(54ai) How Can Learning from Process Safety Near Misses Prevent Major Incidents?

Several deadly accidents could have been prevented if the process safety near misses were captured and investigated. These near misses are warning signs/weak signals/precursors for a high potential incident. These precursors provide early warning about the weaknesses in the process safety management program and human performance, required to maintain the integrity of process equipment and physical barriers.

It has been learned that there were numerous precursors before majority of the major incidents which were either ignored altogether or not taken seriously due to a poor process safety culture or poorly implemented process safety management programs. CSB has highlighted the importance of investigating process safety near misses in number of their investigation reports and demonstrated that the deadly accidents could have been prevented. Therefore, it is very important to identify this gap and address it by effectively implementing the process safety near miss incident investigation and learning process.

This paper will cover how can we get most from the process safety near misses and prevent major disasters. Emphasis will be given on the reporting and investigating the process safety near misses which is one of the key process safety elements in the learning and improvement cycle. The author will explain the importance and discuss the practical examples about the most pertinent gaps, challenges, and best industry practices for reporting and investigating process safety near misses. Several real life examples from variety of high hazard industries will be presented to share the opportunities for improvement and well tested tips for developing or updating an existing incident investigation program.

Best industry practices will be shared on how to develop the criteria for reporting the process safety near misses, investigating to the root causes for their potential consequences and develop recommendations for preventing potentially serious incidents by implementing the actions to improve process safety program. Examples will include, how the learning from the near misses and minor process incidents can be applied during design as well as operating stage of the facility.

The paper will conclude by explaining how a well written and implemented process safety management program in general and incident investigation program in particular plays a vital role in preventing major accidents.