What Went Wrong? 6th Edition provides a complete analysis of the design, operational, and management causes of process plant accidents and disasters. Co-author Paul Amyotte has built on Trevor Kletz's legacy by incorporating questions and personal exercises at the end of each major book section. Case histories illustrate what went wrong and why it went wrong, and then guide readers in how to avoid similar tragedies and learn without having to experience the loss incurred by others. Updated throughout and expanded, this sixth edition is the ultimate resource of experienced-based analysis and guidance for safety and loss prevention professionals. - 20% new material and updating of existing content with parts A and B now combined - Exposition of topical concepts including Natech events, process security, warning signs, and domino effects - New case histories and lessons learned drawn from other industries and applications such as laboratories, pilot plants, bioprocess plants, and electronics manufacturing facilities
Human error is implicated in nearly all aviation accidents, yet most investigation and prevention programs are not designed around any theoretical framework of human error. Appropriate for all levels of expertise, the book provides the knowledge and tools required to conduct a human error analysis of accidents, regardless of operational setting (i.e. military, commercial, or general aviation). The book contains a complete description of the Human Factors Analysis and Classification System (HFACS), which incorporates James Reason's model of latent and active failures as a foundation. Widely disseminated among military and civilian organizations, HFACS encompasses all aspects of human error, including the conditions of operators and elements of supervisory and organizational failure. It attracts a very broad readership. Specifically, the book serves as the main textbook for a course in aviation accident investigation taught by one of the authors at the University of Illinois. This book will also be used in courses designed for military safety officers and flight surgeons in the U.S. Navy, Army and the Canadian Defense Force, who currently utilize the HFACS system during aviation accident investigations. Additionally, the book has been incorporated into the popular workshop on accident analysis and prevention provided by the authors at several professional conferences world-wide. The book is also targeted for students attending Embry-Riddle Aeronautical University which has satellite campuses throughout the world and offers a course in human factors accident investigation for many of its majors. In addition, the book will be incorporated into courses offered by Transportation Safety International and the Southern California Safety Institute. Finally, this book serves as an excellent reference guide for many safety professionals and investigators already in the field.
Bridging an identified gap between research and practice in the domain of risk and organizational learning with respect to human/organizational factors and organizational behaviour, this book highlights the common and recurring threads in contributory factors to accident causation. Based on an extensive research project, it investigates how shipping companies as organizations learn from, filter and give credence/acceptability to differing risk perceptions and how this influences the work culture with special regard to group/team dynamics and individual motivation. The work is presented in the context of the literature regarding conceptual links between risk and the theoretical and operational themes of organizational learning, and in light of interviewees' comments. The themes include processes and structures of knowledge acquisition, information interpretation and distribution, organizational memory and change/adaptation and also levels of learning. The book concludes by discussing some practical implications of the research carried out in various maritime contexts and gives recommendations for the industry and other stakeholders.
These proceedings document the various presentations at the Fourth Resilience Engineering Symposium held on June 8-10, 2011, in Sophia-Antipolis, France. The Symposium gathered participants from five continents and provided them with a forum to exchange experiences and problems, and to learn about Resilience Engineering from the latest scientific achievements to recent practical applications. The First Resilience Engineering Symposium was held in Söderköping, Sweden, on October 25-29 2004. The Second Resilience Engineering Symposium was held in Juan-les-Pins, France, on November 8-10 2006, The Third Resilience Engineering Symposium was held in Juan-les-Pins, France, on October 28-30 2008. Since the first Symposium, resilience engineering has fast become recognised as a valuable complement to the established approaches to safety. Both industry and academia have recognised that resilience engineering offers valuable conceptual and practical basis that can be used to attack the problems of interconnectedness and intractability of complex socio-technical systems. The concepts and principles of resilience engineering have been tested and refined by applications in such fields as air traffic management, offshore production, patient safety, and commercial fishing. Continued work has also made it clear that resilience is neither limited to handling threats and disturbances, nor confined to situations where something can go wrong. Today, resilience is understood as the intrinsic ability of a system to adjust its functioning prior to, during, or following changes and disturbances, so that it can sustain required operations under both expected and unexpected conditions. This definition emphasizes the ability to continue functioning, rather than simply to react and recover from disturbances and the ability to deal with diverse conditions of functioning, expected as well as unexpected. For anyone who is interested in learning more about Resilience Engineering, the books published in the Ashgate Studies in Resilience Engineering provide an excellent starting point. Another sign that Resilience Engineering is coming of age is the establishment of the Resilience Engineering Association. The goal of this association is to provide a forum for coordination and exchange of experiences, by bringing together researchers and professionals working in the Resilience Engineering domain and organisations applying or willing to apply Resilience Engineering principles in their...
