![American Society of Safety Engineers â Middle East Chapter (ASSE-MEC) 9th Professional Development Conference & Exhibition (PDC&E) February 20-24, 2010 Kingdom of Bahrain The study of near misses and the knowledge management in mature industries Patrizia Agnello, Silvia Ansaldi, Paolo A. Bragatto, Paolo Pittiglio ISPESL - Italian Institute for Occupational Safety and Prevention Via Fontana Candida 1 â Monteporzio Catone (Roma) â 00040 Italy Contact author: [email_address]](https://image.slidesharecdn.com/assebragatto24feb10-100430104611-phpapp02/85/Asse-bragatto-24_feb_10-1-320.jpg)
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- 1. American Society of Safety Engineers â Middle East Chapter (ASSE-MEC) 9th Professional Development Conference & Exhibition (PDC&E) February 20-24, 2010 Kingdom of Bahrain The study of near misses and the knowledge management in mature industries Patrizia Agnello, Silvia Ansaldi, Paolo A. Bragatto, Paolo Pittiglio ISPESL - Italian Institute for Occupational Safety and Prevention Via Fontana Candida 1 â Monteporzio Catone (Roma) â 00040 Italy Contact author: [email_address]
- 5. Regulatory Inspections Penalties Internal Audits Control Sanctioned by Authorities or by Experts Committees Internal Approval by the duty-holder Ratification Weak, Layered, Not conflicting each-other Strong, Hierarchical Structure (reciprocal links among single rules in the system) Experience Based, Prescriptive Risk Based, Deductive Based on- An entire industry A single firm Scope 10 years or more 1 year or less Life cycle (typical revision time) Public Domain Proprietary / Internal Ownership of the Knowledge Safety Regulatory System Safety Management System
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- 10. List of top events Event Risk assessment Accidental sequence unit Facility Accessory Mond Index Penality Credit Component Risk Management Emergency Plan Emergency Action
- 11. Safety Mgmnt System List of top events Event Safety Report Accidental sequence Emergency Plan Emergency Action Inspection Plan Inspection OperatingManual Operating Procedure Action unit Facility Accessory Mond Index Penality Credit Component
- 12. List of top events Event Risk assessment Accidental sequence Emergency Plan OperatingManual Inspection Plan Emergency Action Operating Procedure Risk Management Inspection Action unit Facility Accessory Mond Index Penality Credit Component
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- 22. The study of near misses and the knowledge management in mature industries Patrizia Agnello, Silvia Ansaldi, Paolo A. Bragatto, Paolo Pittiglio ISPESL - Italian Institute for Occupational Safety and Prevention Via Fontana Candida 1 â Monteporzio Catone (Roma) â 00040 Italy Contact author: [email_address] Thanks for your attention! Grazie!
Hinweis der Redaktion
- Basically Safety Digital Representation is Equipment digital representation plus digital safety documents plus link between each other. Iâm going to shoow The benefits of this model f or assisting operators in analyzing near misses as well for updating the safety documents The backbone of the proposed system is the digital representation of the equipment. The equipment representation has been integrated with a digital representation of the safety system. In our approach, the scrutiny of the plant, required by the HAZID methods, is exploited to build step by step a plausible representation of the plant. The hierarchical structure has basically five nested levels: Facility, Unit, Assembly, Component, Accessory or Instrument. Examples are all based on MOND index. (Mond index is based on penalities and credits)
- CLICK There are many links between equipment and safety documents, which may be used. CLICK Namely any single items of the Mond check list is linked to one or more components or assembly, Penality are linked to unit beacuse hazardous substances Credit are linked to safety system component or acessory.CLICK any event in a chain leading to a top event is linked to a component, any action of a safety procedure is linked to an accessory or a component Components and accessories are considered critical if their failures are in a chain of events, which could lead to a major accident. They are tagged and linked to a top event,, as handled in the SR. In this way the top event list is embedded in the digital representation of the plant. CLICK At the end, the emergency plan may be included in the net, too. For each major event found by the hazard analysis, the plan should have an action or a sequence of actions. In this way any emergency action is linked to an event, which is in the top events list. Furthermore the actions require usually operations to be done on accessories (e.g. valves), which have to be included in the plant digital representation.
- procedure of the safety management system has action on the accessories (may be valve, switch), on machine, pumpe, reactor or other component CLICK In the safety management system there is also the inspection plan, which says when an acessory or a component has to be checked For instance for pressure equipment there os an yealry inspection on relief valves and avery five or the years a general inspection on mechanical condition. CLICK Just SR and safety manual, which are mandatory according to the Seveso legislation, have been used. The pieces of information, usually lost after the job of preparing mandatory safety documents, are stored in a structured way, in order to have a complete representation of the whole system, including the equipment, the hazard ranked according to the Mond index, the list of the top events, the sequences of failures that lead a top event, the sequence of actions in the emergency plan, the SMS and the operating manual.
- ANALYSING NEAR MISSES In this structured digital environment, the near misses shall be recorded. The backward path from the single event (failure, near miss or accident) to the safety system is supported by the complete digital representation of the plant. When a failure or near miss is reported, it is connected to a piece of equipment (component or accessory), present in the plant digital representation. The details will be demonstrated later The basic result of this continuous trial of reporting any non conformance, which happens somewhere in the plant, and walks inside the plant digital safety representation, is to have, after a short time, the safety documents (basically Mond check list, top event sequences and safety procedures) with a large number of notes, which should be used for the periodic reviewing.