASA Challenger Space Shuttle Disaster
342(1)
15.6.4. Tosco Avon Oil Refinery Fire
343(2)
15.6.5. Shell Deer Park Olefins Plant Explosion
345(1)
15.6.6. Texas Utilities Concrete Stack Collapse
346(3)
15.6.7. Three Mile Island Nuclear Accident
349(1)
15.6.8. Concorde Air Crash
350(1)
15.7 Sharing Lessons Learned
351(2)
References
353(2)
Appendix A Relevant Organizations 355(4)
Appendix B Professional Assistance Directory 359(2)
Appendix C Photography Guidelines for Maximum Results 361(4)
Appendix D Example Case Study-Fictitious NDF Company Incident 365(30)
Appendix E Example Case Study-More Bang for the Buck: Getting the Most from Accident Investigations 395(20)
Appendix F Selected OSHA and EPA Incident Investigation Regulations 415(4)
Appendix G Quick Checklist for Investigators 419(6)
Appendix H Additional Resources 425(6)
Appendix I Contents of CD-ROM 431(2)
Glossary 433(10)
Index 443