Promoting lessons learned

A guest post by Arnab Chakrabarty, a chemical engineer at Baker Engineering & Risk Consultants.

Accidents happen in both academia and industry. To help prevent recurrence of similar events, it’s important to learn what we can from those incidents. Mark Kaszniak, an investigator with US Chemical Safety and Hazard Investigation Board (CSB), summarized in a recent Process Safety Progress article lessons learned from 21 CSB investigations (DOI: 10.1002/prs.10373). Kaszniak points out that, of the cases studied, no process hazard analysis was conducted prior to 43% of the incidents. In 38% of the cases, process hazard analyses were done but did not include lessons learned from previous incidents. Incomplete implementation of recommendations from hazard analyses, no facility siting studies, and inadequate evaluation of safeguards and layers of protection are among the other issues that Kaszniak links to undetected or underappreciated process hazards.

In another article in the Journal of Loss Prevention in the Process Industries, Miloš Ferjenčik and Zdeněk Jalový of the Institute of Energetic Materials at the Czech Republic’s University of Pardubice go over lessons learned from incidents in chemistry laboratories at their school (DOI: 10.1016/j.jlp.2010.06.009). Ferjenčik and Jalový propose that a systematic root cause analysis of incidents be done with students to identify errors—including errors committed by teachers—and come up with corrective measures. “The best way to show students how to learn from their own errors is for teachers to demonstrate how they have learned from their own experiences,” the authors write. They add that setting up such a system not only teaches students cause analysis but promotes a cultural behavior pattern of learning from mistakes.

Author: Jyllian Kemsley

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