Process

safety Safety
Sharingtheexperience
sharingtheexperienc
e

Herald of Free Enterprise - 1987

Process safety moment

Lessons from past incidents
safety
sharingtheexperienc
e

Picture credit: MV Herald of Free Enterprise. Report of Court No. 8074 - Formal Investigation, July 29th 1987”, Department of Transport (UK),
 Further reading

 “MV Herald of Free Enterprise. Report of Court No. 8074 - Formal Investigation (Hon. Mr
Justice Sheen - Wreck Commissioner), July 29th 1987”, Department of Transport (UK),
Her Majesty's Stationery Office, 1987, ISBN 0 11 550828 7. *
 “Reducing error and influencing behaviour”, UK Health and Safety Executive – (HSG 48).
 Incidents that define Process Safety, CCPS, ISBN 978 0 47012, 204 4 (available from
Wiley http://eu.wiley.com/WileyCDA/WileyTitle/productCd-0470122048.html )
 “Operating Procedures” UK Health & Safety Executive
http://www.hse.gov.uk/comah/sragtech/techmeasoperatio.htm
 “Guidelines for Writing Effective Operating and Maintenance Procedures” CCPS, ISBN
978-0-8169-0658-1(available from Wiley
http://www.wiley.com/WileyCDA/WileyTitle/productCd-0816906580.html )
* Main information sources used for the animation development
 Disclaimer

 The objective of this series of animations is not to replace investigation reports: each of the incidents
described in this series led to hundreds, if not thousands, pages thick reports and many specialized books
have been written by experts. However, it is felt that there is a need to disseminate more widely and with a
simple, user-friendly tool, the main lessons from major past incidents.

 This animation’s only ambition is to be an awareness-raising tool and to give the useful references that may
be needed for more detailed analysis. It was developed from articles published in the specialized press and
is intended for educational purposes only. Some errors may appear, caused by lack of information,
inaccurate information or necessary simplification of the hundreds of pages published on each incident by
investigators. Their use must thus be limited to the promotion of safety awareness on the basis of general
recommendations.

 It is sincerely hoped that the information presented in this document will lead to an even more impressive
safety record for the entire industry; however, whilst the Institution of Chemical Engineers and BP have
made every effort to ensure the accuracy of the information contained in this presentation, the Institution of
Chemical Engineers and BP and their employees do not warrant or represent, expressly or by implication,
the correctness or accuracy of the content of the information presented. As between (1) the Institution of
Chemical Engineers and BP and their employees, and (2) the user of this animation, the user accepts any
legal liability or responsibility whatsoever for the consequence of its use or misuse.
 Content and use

Content
• A Process Safety moment animation for a 5 minutes (minimum) discussion;
• References to learn more

Examples of themes that it can be used for:

• Reliance on Procedures
• Design of alarm systems
• Management of change (Organisational and creeping changes)
• Major accident potential
• Layers Of Protection concept
• Hazard Identification
 Preparation

 The key to a successful process safety moment/exercise will be the time that you can put aside for
preparation. It is important that you are both familiar and comfortable with the material and structure
of the presentation.
 These notes are provided to help you and should be used to complement your knowledge of the
subjects to be discussed. They aren’t meant to be used in their totality, verbatim; but more as a
reference.
 We would suggest that as a minimum:
 Read these notes; work through the detail of presentation and animation at least two or three
times
 Print off the slides and notes
 It is essential that you identify examples within your operation. It would be even better if one of the
examples was something that you are involved in.
 Prepare at least two examples of your site safeguards.
 Identify the human element associated with operations stages.
 Identify what will happen to the situations identified during the brainstorming that are not within the
teams control e.g. they will be fed into the local HSE committee.
Equipment:
 If this presentation is for more than 3-4 people, we strongly advise
you use a video projector and speakers.
 Troubleshooting
1. I DON'T HAVE FLASH PLAYER SOFTWARE:
 The animations should start automatically in slide show mode. If not, make sure you have a Flash Player
program (this is usually installed on your machine if you browse the Web regularly). You can download the
latest Flash Player Plugin by copying the following address in your Internet explorer:
http://www.adobe.com/products/flashplayer/

 Follow the steps and install the player (you'll know when it's done when it shows you a little Flash label animation). It may not
install at first, and may prompt you to select a small ActiveX title bar before installing.

2. I ALREADY HAVE FLASHPLAYER SOFTWARE BUT THE ANIMATIONS DON'T PLAY:

or/and WHEN I OPEN THE POWERPOINT FILE, A WINDOW TELLS ME THAT SOME CONTROLS ARE NOT
REGISTERED
or/and I INSTALLED A NEW VERSION OF THE FLASHPLAYER SOFTWARE AND THE ANIMATIONS DON'T WORK
ANYMORE:
 You will have to un-install FLASH PLAYER and re-install it again. This is due to a previous uploading of FLASH PLAYER
software without 'cleaning' the older versions first.
 To un-install FLASH PLAYER, go to
http://kb.adobe.com/selfservice/viewContent.do?externalId=tn_14157&sliceId=2
 Then install it again (see question 1 above).

3. SOUND:
 Make sure the sound setting on your computer is ON. It is recommended to add external speakers to your computer to play this
for a large audience.

 4. I'VE DONE ALL THE ABOVE AND STILL HAVE TROUBLE:

 Please contact your local IT support.
 Commercial terms

 This presentation is for use solely within the individual/company

which has purchased it and for the number of users paid for. No
further dissemination within or outside of the purchasing company is
allowed. The presentation must not be altered or elements of it used
to produce other training material without the express permission of
IChemE and payment of an appropriate fee if deemed necessary.