(96c) Connecting the Dots – Managing the Little Things That Lead to Big Accidents

Major accidents often result from a failure to attend to seemingly little details.  Examples might include an improperly designed injection point, a procedure that is mostly, but not completely followed, a small part with the wrong metallurgy or other design, maintenance or operating discrepancies.   In many cases, these system flaws can lay dormant for extended periods of time, detected or undetected, with little or no consequence.  However, on occasion, and with the right initiating event, they can combine with other system flaws, allowing an unforeseen chain of events to propagate into a major accident.

This paper will review aggregated information from a range of process safety incidents, including "subtle" accidents resulting from a series of "little" failures.  It will highlight the management system breakdowns that contributed to the incidents, and examine the complex interactions among people, process safety systems and equipment as orchestrated by the overall organizational culture.  The paper will reinforce the concept that an effective process safety culture is key to "connecting the dots" that, if unchecked, can result in a a major accident.  The paper will also offer practical suggestions on strengthening that culture.