Appendix H

Additional Resources

29 CFR 1904, Recording and Reporting Occupational Injuries and Illnesses. Effective January 1, 2002; The OSHA website for recordkeeping revisions is www.osha.gov/recordkeeping/index.html. American Chemistry Council. Responsible Care, A Resource Guide for the Process Safety Code of Management Practices. Washington, DC, 1990. American National Standards Institute. ANSI Z16.2 Method of Recording Basic Facts Relating to the Nature and Occurrence of Work Injuries. New York. American Society of Safety Engineers. Dictionary of Terms Used in the Safety Profession, 3rd ed. Des Plains, IA: American Society of Safety Engineers 1988. Bea, Holdsworth, Smith. Summary of Proceedings and Submitted Papers. Workshop on Human Factors in Offshore Operations, 1996. Bridges, W. G. Get Near Misses Reported. Center for Chemical Process Safety International Conference and Workshop on Process Industry Incidents, October 2000, Orlando Florida. New York: AIChE, 2000. Carper, K. Forensic Engineering. New York: Elsevier, 1989. Center for Chemical Process Safety (CCPS). Guidelines for Hazard Evaluation Procedures, Second Edition with Worked Examples. New York: American Institute of Chemical Engineers, 1992. Center for Chemical Process Safety (CCPS). Guidelines for Technical Management of Chemical Process Safety. New York: American Institute of Chemical Engineers, 1989. Dowell, A. M., Philley, J., and Pearson, K. Structured Root Cause Investigation. Training course presented at Texas Chemical Council Safety Seminar, 1999. Feynman, R. P. What Do You Care What Other People Think? New York: Norton, 1988. Gano, D. L. Apollo Root Cause AnalysisA New Way of Thinking. Apollonian Publications, September 1994. Gilovich, T. How We Know What Isnt So: The Fallibility of Human Reason in Everyday Life. New York: Macmillian, 1991. Greenwood, M., and Woods, H.M. The Incidence of Industrial Accidents with Special Reference to Multiple Accidents, Ind. Fatigue Res. Board, Report 4, HMSO, London, England, 1919.
425

426

Guidelines for Investigating Chemical Process Incidents

Hon. Lord Cullen. The Public Inquiry into the Piper Alpha Disaster. London: UK Department of Energy, HMSO, 1990. Jones, B. A Process Quality Management Tool, Prevention of Unwanted Events, Training and Text, 1991. Kepner, C. H. and Tregoe, B. B. The Rational Manager. 2nd ed. Princeton, NJ: Kepner-Tregoe, Inc. 1976. Kletz, T. A. Accident Investigation: How Far Should We Go? Paper presented at the American Institute of Chemical Engineers Loss Prevention Symposium, 1983. Kletz, T. A. Organizations Have No Memory. Paper presented at the AIChE Loss Prevention Symposium, April 1979. Kuhlman, R. Professional Accident Investigation. Loganville, GA: Institute Press, International Loss Control Institute. Livingston, A. D., Jackson, and Priestly. Root Causes Analysis: Literature Review. WS Atkins Consultants Ltd. Birchwood, Warrington: WS Atkins House, 2001. Loss Prevention Bulletin #061. Rugby, England: Institution of Chemical Engineers, February 1985. Lucas, D. A. and Embrey, D. E. Human Reliability Data Collection for Qualitative Modeling and Quantitative Assessment. In Colombari, V. (Ed.), Reliability Data Collection and Use in Availability Assessment. New York: Springer Verlag, 1989. Norman, D. A. The Design of Everyday Things. New York: Basic Books, 1988. Petersen, D. Techniques of Safety Management, 2nd ed. New York: McGraw-Hill, 1978. Philley, J. Root Cause Incident Investigation Can Be Tricky. Presented at International System Safety Conference, 2001. Sanders, M. S. and McCormick. E. J.. Human Factors in Engineering and Design, 6th ed. New York: McGraw-Hill, 1987. Smith, K., and Franklyn, C. Conquering Cultural Change in Incident Investigation. Center for Chemical Process Safety International Conference and Workshop on Process Industry Incidents, October 2000, Orlando Florida. New York: AIChE, 2000. Stern, A., and Keller, R. Human Error and Equipment Design in the Chemical Industry Professional Safety. May 1991. Vaughan, D. The Challenger Launch Decision. Chicago: University of Chicago Press, 1996. Winsor, D. A. Challenger: A Case of Failure to Communicate. Chemtech. September 1989.

