How to hike safety, reduce failures

Because catastrophic incidents are so rare and their consequences so severe, organizations are poorly equipped to self investigate. High-hazard process industries require increasingly stronger safety systems that reduce the potential for catastrophic failures.


Without a stronger safety infrastructure, incidents have the potential to grow as larger populations demand greater productivity from process industries over the next several decades. Managing these risks requires instituting specialized systems of process safety and the adequacy of these systems depends on continuously high levels of vigilance and preparedness.

When catastrophic incidents do occur—and they do occur like the Union Carbide pesticide facility in Bhopal, India, in 1984; the Phillips plastics facility along the Houston Ship Channel in Texas in 1989; and the AZF fertilizer factory in Toulouse, France, in 2001—responsible organizations should pursue a high-quality investigation that gathers evidence and illuminates root and contributing causes that can bring about better policies, practices and strategies.

The catch is, however, because catastrophic incidents are so rare and their consequences so severe, organizations are likely poorly equipped to self investigate. In addition, severe incidents may precipitate investigations by regulatory agencies interested in the process facility's adhering to governmental regulations, standards and practices which distract organizations from also pursuing broader incident investigations.

That all means high-hazard process industries require increasingly stronger safety systems that reduce the potential for catastrophic failures. Along those lines the American Institute of Chemical Engineers (AIChE) Center for Chemical Process Safety (CCPS) put together a white paper discussing one way to increase safety and reduce those failures.

Their thinking is to expand the number of national Process Safety Investigation Boards (PSIBs).

PSIBs can investigate catastrophic events resulting in severe damages; identify their circumstances and causes; recommend specific ways to prevent their recurrence; communicate with audiences vulnerable to experiencing similar incidents; and coordinate with other relevant governmental agencies and the private sector to strengthen the policies and practice of process safety. A knowledgeable, skilled, diverse board selected by high-level, public officials and subject to limited terms, can help ensure performance and accountability for the PSIB and its more permanent, hired expert staff who establish and maintain the core technical competencies needed to fulfill the PSIB's functions.

Key factors critical to the success of a PSIB include:

Create a high performance organization

  • Create a board with a sufficient number of qualified members with diverse backgrounds. Board members should have the necessary technical skills, knowledge and experience. Ideally select an odd number of members to avoid deadlocks on voting matters. Appoint a chair, and assign other responsibilities clearly to Board members.
  • Support legitimacy of the Board by appointing members through a high government official. Establish term limits that encourage periodic turnover, with the term limit not coinciding with the term of the appointing official
  • Ensure Board member performance through a transparent evaluation process
  • Provide the Board with a skilled staff representing the necessary technical, political, and administrative skills needed to support investigations, communications, organizational funding, and management oversight. Technical skills include a deep knowledge of process safety and the process of root cause investigation.

Define clear scope of investigations

  • Identify reliable methods to learn the occurrence of incidents and means to track incident statistics
  • Establish clear criteria to define which incidents to investigate, and mechanisms to choose between incidents when resources are constrained
  • Define a clear scope of investigations.

Ensure high-quality investigations

  • Conduct in-depth investigation to identify root causes and contributing causes, either of individual incidents or groups of similar incidents
  • Be timely in completing investigations and reporting findings
  • Issue recommendations supported by evidence to the parties' best placed to respond, and track recommendations to resolution. Such recommendations may address regulations, enforcement, consensus standards, industry guidelines, practices at the company whose incident is being investigated, and others relevant to improvements to process safety.

Operate effectively and efficiently

  • Create trust among government, industry, labor, public, and other stakeholders
  • Increase efficiency by partnering with other national and local agencies and with industry to maximize the accumulation and communication of lessons learned
  • Streamline investigations by pre-establishing mechanisms with other national and local agencies to provide investigators with access to the site as soon as feasible.

Share lessons learned

  • Issue communications which inform stakeholders of lessons learned and maintain continued awareness
  • Support the mission of the Board with policies that encourage cooperation of the investigated company, such as protecting the company from private torts related to information revealed uniquely through the Board investigation.

Gregory Hale is the editor and founder of Industrial Safety and Security Source (, a news and information website covering safety and security issues in the manufacturing automation sector. This content originally appeared on the ISSSource website. Edited by Joy Chang, digital project manager, CFE Media, 

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