Rethinking Bhopal

A Definitive Guide to Investigating, Preventing, and Learning from Industrial Disasters
 
 
Elsevier (Verlag)
  • 1. Auflage
  • |
  • erschienen am 27. Mai 2016
  • |
  • 510 Seiten
 
E-Book | ePUB mit Adobe DRM | Systemvoraussetzungen
E-Book | PDF mit Adobe DRM | Systemvoraussetzungen
978-0-12-803842-0 (ISBN)
 

Rethinking Bhopal: A Definitive Guide to Investigating, Preventing, and Learning from Industrial Disasters is the go-to source for anyone seeking to learn how to improve process safety management (PSM) through applying fundamental asset reliability and incident investigation concepts.

The seeds that unified PSM on a global scale were planted in Bhopal, India on December 3, 1984. Since then, considerable progress has been made to protect both workers and communities from catastrophic industrial failures. Industry acknowledges its responsibility to create value with accrued operating experience and that using information received from previous failures is a direct way to prevent future incidents. With this principle in mind, Bloch evaluates modern references related to the Bhopal Disaster, using recognized industrial asset reliability and incident investigation concepts.

The practice of objective incident investigation offers a compelling insight into specific decisions and actions that resulted in history's worst industrial disaster. Recording a fully transparent sequence of events promotes a personal sense of accountability for anyone involved in the manufacturing industry. Lessons learned can be immediately implemented by those with direct PSM, management, engineering, and operating responsibilities. Case histories demonstrate how patterns observed in the timeline leading up to the Bhopal Disaster can be detected in modern incidents and by recognizing these patterns in present-day processes avoids counterproductive operating decisions and unprecedented destruction.

This text is instrumental in helping existing organizations re-evaluate their own exposures and risks, and would be a valuable read for any member of a process safety management team. Rethinking Bhopal: A Definitive Guide to Investigating, Preventing, and Learning from Industrial Disasters provides an expansion of knowledge and understanding for the novice in PSM while also providing depth and application considerations to challenge more experienced industry professionals. Note: All royalties from this book go to the Process Safety Heritage Trust Scholarship at Lamar University in Beaumont, Texas, USA.


  • Learn how to improve Process Safety Management (PSM) performance by applying fundamental asset reliability and incident investigation concepts
  • Understand your personal role in detecting and preventing Loss of Primary Containment (LOPC) incidents before they occur
  • Take immediate action to stabilize processes under your control while promoting a systematic approach to eliminating persistent failure mechanisms
  • Includes case histories to helpfully illustrate how to detect potentially destructive patterns in your own organization


