“The 1990 HAZOP team recognized the possibility that personnel could be injured when opening the polymer catch tank cover if pressure had accumulated. A pressure gauge
was installed on the vent line to address this concern, as recommended. However, neither the 1990 nor 1999 HAZOP studies identified the possibility that the polymer
plugging in the line could render the gauge useless.”
“However,” like “nevertheless” mentioned previously, is a warning flag that a “did not” is about to pop up. In this case, it’s the “neither – nor” preface to the assertion that
the two studies missed a critical event with likelihood of precipitating catastrophe.
“The potential hazards associated with startup and shutdown operations were not addressed because this was not a requirement of the HAZOP protocols.”
The “were not” and “was not” excuses seem to allege that the HAZOP protocols were inherently incompetent, yet these potentially revealing omissions are just permitted to lie
there without further inquiry or explanation, or assignment of accountability.
Similar vagueness is reflected in the report’s Executive Summary, wherein the key issues are “…recognition of reactive hazards, learning from near miss accidents, and opening
of process equipment.” Note that all are couched in terms of explicit “did nots”:
- Amoco, the developer of the Amodel process, did not adequately review the conceptual process design to identify chemical reaction hazards;
- The Augusta facility did not have an adequate review process for correcting design deficiencies; and
- The Augusta site system for investigating incidents and near-miss accidents did not adequately identify causes or related hazards. The information was needed to
correct the design and operating deficiencies that led to the recurrence of incidents.
How do we know that these factors were inadequate? Because had they been adequate, the mishap wouldn’t have occurred, would it?
These are a few of the forms of “did not” that are inserted into mishap reports to avoid identifying explicit deficiencies or behaviors that need changing. Will any of these
conclusions help improve the system’s operation? Don’t bet on it. Stick your neck out and specify to the investigators that you need them to identify what happened,
define specific deficiencies – without “did nots” – and make specific recommendations to change the behaviors that produced the mishaps.
Copyright © 2005 by Ira J. Rimson and Ludwig Benner, Jr. All rights reserved.
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