Process Accidents;

Lessons Learned the Hard Way

(and how to avoid them)
Paul Gruhn, P.E., ISA Fellow
Standards
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Introduction of Speaker

Paul Gruhn
Safety Systems Specialist for >25 years
ISA Fellow
Member of ISA 84 & 101 committees
Developer & Instructor for ISAs courses on
Safety Instrumented Systems
Author of two ISA books
Developer of 1st commercial safety system
modeling software
Registered Professional Engineer in Texas
(and member of CSE exam team)
ISA 84 Expert

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Accidents continue to happen

And theyre hard to explain away

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Even simple things can go horribly wrong

Accidents are not caused by single failures

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Its usually unforeseen combination of events

Everyone needs training

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People must be competent & qualified

People must follow procedures

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People must follow procedures

Yet trained people still do stupid things

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And even trained people make mistakes

And more mistakes

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It only takes one slip-up

Some dont know what they dont know

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Were not as indestructible as we think

Perform thorough hazards analysis

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We cant think of every scenario

We cant think of every scenario

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Reuse of software is not always successful

Ariane 5 missile
Therac-25

Near misses not followed up

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Near misses not followed up

Dont ignore the past

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Learn from past mistakes

Key take away

It should not be necessary for each

generation to rediscover principles of
process safety which the generation
before discovered. We must learn from
the experience of others rather than
learn the hard way. We must pass on to
the next generation a record of what we
have learned. Jesse C. Ducommun
Remember Flixborough, Seveso, TMI,
Bhopal, Piper Alpha, Chernobyl, Norco,
Pasadena, Channelview, P36

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Lessons learned

Safety must come from the

top down
Learn from the mistakes of
others; youre not immune
Learn from near misses
Perform thorough hazards
analysis
Identify and specify
requirements
Maintain and test systems
properly
Follow management of
change

Safety The Easy Way!

Hey, now wait a minute !

If all this is too much
do what the French did 200 years ago...
they passed a law requiring an
explosives manufacturer to
live on the premises...
with his family!

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Questions / Discussion

Paul Gruhn, P.E.

Rockwell Automation
pgruhn@ra.rockwell.com

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