Kenneth P. Bloch is a Senior HES Professional who specializes in petrochemical industry incident investigation and failure analysis. His experience includes thirty years of downstream service in maintenance, PSM, technical, and operations roles. He speaks regularly at AFPM, API, and AIChE process safety symposiums about experiences that help prevent recurring process safety failures throughout the manufacturing industry. Mr. Bloch graduated with honors from Lamar University in Beaumont, Texas with an Environmental Science Degree in 1988. Relevant publications include:
• The Bhopal Disaster: understanding the impact of unreliable machinery, Hydrocarbon Processing Magazine, June 2012, pp 73-76
• Update your reliability performance to meet process safety expectations, Hydrocarbon Processing Magazine, June 2011, pp 45-53
• Process safety management lessons learned from a petroleum refinery spent caustic tank explosion, Process Safety Progress, December 2010, pp 332-339
  • Englisch
  • San Diego
  • |
  • USA
Elsevier Science
  • 6,46 MB
978-0-12-803842-0 (9780128038420)
012803842X (012803842X)
weitere Ausgaben werden ermittelt
  • Front Cover
  • Rethinking Bhopal
  • Rethinking Bhopal
  • Copyright
  • Dedication
  • Contents
  • About the Author
  • Foreword
  • Acknowledgments
  • Introduction
  • REFERENCES
  • A Note for Readers
  • 01 - Process Reliability
  • 1 - Industrial Learning Processes
  • THE BHOPAL DISASTER
  • POLICIES AND REGULATIONS
  • THE PROCESS SAFETY MANAGEMENT MOVEMENT
  • REPEAT FAILURES
  • THE INCENTIVE TO CHANGE
  • FROM SIMPLICITY TO COMPLEXITY
  • INCIDENT PREVENTION
  • INVESTIGATION REPORTS
  • LESSONS FOR US
  • REFERENCES
  • 2 - Equipment Reliability Principles
  • BEING IN CONTROL
  • BREAK-EVEN ANALYSIS
  • PATENTS AND TRADE SECRETS
  • PROCESS FLEXIBILITY
  • ASSET PROTECTION
  • FUNCTIONAL COMBINATIONS
  • MANAGING PERFORMANCE LOSS
  • FUNCTIONAL FAILURES
  • RELIABILITY PLANS
  • RELIABILITY ANALYSIS
  • JUSTIFYING DESIGN CHANGES
  • PREVENTING PREMATURE FAILURE
  • SPARE ASSETS
  • RELIABILITY PERFORMANCE METRICS
  • MEAN TIME TO REPAIR
  • FAILURE RATE
  • MEAN TIME BETWEEN FAILURE
  • THE HUMAN CONDITION
  • LESSONS FOR US
  • REFERENCES
  • 3 - Incident Investigation
  • THE NORMALIZATION OF DEVIANCE
  • INVESTIGATION TRIGGERS
  • CULTURE AND CONTEXT
  • NEUTRALITY
  • THE INVESTIGATION PROCEDURE
  • PHASE I: FRONT-END LOADING
  • STEP 1: COLLECT WITNESS STATEMENTS
  • Supervised Witness Statements
  • STEP 2: GATHER PHYSICAL EVIDENCE
  • STEP 3: START CONSTRUCTING A TIMELINE
  • Managing Inconsistent Information
  • STEP 4: WITNESS CLARIFICATION
  • Transition Point
  • STEP 5: ASSESS CONTRADICTIONS AND CAVITIES
  • PHASE II: PATTERN MATCHING
  • STEP 6: ORGANIZE FACTS AND EVIDENCE
  • STEP 7: PROPOSE POSSIBLE SCENARIOS
  • STEP 8: POPULATE THE FACT-HYPOTHESIS MATRIX [27]
  • STEP 9: CREATE A LOGIC PROBLEM
  • STEP 10: SOLVE THE LOGIC PROBLEM
  • STEP 11: RECORD LOGIC PROBLEM RESULTS
  • STEP 12: DEAD-END ASSESSMENT
  • STEP 13: REJECT SCENARIO AND SELECT A NEW SCENARIO
  • STEP 14: DOCUMENT CONCLUSIONS
  • STEP 15: UPDATE THE TIMELINE
  • PHASE III: CLOSURE
  • DISCIPLINE
  • STEP 16: ASSESS TIMELINE COMPLETION
  • STEP 17: DEVELOP RECOMMENDATIONS
  • PRESERVING ACQUIRED KNOWLEDGE
  • STEP 18: INDEPENDENT INVESTIGATION REVIEW
  • PROBABLE AND PRECISE CAUSE
  • LESSONS FOR US
  • REFERENCES
  • 4 - Role Statement and Fulfillment
  • INDUSTRIAL AMNESIA
  • ESTABLISHING PROCESS RELIABILITY EXPECTATIONS
  • PRODUCTION CONSTRAINT REMOVAL
  • TRACKING PERFORMANCE MEASURES
  • DEVELOPING PROCESS SAFETY SKILLS
  • ASSESSING PROCESS PERFORMANCE AND IMPROVEMENT
  • JUSTIFYING CASES FOR ACTION
  • VALIDATING PERFORMANCE RESULTS
  • PRESERVING THE VALUE OF ACQUIRED KNOWLEDGE
  • COOPERATIVE COMMUNICATION
  • SUPERVISION'S RESPONSIBILITIES
  • LESSONS FOR US
  • REFERENCES
  • 5 - Spent Caustic Tank Explosion: A Case Study in Inherently Safer Design [1]
  • WITNESS STATEMENTS
