Use root cause analysis to understand and improve process safety culture

Abstract

This article describes the topics of root cause analysis and company culture. An evaluation of the root causes of incidents can help identify areas where the culture requires improvement. In addition, an analysis of the nature of root cause can help companies understand their culture. Following an incident, root cause analysis can be conducted for at least four levels of management, (a) line supervision, (b) facility management, (c) executive management, and (d) professionals who write and then implement regulations and standards. This article makes a distinction between root causes for occupational losses and for major process accidents; it emphasizes the teachings that improve one does not automatically improve the other. In other words, a root cause analysis program that addresses the behaviors that correct occupational safety problems may not help correct those behaviors that cause process safety incidents. Examples of how root cause analysis can help a company understand and improve its culture are provided. For instance, companies should recognize the need for both training and education. If process risk is to be reduced, employees need to be educated as well as trained because education creates new behaviors that allow for improved root cause analysis and the aversion of major events. © 2008 American Institute of Chemical Engineers Process Saf Prog 2008

Process safety management—You can't get it right without a good safety culture

“…Similar themes can be found in previous articles published in Process Safety Progress [12][13][14][15].…”

Improving the performance of established PSM programs

“…Most companies now have the technical knowledge and capabilities to safely identify and manage process hazards and risks. As improved guidance and tools for implementing PSM have been developed, the focus on underlying causes of major incidents has shifted in many cases to understanding and improving organizational and cultural causes [20–23], as evidenced in particular by the Texas City explosion in 2005 [24]. Kletz [25] expressed in the early 1990s that “new” accidents rarely occur; rather the same kinds of accidents are repeated and therefore should be preventable.…”

“…This section is a “catch‐all” for other organizational and cultural issues at a facility that can impact PSM performance, where different locations may have somewhat different priorities that must be identified and pursued. A range of possibilities exist as outlined in the many sources on this topic [1, 21–23]. There could be a fundamentally‐poor balance of safety and production priorities on a daily basis, at least by some members of supervision.…”

Implementation Issues of PSM in a Fertilizer Plant: An Operations Engineer's Point of View

“…Now the need is to address the practical difficulties faced in implementing PSM elements and provide guidance for industries to overcome the issues. Many authors have provided recommendations for continuous improvements in PSM systems [2][3][4][8][9][10][11].…”