The blowout of the Macondo well on April 20, 2010, led to enormous consequences for the individuals involved in the drilling operations, and for their families. Eleven workers on the Deepwater Horizon drilling rig lost their lives and 16 others were seriously injured. There were also enormous consequences for the companies involved in the drilling operations, to the Gulf of Mexico environment, and to the economy of the region and beyond. The flow continued for nearly 3 months before the well could be completely killed, during which time, nearly 5 million barrels of oil spilled into the gulf. Macondo Well-Deepwater Horizon Blowout examines the causes of the blowout and provides a series of recommendations, for both the oil and gas industry and government regulators, intended to reduce the likelihood and impact of any future losses of well control during offshore drilling. According to this report, companies involved in offshore drilling should take a "system safety" approach to anticipating and managing possible dangers at every level of operation-from ensuring the integrity of wells to designing blowout preventers that function under all foreseeable conditions-in order to reduce the risk of another accident as catastrophic as the Deepwater Horizon explosion and oil spill. In addition, an enhanced regulatory approach should combine strong industry safety goals with mandatory oversight at critical points during drilling operations. Macondo Well-Deepwater Horizon Blowout discusses ultimate responsibility and accountability for well integrity and safety of offshore equipment, formal system safety education and training of personnel engaged in offshore drilling, and guidelines that should be established so that well designs incorporate protection against the various credible risks associated with the drilling and abandonment process. This book will be of interest to professionals in the oil and gas industry, government decision makers, environmental advocacy groups, and others who seek an understanding of the processes involved in order to ensure safety in undertakings of this nature.
U.S. Arctic waters north of the Bering Strait and west of the Canadian border encompass a vast area that is usually ice covered for much of the year, but is increasingly experiencing longer periods and larger areas of open water due to climate change. Sparsely inhabited with a wide variety of ecosystems found nowhere else, this region is vulnerable to damage from human activities. As oil and gas, shipping, and tourism activities increase, the possibilities of an oil spill also increase. How can we best prepare to respond to such an event in this challenging environment? Responding to Oil Spills in the U.S. Arctic Marine Environment reviews the current state of the science regarding oil spill response and environmental assessment in the Arctic region north of the Bering Strait, with emphasis on the potential impacts in U.S. waters. This report describes the unique ecosystems and environment of the Arctic and makes recommendations to provide an effective response effort in these challenging conditions. According to Responding to Oil Spills in the U.S. Arctic Marine Environment, a full range of proven oil spill response technologies is needed in order to minimize the impacts on people and sensitive ecosystems. This report identifies key oil spill research priorities, critical data and monitoring needs, mitigation strategies, and important operational and logistical issues. The Arctic acts as an integrating, regulating, and mediating component of the physical, atmospheric and cryospheric systems that govern life on Earth. Not only does the Arctic serve as regulator of many of the Earth's large-scale systems and processes, but it is also an area where choices made have substantial impact on life and choices everywhere on planet Earth. This report's recommendations will assist environmentalists, industry, state and local policymakers, and anyone interested in the future of this special region to preserve and protect it from damaging oil spills.
