(104b) What I Learned as an Investigator with the CSB

After a long career with the Dow Chemical Company and several years in process safety consulting, I had the privilege of working as an investigator with the U. S. Chemical Safety and Hazard Investigation Board. During my five years at the CSB, I led four major investigations and participated in a total of nine investigations. The investigations ranged from the Reactive Hazard Investigation which analyzed reactive chemical incidents in the U S. over a twenty year period to individual incidents that occurred in small, medium and large companies both inside and outside the chemical processing industries. From these investigations, I have learned some common lessons regarding the nature of chemical plant incidents. This paper discusses the incident investigations that I was involved in and the common lessons learned from these investigations.