This paper explored the barrier system (e.g. controls) performance in the genesis of the 2005 BP Texas City disaster. Not much to say – the images say enough. Some extracts: · As per image 1, several organisational factors or management delivery system were central in the poor barrier system performance · They propose many of these factors… Continue reading Barrier / control system failures in the BP Texas City disaster & organisational factors
Tag: process safety
Learning from experience
More practical wisdom from the late, great Trevor Kletz. This explored a few elements of learning from experience – like the problems of just blaming people or changing procedures. First he targets the focus on changing procedures instead of improving designs. First, our first step should be, wherever reasonably practicable, is to remove the hazard… Continue reading Learning from experience
“We might just as well reprimand a light-bulb for going out” than tell people to be more careful: Trevor Kletz and his classic aphorisms
There’s no use telling people to be more careful, “We might just as well reprimand a light-bulb for going out”. Trevor Kletz with his classic aphorisms about focusing on error and blame when we should instead be improving the design of workplaces and plant. Other extracts from his 1976 article ‘Accident Data – the need… Continue reading “We might just as well reprimand a light-bulb for going out” than tell people to be more careful: Trevor Kletz and his classic aphorisms
Audits, excessive compliance focus and risk blindness
Still genuinely surprised that our last paper on audit failures has generated, relatively speaking, so much interest: now the second-most accessed paper in the Process Safety Progress journal. [* It shows as number 1 but that’s a glitch in the matrix. There’s a study on ‘red squirrels tests’ that has HEAPS more views.] No doubt… Continue reading Audits, excessive compliance focus and risk blindness
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