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Management System Failures Identified in Incidents Investigated by the U.S. Chemical Safety and Hazard Investigation Board

机译:美国化学安全与危害调查委员会调查的事件中识别出的管理系统故障

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摘要

A key mission of the US Chemical Safety and Hazard Investigation Board (CSB) is to determine the root causes of incidents, report the findings, and issue recommendations to prevent similar incidents from occurring. CSB investigators respond to a variety of events occurring in a wide range of workplaces, from chemical plants and refineries to food-flavoring factories and steel mills. The details of each investigation are unique and the root causes are pertinent to each specific case. However, a common thread that emerges in CSB investigations is the inadequacy of management systems that might have prevented the incident from occurring. Examples of the systemic issues identified in CSB reports are: 1. Lack of hazard review to predict and prevent incidents 2. Insufficient investigation and follow-up after previous incidents 3. Inadequate training of staff 4. Failure to implement effective mechanical integrity programs These issues are well recognized as elements of a process safety management (PSM) program, although many incidents investigated by the CSB occurred at facilities that are not regulated by OSHA's process safety management rule. Indeed, a number of these incidents occurred at facilities that are well outside society's definition of "chemical plants." Please note that the opinions and conclusions expressed in this paper are those of the author, and do not necessarily represent the opinions of the Chemical Safety and Hazard Investigation Board.
机译:美国化学安全与危害调查委员会(CSB)的主要任务是确定事故的根本原因,报告调查结果并发布建议,以防止发生类似的事故。 CSB的调查人员应对从化工厂,精炼厂到调味食品厂和钢厂等各种工作场所中发生的各种事件。每次调查的细节都是唯一的,根本原因与每个具体案例有关。但是,CSB调查中出现的一个共同线索是管理系统的不足,这可能阻止了事件的发生。 CSB报告中发现的系统性问题的示例包括:1.缺乏危害评估以预测和预防事件的发生2.先前事件发生后的调查和跟进不足3.对员工的培训不足4.无法实施有效的机械完整性计划这些问题尽管CSB所调查的许多事件发生在不受OSHA流程安全管理规则约束的设施上,但它们仍被公认为流程安全管理(PSM)计划的要素。确实,其中许多事件发生在社会对“化工厂”的定义之外的设施中。请注意,本文中表达的观点和结论是作者的观点,并不一定代表化学安全与危害调查委员会的观点。

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