Appendix H

Additional Resources

427

Proceedings of the Center for Chemical Process Safety International Conference and Workshop: Process Industry IncidentsInvestigation Protocols, Case Histories, Lessons Learned. New York: American Institute of Chemical Engineers, 2000.
Case Studies/Lessons Learned
Lessons Learned from an On-Plot Refinery Tank Explosion, K. Ann Paine Case History of the Tosco Avon Refinery Investigation: January 1997 through November 1998, Dorian S. Conger A Review of Past Accidents Occurring in Major Hazard Installations in Italy: Discussion of the Causes, Consequences, and Lessons Learned, Giancarlo Ludovisi and Fiorenzo Damiani Lessons Learned from a Process Tank Explosion, Steven R. Marwitz, Randall P. Smith, and Rashid Hamsayeh

Management Systems
Incident Severity Rating and Investigation Guidelines, Dave Gaydos and Gary York The Development of Approaches to Incident Selection for the Chemical Safety Board, Daniel E. Sliva and Jack Weaver The Chemical Safety and Hazard Investigation Boards Process for Selecting Incident Investigations, Bill Hoyle, Shannon McCleary, and Isadore Rosenthal

Case Studies/Lessons Learned

A Structured Approach to Safe Design or Do the Safety Risks Outweigh the Environmental Benefit? Peter J. Hunt Investigation of a Pesticide Explosion, Awilda Fuentes A Compressor Failure That MOC May Not Have Caught! Alfred W. Bickum

Investigation Technologies
Premature Stopping Points for Determining the Root Cause of Human Error in Process Investigations, Jack Philley Using Advanced Trending Techniques to Learn from Your Incident Statistics, Mark Paradies and Ed Skompski Human Factors in Accident Investigations, Valerie E. Barnes

428

Guidelines for Investigating Chemical Process Incidents

Case Studies/Lessons Learned

Lessons Learned from a Cold Weather Explosion and Fire in an Oil Refinery, Brian D. Kelly Steam Line Rupture at Tennessee Eastman Division, Peter N. Lodal Lessons Learned from the Longford Royal Commission Investigation into the Explosion and Fire on 25 September 1998 at the Esso Gas Processing Plant, Mark Boult Gary Kenney, Robin Pitblado Risk Reduction by Learning from Incidents and Near-Misses, K. A. Ruppert and E. Meyer zu Riemsloh

Investigation Technologies
Root Cause Analysis-NOT What You Might Think, C. Robert Nelms Investigation into the Root Causes of Repeated Incinerator Incidents, Donald K. Lorenzo Investigation of Explosion Accidents, Quentin A. Baker, Adrian J. Pierorazio, Donald E. Ketchum

Case Studies/Lessons Learned

Central Collecting and Evaluating of Major Accidents and Near-Misses in the Federal Republic of Germany, Hans-Joachim Uth Impact of Identifying Root Causes, Jack McCavit A Reactive Chemical Incident: Morton International, Paterson, New Jersey, David Heller and William Hoyle

Management Systems
Safety Management through Learning from Experience in the Chemical Industry: Example of a New Incident Analysis Methodology, B. Wilpert, H. J. Uth, R. Miller, and E. Ninov Using Process Tools, System Evaluation, and Accident Trends to Improve Operational Reliability, Ed Koshka Quality Assurance in Incident Reporting and Investigation, Ujwal Ritwik

Management Systems
Organizational Unlearning: Detrimental Behaviors Present In Chemical Process Incident Investigation Teams, Robert K. Urian A Case Study of the Use of Electronic Networking for Incident Notification, Response, Mitigation, and Sharing, David W. Owens Legal Issues and Incident Investigations, Mark S. Dreux Conquering Cultural Change in Incident Investigation, Kris Smith and Christy Franklin

Appendix H

Additional Resources

429

Case Studies/Lessons Learnedr

Get Near Misses Reported, William G. Bridges The Case of the Pressurized Drums (Unexpected Oxidation-Reduction Reaction), Larry G. Holloway Acrylic Polymer Reactor Accident Investigation: Lessons Learned and Three Years Later, Michael Gromacki

Incident Data Workshop

Recent Developments in European Commission Tools to Manage Industrial Risks in Europe, Christian Kirchsteiger and Stuart Duffield Establishment of an Industrial Accident Database in Korea, Hyuck-myun Kwon, Dae-ski Yim, Chang-kyu Lee, Soon Joong Kang, Hyung-suk Kim and Young-soon Lee

Chemical Accident Investigation Around the World Workshop

Chemical Accident Investigation and Management in Korea, Kyo-Shik Park and En Sup Yoon The Loss and Claim Adjusting Process Workshop: Cost Estimation, Investigation Objectives, and the Settlement, Eric Lenoir, Straun Robertson, Michael Misurelli, Larry Collins, Berrin Tansel Consequence Analysis of an Oil Refinery Explosion in Thailand, Pramuk Osiri, Berrin Tansel, Chalermchai Chaikittiporn, and Preecha Loosereewanich Estimating Chemical Accident Costs in the United States: A New Analytical Approach, Larry Collins, Carmen DAngelo, Craig Mattheissen, and Michael Perron

Poster Session
Insurance, Terrorism and the Risk Management Program, Danl Steward, Mike Duncan, and Ahmad Shafaghi The Secret to Measuring Process Safety Performance: Combine Process Incident Data with Leading Indicators, Steve Arendt Use of Computational Modeling to Identify the Cause of Vapor Cloud Explosion Incidents, J. Keith Clutter and Mark G. Whitney Realistic Dispersion Modeling of Chlorine Release Incident. Al Waller