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Rethinking bhopal : a definitive guide to investigating, preventing, and learning from industrial disasters / Kenneth Bloch.

By: Material type: TextTextPublisher: Boston, MA : Elsevier, 2016Description: xxix, 479 p. : ill, map ; 24 cmContent type:
  • text
Media type:
  • unmediated
Carrier type:
  • volume
ISBN:
  • 9780128037782 (pbk.)
Subject(s): DDC classification:
  • 23 363.11 BLO 009137
Online resources:
Contents:
pt. 1 PROCESS RELIABILITY ch. 1 Industrial Learning Processes The Bhopal Disaster Policies and Regulations The Process Safety Management Movement Repeat Failures The Incentive to Change From Simplicity to Complexity Incident Prevention Investigation Reports Lessons for Us References ch. 2 Equipment Reliability Principles Being in Control Break-Even Analysis Patents and Trade Secrets Process Flexibility Asset Protection Functional Combinations Managing Performance Loss Functional Failures Reliability Plans Reliability Analysis Justifying Design Changes Preventing Premature Failure Spare Assets Reliability Performance Metrics Mean Time to Repair Failure Rate Mean Time Between Failure The Human Condition ch. 3 Incident Investigation The Normalization of Deviance Investigation Triggers Culture and Context Contents note continued: Neutrality The Investigation Procedure Phase I Front-End Loading Step 1 Collect Witness Statements Step 2 Gather Physical Evidence Step 3 Start Constructing a Timeline Step 4 Witness Clarification Step 5 Assess Contradictions and Cavities Phase II Pattern Matching Step 6 Organize Facts and Evidence Step 7 Propose Possible Scenarios Step 8 Populate the Fact Hypothesis Matrix Step 9 Create a Logic Problem Step 10 Solve the Logic Problem Step 11 Record Logic Problem Results Step 12 Dead-End Assessment Step 13 Reject Scenario and Select a New Scenario Step 14 Document Conclusions Step 15 Update the Timeline Phase III Closure Discipline Step 16 Assess Timeline Completion Step 17 Develop Recommendations Preserving Acquired Knowledge Step 18 Independent Investigation Review Probable and Precise Cause ch. 4 Role Statement and Fulfillment Contents note continued: Industrial Amnesia Establishing Process Reliability Expectations Production Constraint Removal Tracking Performance Measures Developing Process Safety Skills Assessing Process Performance and Improvement Justifying Cases for Action Validating Performance Results Preserving the Value of Acquired Knowledge Cooperative Communication Supervision's Responsibilities ch. 5 Spent Caustic Tank Explosion: A Case Study in Inherently Safer Design Witness Statements Process and Asset Description Hazard Control Background Process Hazard Analysis Action Item Design Change Incident Investigation Design Defects Procedure Deviation Worker Interviews Warning Signals Ignition Source Evaluating Causes Functional Recovery Organizational Culture pt. 2 RESEARCH AND DEVELOPMENT ch. 6 Inventing Solutions Event Description Contents note continued: Technical Analysis ch. 7 Product Manufacturing and Distribution Technical Assessment Hazard Awareness Process Optimization ch. 8 Process Selection ch. 9 Industry Compliance ch. 10 Production Commitments pt. 3 PROCESS CONFIGURATION ch. 11 Licensing ch. 12 Factory Construction Methyl Isocyanate Refining Still Methyl Isocyanate Storage Tanks Methyl Isocyanate Circulation and Transfer Pumps Methyl Isocyanate Refrigeration Methyl Isocyanate Vapor Management Vent Gas Scrubber Contents note continued: Instrumentation, Gauges, and Alarms ch. 13 Process Hazard Awareness and Analysis Summary Rundown Tank Node Hypothetical Scenario Risk Calibration Consequence Category Frequency of Consequence Independence Passive Protection Evaluating Double Jeopardy Human Intervention ch. 14 Commissioning Phase ch. 15 Repeat Mechanical Seal Failures: A Case Study in Pump Reliability Improvement Acceleration Basics Detecting and Investigating a Vibration Problem Acceleration Limit Revisiting Reliability Growth Plots Unstable Hydraulics Casting Defects Suspected Applying Modern Hydraulic Selection Criteria Suction Recirculation Reliability Factor Busting Cavitation Myths Contents note continued: pt. 4 OPERATIONS AND PRODUCTION ch. 16 Management of Change ch. 17 Process Isolation and Containment ch. 18 Employee Participation ch. 19 Compliance Audits ch. 20 Process Optimization ch. 21 Maintenance Failure ch. 22 Human Error pt. 5 LESSONS LEARNED ch. 23 Crude Unit Fire: A Case Study in Human Error Introduction Process Overview Investigation Inspection Results Contents note continued: Interviews Integrity Closure Instinct ch. 24 Reliability Commitment Lessons Learned What You Can Do.