  • PROCESS AND ASSET DESCRIPTION
  • HAZARD CONTROL
  • BACKGROUND
  • PROCESS HAZARD ANALYSIS ACTION ITEM
  • DESIGN CHANGE
  • INCIDENT INVESTIGATION
  • DESIGN DEFECTS
  • PROCEDURE DEVIATION
  • WORKER INTERVIEWS
  • WARNING SIGNALS
  • IGNITION SOURCE
  • EVALUATING CAUSES
  • FUNCTIONAL RECOVERY
  • ORGANIZATIONAL CULTURE
  • LESSONS FOR US
  • REFERENCES
  • 02 - Research and Development
  • 6 - INVENTING SOLUTIONS*
  • EVENT DESCRIPTION
  • TECHNICAL ANALYSIS
  • LESSONS FOR US
  • REFERENCES
  • 7 - PRODUCT MANUFACTURING AND DISTRIBUTION*
  • EVENT DESCRIPTION
  • TECHNICAL ASSESSMENT
  • HAZARD AWARENESS
  • PROCESS OPTIMIZATION
  • LESSONS FOR US
  • REFERENCES
  • 8 - PROCESS SELECTION*
  • EVENT DESCRIPTION
  • TECHNICAL ASSESSMENT
  • LESSONS FOR US
  • REFERENCES
  • 9 - Industry Compliance*
  • EVENT DESCRIPTION
  • TECHNICAL ASSESSMENT
  • LESSONS FOR US
  • REFERENCES
  • 10 - Production Commitments*
  • EVENT DESCRIPTION
  • TECHNICAL ASSESSMENT
  • LESSONS FOR US
  • REFERENCES
  • 03 - Process Configuration
  • 11 - Licensing*
  • EVENT DESCRIPTION
  • TECHNICAL ASSESSMENT
  • LESSONS FOR US
  • REFERENCES
  • 12 - FACTORY CONSTRUCTION*
  • EVENT DESCRIPTIONT
  • METHYL ISOCYANATE STORAGE TANKS
  • METHYL ISOCYANATE CIRCULATION AND TRANSFER PUMPS
  • METHYL ISOCYANATE REFRIGERATION
  • METHYL ISOCYANATE VAPOR MANAGEMENT
  • VENT GAS SCRUBBER
  • INSTRUMENTATION, GAUGES, AND ALARMS
  • TECHNICAL ASSESSMENT
  • LESSONS FOR US
  • REFERENCES
  • 13 - Process Hazard Awareness and Analysis
  • SUMMARY
  • TECHNICAL ASSESSMENT
  • RUNDOWN TANK NODE
  • HYPOTHETICAL SCENARIO
  • RISK CALIBRATION
  • CONSEQUENCE CATEGORY
  • FREQUENCY OF CONSEQUENCE
  • INDEPENDENCE
  • PASSIVE PROTECTION
  • EVALUATING DOUBLE JEOPARDY
  • HUMAN INTERVENTION
  • LESSONS FOR US
  • REFERENCES
  • 14 - COMMISSIONING PHASE*
  • EVENT DESCRIPTION
  • TECHNICAL ASSESSMENT
  • LESSONS FOR US
  • REFERENCES
  • 15 - Repeat Mechanical Seal Failures: A Case Study in Pump Reliability Improvement
  • ACCELERATION BASICS
  • DETECTING AND INVESTIGATING A VIBRATION PROBLEM
  • ACCELERATION LIMIT
  • REVISITING RELIABILITY GROWTH PLOTS
  • UNSTABLE HYDRAULICS
  • CASTING DEFECTS SUSPECTED
  • APPLYING MODERN HYDRAULIC SELECTION CRITERIA
  • SUCTION RECIRCULATION
  • RELIABILITY FACTOR
  • BUSTING CAVITATION MYTHS
  • LESSONS FOR US
  • REFERENCES
  • 04 - Operations and Production
  • 16 - MANAGEMENT OF CHANGE*
  • EVENT DESCRIPTION
  • TECHNICAL ASSESSMENT
  • LESSONS FOR US
  • REFERENCES
  • 17 - Process Isolation and Containment*
  • EVENT DESCRIPTION
  • TECHNICAL ASSESSMENT
  • LESSONS FOR US
  • REFERENCES
  • 18 - EMPLOYEE PARTICIPATION*
  • EVENT DESCRIPTION
  • TECHNICAL ASSESSMENT
  • LESSONS FOR US
  • REFERENCES
  • 19 - Compliance Audits*
  • EVENT DESCRIPTION
  • TECHNICAL ASSESSMENT
  • LESSONS FOR US
  • REFERENCES
  • 20 - Process Optimization*
  • EVENT DESCRIPTION
  • TECHNICAL ASSESSMENT
  • LESSONS FOR US
  • REFERENCES
  • 21 - Maintenance Failure*
  • EVENT DESCRIPTION
  • TECHNICAL ASSESSMENT
  • LESSONS FOR US
  • REFERENCES
  • 22 - Human Error*
  • EVENT DESCRIPTION
  • TECHNICAL ASSESSMENT
  • LESSONS FOR US
  • REFERENCES
  • 05 - Lessons Learned
  • 23 - Crude Unit Fire: A Case Study in Human Error
  • INTRODUCTION
  • PROCESS OVERVIEW
  • EVENT DESCRIPTION
  • INVESTIGATION
  • INSPECTION RESULTS
  • INTERVIEWS
  • INTEGRITY
  • CLOSURE
  • INSTINCT
  • LESSONS FOR US
  • REFERENCES
  • 24 - Reliability Commitment
  • LESSONS LEARNED
  • WHAT YOU CAN DO
  • Appendix
  • CHAPTER 6
  • CHAPTER 7
  • CHAPTER 8
  • CHAPTER 9
  • CHAPTER 10
  • CHAPTER 11
  • CHAPTER 12
  • CHAPTER 14
  • CHAPTER 16
  • CHAPTER 17
  • CHAPTER 18
  • CHAPTER 19
  • CHAPTER 20
  • CHAPTER 21
  • CHAPTER 22
  • Glossary
  • Index
  • A
  • B
  • C
  • D
  • E
  • F
  • H
  • I
  • L
  • M
  • N
  • O
  • P
  • R
  • S
  • T
  • U
  • V
  • W
  • Back Cover

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