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May 13, 2010

Why corporate memory is vital to safety

Dr Julian Hought explains why corporate memory is vital to maintaining a safe working environment in the high-hazard sector.

Flixborough, Bhopal, Piper Alpha, Toulouse and Texas City – all place names that are well known in health and safety circles, and particularly among those working on major hazard sites. Each of these saw catastrophic safety failures that resulted in multiple fatalities and injuries, widespread environmental destruction, and damage to the buildings and the businesses involved. Undoubtedly, the lives of those connected with the incidents were also changed forever.
These incidents were deemed so catastrophic that they helped change the behaviour of organisations around the world and influenced the formation and enforcement of new legislation designed specifically to prevent similar situations ever happening again. For example, 28 deaths at the Nypro (UK) site at Flixborough caused by the leakage of cyclohexane vapour and the subsequent explosion in June 1974, and the explosion at the ICSEMA chemical plant in Italy in 1976 led to the Seveso and Seveso II Directives in Europe, which are regulated under the COMAH Regulations in the UK.
This regulatory regime has had a profound impact on the way we now look at design, construction, operation and maintenance at high-hazard sites. But even though the regulations are periodically reviewed and amended in an attempt to further improve process safety, and the learning is shared freely around the world, major accidents still occur.
Buncefield and BP Texas City happened within the last five years and yet, in February of this year, we were listening to reports on television of a fatal gas explosion during testing at the Kleen Energy Systems Plant in Connecticut – five people were killed and several injured in an explosion whose effects were felt for 30 miles.
Remember, remember
There are, no doubt, many reasons why history tends to repeat itself despite the industry’s willingness to share information on the lessons learned, and the collective desire to continue to improve safety, so the question is: does corporate memory have a part to play? We know that the costs and therefore the time needed to implement the technological, managerial and cultural changes required following the findings from major accidents can be substantial, leading to loss of momentum as memories of the horrors fade and priorities shift with time. High-profile incidents remind people of the consequences of what can happen when things go wrong, and the fear of the consequences tends to lead to greater conservatism in risk assessment and management of risk.
A more conservative approach will favour the building in of additional, sometimes excessive, layers of protection to prevent and mitigate the effects of major accidents. In truth, conservatism is a good thing, in that it drives down risk and helps counter those that would use risk assessment to justify the status quo, simply treating it as an academic exercise. Left unchecked, however, it can lead to inappropriate allocation of limited resources and a disjointed approach to managing overall risk.
Risk assessment is an uncertain science; we estimate the consequences and likelihood of occurrence and only refine those estimates where the consequences are perceived to be severe, or the likelihood is considered unacceptable, to facilitate the decision making process.
But if incidents help drive conservatism, is the converse also true? Do we all need to be reminded of what can go wrong, and the consequences? And do past incidents cease to be relevant as technology changes?
Experience of incidents leads us to improve our estimates, either in the pursuit of knowledge from a fear of the consequences, or in light of new information about the consequences and/or modes of failure following investigations. The chemicals industry, for example, has amassed and continues to acquire knowledge concerning failure modes and failure rates. This knowledge bank is strengthened as a result of the investigations of incidents across the world, helping to prove or disprove theoretical models.
Mathematical modelling can provide information on consequences and failure modes, or rates, but is this sufficient to add value? Do we need hard evidence to support our theories? Perhaps so: Buncefield is a good example of an event in which the outcome – the over-pressure experienced from the vapour-cloud explosion – was far greater than could have been predicted from the models available at the time.
Corporate memory also comes into play in driving conservatism. As the saying goes, “you can’t teach experience” but you can certainly learn lessons from it. Anyone who has ever experienced a major incident such as Flixborough or Piper Alpha first hand is unlikely to forget the lessons learned, but it is vital that such fervour for safe practice is communicated throughout all generations of the workforce and across industry.
A changing world
There was a time when you could train someone to perform a particular job and be fairly confident that they would stay with the company for 20 or 30 years. Year on year, they would learn from minor incidents and amass knowledge about how the way they performed their tasks influenced the safety of the plant as a whole. But times have changed. A job is rarely for life these days and with younger engineers moving on more frequently and older generations retiring, there is the danger of knowledge vital to the integrity of the plant being lost.
If the original plant designers or operators are no longer at the company, then a seemingly insignificant act such as the replacement of a valve with one of a similar specification, or the change in use of a piece of equipment, could compromise the original design intent. If operators, contractors, or maintenance engineers do not understand why a process must be undertaken in a particular way, or how their actions impact on the rest of the plant in terms of safety, then it can put lives at risk.
The current economic climate and smaller profit margins as a result of overseas competition have made it increasingly difficult for many companies in the UK process industries to justify investment in new plant and equipment. Where ageing plant and equipment is being pushed beyond its planned life, regular risk assessment and a shared corporate memory are vital. The ability to make accurate estimates of consequence and likelihood based on theory and backed by hard evidence can mean the difference between life and death.
The consequence of a pipe fracture at DSM’s naphtha cracker at Beek in the Netherlands in 1975 was the leakage of up to 5 tonnes of hydrocarbons into the atmosphere, which caused an explosion in which 14 people died and 107 were injured. If you had experienced this or any other industrial accident, you would be driven by the potential consequences of failing to check plant, especially pipework, for integrity.
Corporate memory is vitally important and we must take steps to ensure that we absorb the lessons of the past. We shouldn’t have to wait for reports of another fatal accident to jolt us into undertaking regular risk assessments and acting in the interests of protecting those who work and live near our companies.
Dr Julian Hought is managing director of HFL Services.

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K9Shallcross
K9Shallcross
14 years ago

trevor kletz was saying the same thing years ago in a number of publications he reckoned that corporate memory was lost in 10 years and the same mistakes were repeated.