(41n) Remember or Repeat - a Brief Historical Perspective on Significant Process Safety Events

This presentation is an enhanced, expanded version of one I presented at the initial “The Day Process Safety Hit Home” session during a GCPS PSM Mentoring Forum several years ago and includes summary slides from three incidents discussed in greater detail at a subsequent "Day PS Hit Home” session I chaired a few years later. The intent of this presentation is to provide a brief historical perspective regarding several (~12) significant chemical/petroleum industry incidents, primarily from the 1980s and early 1990s, that led to an industry-wide process safety awakening, and, several years later, following the promulgation of key regulations (and the occurrence of additional incidents), to an industry reawakening. Due to the remarkable similarity of investigative learnings, a few slides related to three catastrophic space program incidents are also included.

The presentation title (“Remember or Repeat”) is intended to convey the fact that if we fail to remember (and learn from) past incidents, we may be destined to repeat them.

The format for each incident presented (typically in 2-3 slides) includes:

1. A photograph (and/or diagram) of the incident scene, generally pulled from initial reports.
2. A brief discussion of immediate impacts and consequences.
3. Key highlights related to initiating events and/or root causes.

Finally, for several of the incidents, relevant quotes from key personnel and/or investigative statements which reinforce the intended learnings are also noted.