رهنمودهایی برای بررسی رخدادهای ایمنی فرایند ۲۰۱۹
Guidelines for Investigating Process Safety Incidents 2019

1. Cover

2. Title Page

3. Title Page

4. Copyright

5. PREFACE

6. ACKNOWLEDGMENTS

7. ACRONYMS AND ABBREVIATIONS

1 INTRODUCTION

2 OVERVIEW OF CHEMICAL PROCESS INCIDENT CAUSATION

3 AN OVERVIEW OF INVESTIGATION METHODOLOGIES

4 DESIGNING AN INCIDENT INVESTIGATION MANAGEMENT SYSTEM

5 INITIAL NOTIFICATION, CLASSIFICATION AND INVESTIGATION OF PROCESS SAFETY INCIDENTS

6 BUILDING AND LEADING AN INCIDENT INVESTIGATION TEAM

7 WITNESS MANAGEMENT

8 EVIDENCE IDENTIFICATION, COLLECTION AND MANAGEMENT

9 EVIDENCE ANALYSIS AND CAUSAL FACTOR DETERMINATION

10 DETERMINING ROOT CAUSES—STRUCTURED APPROACHES

11 THE IMPACT OF HUMAN FACTORS

12 DEVELOPING EFFECTIVE RECOMMENDATIONS

13 PREPARING THE FINAL REPORT

14 IMPLEMENTING RECOMMENDATIONS

15 CONTINUOUS IMPROVEMENT FOR THE INCIDENT INVESTIGATION SYSTEM

16 LESSONS LEARNED

24. APPENDIX A.PHOTOGRAPHY GUIDELINES FOR MAXIMUM RESULTS

25. APPENDIX B. EXAMPLE PROTOCOL – CHECKING POSITION OF A CHAIN VALVE

26. APPENDIX C.PROCESS SAFETY EVENTS LEVELING CRITERIA

27. APPENDIX D.EXAMPLE CASE STUDY

28. APPENDIX E. QUICK CHECKLIST FOR INVESTIGATORS

29. APPENDIX F. EVIDENCE PRESERVATION CHECKLIST – PRIOR TO ARRIVAL OF THE INVESTIGATION TEAM

30. APPENDIX G. GUIDANCE ON CLASSIFYING POTENTIAL SEVERITY OF A LOSS OF PRIMARY CONTAINMENT

31. GLOSSARY

32. REFERENCES

33. INDEX

34. WILEY END USER LICENSE AGREEMENT