Considerable reductions in process safety incidents have not been realized over the past 40 years despite the extensive developments in technology. Root causes for these incidents remain the same but the likelihood and severity of consequences have been slightly reduced. The debate continues - Why do we continue to experience similar incidents even with establishment of new tools, technologies, management systems and lessons learned?

Is it the lack of process safety competency, corporate culture, or complexity of current management systems and associated tools contributing to the continuation of the learning failures?

This paper will review the mutual causes of learning failures from past major process safety incidents and examine what has not changed over several decades. Improvement opportunities are provided for the most common learning gaps.


Learning from incidents is not limited to just incident investigation, but much beyond that, learning from incidents is also ingrained into corporate policies, engineering and design standards, and operating management systems. So, it is important to identify and eliminate the gaps in these processes and systems to prevent the recurrences of major accidents.

With enormous overall technological developments in the last several decades, processes, tools and management systems are getting more complex leading to inconsistency in operating management systems and hamper the effective implementing.

The design, construction, and operation bring several opportunities for errors and mistakes during the life cycle of a project. That's why every project, when handed over to operations, has a long list of design and installation deficiencies.

During the initial startup, operating set points are changed and a number of safety systems and alarms are bypassed. Some of these bypassed critical systems are never restored due to a lack of effective management programs.

Consistent gaps are discovered in the operating management systems and process safety knowledge of the workforce. The most common causes of learning failures and improvement opportunities are clarified in order for each of the identified gaps to advance the learning process and prevent the recurrences of process safety incidents.

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