Link to Task Analysis resources

 

Over the last couple of year I have led a small team writing a compendium of Trevor Kletz's work on behalf of IChemE. I am very pleased and excited to say it now available to buy from the publisher's website https://lnkd.in/d3uEwsY

The book showcases the work of Trevor Kletz with new case studies and insights into latest practices. It covers the topics that he identified to process safety.

Rereading all of Trevor's books and other works reminded me how much I have been influenced by him in my career. I was genuinely surprised at how much of what he said I still apply today, almost instinctively. Unfortunately we are still having accidents around the world that perfectly illustrate what Trevor was saying decades ago.

Presented 2018 via Skype to process safety professionals in Pakistan

Incident investigations often conclude that one of the causes was either that people did not follow a “good” procedure or that procedures were not fit for purpose. These findings are often based on an inflated opinion of what procedures can achieve. The reality is that procedures appear very low on the hierarchy of risk control and will only ever make a fairly modest contribution to safety. Avoiding hindsight bias when considering the role of procedures in incidents can mean that more effective recommendations can be made, leading to a set of procedures that provide effective support to competent people.

Published in Loss Prevention Bulletin December 2018.  Available as a free download at https://www.icheme.org/media/7205/lpb264_pg09.pdf

Poor communication at shift handover was identified as one of the causes of the Piper Alpha disaster. The operators decided to start the standby condensate pump but did not realise its relief valve was not in place. The inquiry into the disaster found no evidence to suggest that the people involved had done this intentionally and concluded that they made decisions that, in hindsight, were clearly wrong because they did not have a full and accurate understanding of equipment status and condition.
Unfortunately, in the 30 years since Piper Alpha there has been relatively little effort put into improving shift handover across industry. This is despite subsequent major accidents where problems with shift handover failures have been identified.
This paper summarises the issues of shift handover and the challenges with achieving improvement. It refers to work carried out at a client’s site to improve shift handover, which has had a very positive effect on shift workers and their managers.

Published in Loss Prevention Bulletin June 2018