Summary: Rethinking Bhopal: A Definitive Guide to Investigating, Preventing, and Learning from Industrial Disasters is the go-to source for anyone seeking to learn how to improve process safety management (PSM) through applying fundamental asset reliability and incident investigation concepts. The seeds that unified PSM on a global scale were planted in Bhopal, India on December 3, 1984. Since then, considerable progress has been made to protect both workers and communities from catastrophic industrial failures. Industry acknowledges its responsibility to create value with accrued operating experience and that using information received from previous failures is a direct way to prevent future incidents. With this principle in mind, Bloch evaluates modern references related to the Bhopal Disaster, using recognized industrial asset reliability and incident investigation concepts. The practice of objective incident investigation offers a compelling insight into specific decisions and actions that resulted in history's worst industrial disaster. Recording a fully transparent sequence of events promotes a personal sense of accountability for anyone involved in the manufacturing industry. Lessons learned can be immediately implemented by those with direct PSM, management, engineering, and operating responsibilities. Case histories demonstrate how patterns observed in the timeline leading up to the Bhopal Disaster can be detected in modern incidents and by recognizing these patterns in present-day processes avoids counterproductive operating decisions and unprecedented destruction. This text is instrumental in helping existing organizations re-evaluate their own exposures and risks, and would be a valuable read for any member of a process safety management team. Rethinking Bhopal: A Definitive Guide to Investigating, Preventing, and Learning from Industrial Disasters provides an expansion of knowledge and understanding for the novice in PSM while also providing depth and application considerations to challenge more experienced industry professionals. Note: All royalties from this book go to the Process Safety Heritage Trust Scholarship at Lamar University in Beaumont, Texas, USA.
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Includes bibliographical references and index.

pt. 1 PROCESS RELIABILITY
ch. 1 Industrial Learning Processes
The Bhopal Disaster
Policies and Regulations
The Process Safety Management Movement
Repeat Failures
The Incentive to Change
From Simplicity to Complexity
Incident Prevention
Investigation Reports
Lessons for Us
References
ch. 2 Equipment Reliability Principles
Being in Control
Break-Even Analysis
Patents and Trade Secrets
Process Flexibility
Asset Protection
Functional Combinations
Managing Performance Loss
Functional Failures
Reliability Plans
Reliability Analysis
Justifying Design Changes
Preventing Premature Failure
Spare Assets
Reliability Performance Metrics
Mean Time to Repair
Failure Rate
Mean Time Between Failure
The Human Condition
ch. 3 Incident Investigation
The Normalization of Deviance
Investigation Triggers
Culture and Context
Contents note continued: Neutrality
The Investigation Procedure
Phase I Front-End Loading
Step 1 Collect Witness Statements
Step 2 Gather Physical Evidence
Step 3 Start Constructing a Timeline
Step 4 Witness Clarification
Step 5 Assess Contradictions and Cavities
Phase II Pattern Matching
Step 6 Organize Facts and Evidence
Step 7 Propose Possible Scenarios
Step 8 Populate the Fact
Hypothesis Matrix
Step 9 Create a Logic Problem
Step 10 Solve the Logic Problem
Step 11 Record Logic Problem Results
Step 12 Dead-End Assessment
Step 13 Reject Scenario and Select a New Scenario
Step 14 Document Conclusions
Step 15 Update the Timeline
Phase III Closure
Discipline
Step 16 Assess Timeline Completion
Step 17 Develop Recommendations
Preserving Acquired Knowledge
Step 18 Independent Investigation Review
Probable and Precise Cause
ch. 4 Role Statement and Fulfillment
Contents note continued: Industrial Amnesia
Establishing Process Reliability Expectations
Production Constraint Removal
Tracking Performance Measures
Developing Process Safety Skills
Assessing Process Performance and Improvement
Justifying Cases for Action
Validating Performance Results
Preserving the Value of Acquired Knowledge
Cooperative Communication
Supervision's Responsibilities
