(53ac) Reckless Operation and Maintenance in the Process Industry: Causes and Prevention Guidelines a Study of 100 Significant Process Safety Incidents.

Process safety incidents occur in different phases of the asset lifecycle from commissioning, through

operation and maintenance, to decommissioning. This report lays out the results of an investigation of

100 significant process safety incidents that occurred in seven different industries. The primary objective

of the research project is to determine correlations between various stages of the asset lifecycle and

process safety incidents.

What stands out in the results is that 97% of the incidents occurred in the operation and maintenance

phases of the asset lifecycle. The research carries out an in-depth investigation of both phases to identify

causes of accidents and process safety management failures.

The research examines the human losses in various industries to highlight the impact of process safety

incidents on people. Overall, 70% of the incidents resulted in fatalities and injuries in which 3363 people

were killed, and another 28,754 were injured. Surprisingly, the human casualties were disregarded in

similar previous studies published by insurers, although addressing the human cost is a useful tool to

accelerate process safety improvement.

The study concludes that 75% of the incidents occurred during routine operation of the asset lifecycle.

Equipment failure makes 60% of the immediate causes in the operation phase while an absence of

appropriate hazard identification and risk assessment process is the most dominant root cause.

Incidents that happened during the maintenance phase make 22% of the total incidents. Failure of

maintenance standards such as PTW, equipment isolation, hot work and equipment lifting make up 45%

of the immediate causes. The vast majority of maintenance incidents took place during shutdown and

start-up stages.

Finally, the study concludes with preventive guidelines, leading and lagging indicators and bowtie figure,

an endeavour to provide a practical approach that suits different process industries and various phases of

the asset lifecycle.