Driving Continuous Process Safety Improvement from Investigated Incidents

Nearly everything we do today to prevent process safety incidents originated in conditions similar to those that led to past incidents. Our engineering forebears recognized the need to learn from past incidents at the beginning of the industrial revolution, and they and we have been building the modern practice of process safety since then. So, after more than 200 years, why do incidents continue to happen? More specifically, why do we as an industry allow incidents with the same root causes to happen repeatedly? Why are we as industry struggling to learn from these incidents?

The Center for Chemical Process Safety (CCPS) recently completed a project to understand the barriers that prevent findings from past accidents from translating to permanent corporate change that prevents future incidents, and develop a process to overcome those barriers. The resulting book, “Driving Continuous Process Safety Improvement from Investigated Incidents,” introduces the Recalling Experiences and Learning (REAL) Model. The REAL Model has been designed to help companies move past simply having practitioner awareness of the learnings from incidents to the desired end state where the organization has embedded and institutionalized the learnings within their programs and procedures. The REAL Model ties a company’s process safety expertise to specific improvement goals, mines useful information from previous incidents, translates this information into specific improvement and change plans, and describes ways to continually reinforce the reasons for the change so lessons-learned become embedded in the way things are done. Through this process, the learnings become institutionalized within our organization and then future incidents can truly be prevented, we are no longer dependent solely on practitioner knowledge to drive improvements.

This paper will introduce the REAL Model, and present a hypothetical but realistic scenario as an example how a company would use it to drive improvement.