ch. 5 Spent Caustic Tank Explosion: A Case Study in Inherently Safer Design
Witness Statements
Process and Asset Description
Hazard Control
Background
Process Hazard Analysis Action Item
Design Change
Incident Investigation
Design Defects
Procedure Deviation
Worker Interviews
Warning Signals
Ignition Source
Evaluating Causes
Functional Recovery
Organizational Culture
pt. 2 RESEARCH AND DEVELOPMENT
ch. 6 Inventing Solutions
Event Description
Contents note continued: Technical Analysis
ch. 7 Product Manufacturing and Distribution
Technical Assessment
Hazard Awareness
Process Optimization
ch. 8 Process Selection
ch. 9 Industry Compliance
ch. 10 Production Commitments
pt. 3 PROCESS CONFIGURATION
ch. 11 Licensing
ch. 12 Factory Construction
Methyl Isocyanate Refining Still
Methyl Isocyanate Storage Tanks
Methyl Isocyanate Circulation and Transfer Pumps
Methyl Isocyanate Refrigeration
Methyl Isocyanate Vapor Management
Vent Gas Scrubber
Contents note continued: Instrumentation, Gauges, and Alarms
ch. 13 Process Hazard Awareness and Analysis
Summary
Rundown Tank Node
Hypothetical Scenario
Risk Calibration
Consequence Category
Frequency of Consequence
Independence
Passive Protection
Evaluating Double Jeopardy
Human Intervention
ch. 14 Commissioning Phase
ch. 15 Repeat Mechanical Seal Failures: A Case Study in Pump Reliability Improvement
Acceleration Basics
Detecting and Investigating a Vibration Problem
Acceleration Limit
Revisiting Reliability Growth Plots
Unstable Hydraulics
Casting Defects Suspected
Applying Modern Hydraulic Selection Criteria
Suction Recirculation
Reliability Factor
Busting Cavitation Myths
Contents note continued: pt. 4 OPERATIONS AND PRODUCTION
ch. 16 Management of Change
ch. 17 Process Isolation and Containment
ch. 18 Employee Participation
ch. 19 Compliance Audits
ch. 20 Process Optimization
ch. 21 Maintenance Failure
ch. 22 Human Error
pt. 5 LESSONS LEARNED
ch. 23 Crude Unit Fire: A Case Study in Human Error
Introduction
Process Overview
Investigation
Inspection Results
Contents note continued: Interviews
Integrity
Closure
Instinct
ch. 24 Reliability Commitment
Lessons Learned
What You Can Do.

Rethinking Bhopal: A Definitive Guide to Investigating, Preventing, and Learning from Industrial Disasters is the go-to source for anyone seeking to learn how to improve process safety management (PSM) through applying fundamental asset reliability and incident investigation concepts. The seeds that unified PSM on a global scale were planted in Bhopal, India on December 3, 1984. Since then, considerable progress has been made to protect both workers and communities from catastrophic industrial failures. Industry acknowledges its responsibility to create value with accrued operating experience and that using information received from previous failures is a direct way to prevent future incidents. With this principle in mind, Bloch evaluates modern references related to the Bhopal Disaster, using recognized industrial asset reliability and incident investigation concepts. The practice of objective incident investigation offers a compelling insight into specific decisions and actions that resulted in history's worst industrial disaster. Recording a fully transparent sequence of events promotes a personal sense of accountability for anyone involved in the manufacturing industry. Lessons learned can be immediately implemented by those with direct PSM, management, engineering, and operating responsibilities. Case histories demonstrate how patterns observed in the timeline leading up to the Bhopal Disaster can be detected in modern incidents and by recognizing these patterns in present-day processes avoids counterproductive operating decisions and unprecedented destruction. This text is instrumental in helping existing organizations re-evaluate their own exposures and risks, and would be a valuable read for any member of a process safety management team. Rethinking Bhopal: A Definitive Guide to Investigating, Preventing, and Learning from Industrial Disasters provides an expansion of knowledge and understanding for the novice in PSM while also providing depth and application considerations to challenge more experienced industry professionals. Note: All royalties from this book go to the Process Safety Heritage Trust Scholarship at Lamar University in Beaumont, Texas, USA.

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