- An employee jumps from a 4 feet high platform onto a concrete floor in the packaging area of a polyethylene plant. Unfortunately he don't land on his feet, but falls and breaks his back. He is instantly dead. No chemicals were involved. No process equipment was involved. No acute release took place. It is definitely an undesired event.
- During maintenance work on a bulding housing a polyvinylchloride plant a ground operated man lift was used. The bucket controls malfunktioned resulting in an employee in the bucket beeing squezzed to death against some piping on the outside of the building. No chemicals were involved. No acute release took place. It is definitely an undesired event.
- Unplanned shut down of a polyethylene reactor is an abnormal process conditions, which leads to the burning of a significant amount of hydrocarbons and an intense heat flux to nearby ground areas - up to more than 100 feet away from the flare. This event is also a quite costly one - properly in excess of $100.000. There are chemicals involved, but they are realased or burned through equipment designed for this event. There is definitely an acute release, but it is through equipment designed for it. It is definitely an undesired event.
- During patching of some software on a Honeywell PMX system two constants in the computer system was interchanged. The result was, that valves, which should close did the opposite, i.e. they opened, and valves, which should close did also the opposite, i.e. they closed. The result was significant process deviations and releases through safety valves. This was definitely an undesired event.
Could these events have been prevented? Yes, the fall from the packaging platform could have been prevented by equipping it with a stair in place of the vertical ladder. The squezzing of an employee could have been prevented by installation of a dead-man button in the bucket. The incorrect patching of the control system software could have been prevented by patching during plant downtime and testing before plant startup. Would these events have happened if there was no chemical plant at the site? No. They are linked to the production of chemicals!
All four events were treated by management as major undesired events associated with their facilities. The first two events had significant impact on every engineer at the site they occured at. 3 of the 4 events were treated as significant incidents by management. None of them qualify as process safety incidents according to the CCPS criteria. Why? Could it be that the CCPS purpose is just to count events, which are caused by operations errors in running the process, maintenance errors in maintaining the process, or process design errors? I don't know.
A few years ago Shell UK reported in their annual report, that the had experienced to fatalities the previous year. The fatalities did not involve Shell employees. The fatalities did not involve contractors working at Shell UK sites. The fatalities involved road accidents involving a subcontractor.
If we want to improve performance of our chemical plant, then we need to focus on undesired events, and using our employee skill to understand why they occurred, and how we can prevent them in the future. Whether a particular event is labelled as a process safety indicent or somethingelse really is not that important, as long as we see the event as an opportunity to improve our performance. This approach is what drove the quality movement in Japan after WWII, and what drove Ford and many other companies in the 80's. A clear focus and belief, that we can do better!