Milos Ferjencik

Best starting point to comprehensive process safety education

Instruction in process safety began at the Faculty of Chemical Technology, University of Pardubice, in the nineties. In 1994, a course named the Safety Engineering was formed. We aimed to equip our students with a theory that would orientate them in safety problems during their professional lives. Similar to analogous courses at other universities, the Safety Engineering course tends to follow basic steps of the quantitative risk analysis (QRA). An accident analysis and two basic notions—a system and a hazard—were selected as starting points of the course.

IPICA_Lite—Improvements to root cause analysis

Abstract A few modifications can significantly improve root cause analysis using predefined trees. These modifications are based on adopting four ideas: (1) Causes represent deficiencies in processes. (2) Processes connected to causes are grouped into a hierarchy. Superior processes shape the subordinate ones. (3) The same safety management system can be applied to all processes in the hierarchy. (4) The structure described in the CCPS Guidelines for Risk Based Process Safety represents a universally applicable safety management system. Simultaneously, it can be transformed into a universal RBPS Root Cause Map. The resulting IPICA_Lite procedure described in this paper can serve as a tool that identifies underlying causes, including the problems inherent in a safety culture, and promotes corrective recommendations including the third layer recommendations, enforcement of which is often difficult.

An integrated approach to the analysis of causes of crime/public disorder—A case study for the “Tlahuac” incident

Abstract The article by Santos-Reyes et al. (2009) [1] on the cause analysis of the “Tlahuac” incident demonstrates the applicability of the MORT method to a problem concerning crime/public disorder. Although the idea to expand the use of MORT to the complete root cause analysis (RCA) using the predefined tree MORT is natural, at least three deficiencies are expected: (1) limited applicability to causal factors identified in the incident, (2) insufficient depth of cause analysis, and (3) insufficient coverage of safety culture. Therefore, an innovative integrated approach is recommended that extends the abilities of the RCA. The outline of reanalysis illustrates the application of the integrated approach and demonstrates its important features: (i) identification of causal factor processes; (ii) the presence of two cause levels under the root cause level; and (iii) the application of a STAMP-type technique to the causal factors and cause levels where the RCA is not applicable. The integrated approach is able to identify a wider and deeper set of causes than root cause analysis. It is suitable for the cause analysis of causal factors occurring in unorganized and uncontrolled processes, which are considered to be the special features typical for incidents of crime or public disorder.

Velocity and range of fragments from accidental explosions

A method for determining the initial velocity and range of flying fragments is proposed. Quantity‐Distance (Q‐D) principles are discussed and some arguments are presented for why even the observance of Q‐D principles cannot prevent sympathetic explosions due to flying fragments. Example calculations are included and the results are compared to the results of an actual explosion. The results show that this method should be suitable for evaluating fragment velocity and range. Limitations of the method and proposals for possible future improvements are discussed in the conclusions.

Virtual learning for safety, why not a smartphone?

This article aims to examine the effectiveness of a Virtual Learning Environment (VLE) using Kolbs Experiential Learning Theory (ELT) for chemical laboratory safety. A VLE model of a distillation column rig situated at the chemical engineering department, at the University of Nottingham (UK) was designed for the purpose of safety and hazard awareness training for first year laboratory students. The basic pedagogical ideas behind the model were to compare the effectiveness of passive learning used in traditional safety training with the way a VLE can deliver an active learning platform. Based on the collected experience, this article investigates issues that arose while correlating a VLE model with Kolbs ELT. Some of the drawbacks of the VLE model have been taken into consideration while designing a mobile game application for the purpose of laboratory safety training at the Research Laboratory of Energetic Materials at Pardubice University (Czech Republic). This is believed to offer more scope to develop constructivist learning using a smartphone.

The great commandment of process safety

The article [1] is inspired by Old Testament. Ten process safety rules considered to be the most important by the author are listed in the article. It is known from New Testament that Jesus when asked “which is the great commandment in the law” he summarized the entire Jewish law into only two rules. First of them is known as Greatest Commandment (Love thy Lord thy God) and the second one is referred to as the Golden Rule of Christian ethics (Love thy neighbor as thyself). We think that similarly the ten commandments of riskbased process safety from [1] can be boiled up into two most general rules which should be followed by any manager: GR1. Thou shalt always maintain a sense of vulnerability. Any thy equipment may fail, any thy personnel may make an error. Even thou thyself art vulnerable and fallible. GR2. Thou shalt always keep an understanding for vulnerability of thy personnel. They are thy neighbors. Help them resist their fallibility and do not tempt their fragility. We believe that formulation and explanation of ten commandments in [1] is helpful. Nevertheless, we would like to draw attention to the fact that all the commandments flow from a common source. Brief argumentation is given below on why we think that such a reduction is possible and reasonable: I. Thou shalt always honor thy container. Containers represent substantial part of equipment in processes that keep chemicals and energy. Care for the containers stems directly from the knowledge that each of containers can fail and cause damage. Commandment I, therefore, results from GR1. II. Thou shalt always maintain a sense of vulnerability. Commandment II constitutes main part of GR1. Manager that is aware of GR1 feels obliged to disseminate and promote sense of vulnerability among all persons involved in the process. III. Thou shalt eliminate normalization of deviation. Normalization of deviations described in the article represents a sort of mechanisms how human fallibility can be materialized. It is a task of a manager according to GR2 not to allow deviations to promote in this way and cope with them, for example, using tools such as management of change. IV. Thou shalt know thy chemistry. The comment in the article [1] itself identifies Commandment IV to be a consequence of Commandment II (or GR1 in our wording). Knowledge of our chemistry is a piece of information that lays in the fundament of our process. Similarly as any other part of our process it is never perfect and may cause failures or errors. V. Thou shalt educate, train, and drill employees. It means to be concerned about their own safety. Constant and effective training is an important tool to help employees resist their fallibility. This commandment would be then grouped in GR2, as it is all about ensure other human beings integrity. VI. Thou shalt create and nurture a strong risk-based process safety culture. Safety culture is a term related to attitude of personnel. If there is not a safety culture, where people rank safety in first place, no amount of training will suffice. This commandment can be also derived from GR2, for it praises safety among people. VII. Thou shalt recognize those who exemplify process and occupational safety. Again, this commandment would be part of GR2, for recognition is the main way to incentive safety culture, as the safety itself is a difficult concept to actually experience in daily life. VIII. Thou shalt not tolerate omissions in documentation. Omitting things which are obligatory, but can be skipped is always tempting, because it can seem that omission of “unnecessary” details allows us to do our work faster with less effort, no matter it can be less safe. Accepting this attitude is against GR2, because it can expose the personnel to unsafe situations. IX. Thou shalt not manage from behind thy desk. This approach is manifestation of the missing empathy with our neighbors and thus crossing GR2. Manager sitting behind his/her desk does not help his/her subordinates resist their fallibility and does tempt their fragility. X. Thou shalt not violate rules. Violating the rules is similar to omissions—circumventing or altering the barriers, which are set to protect people from their fallibility, is in direct contradiction with GR2.

Is our apparatus foolproof?: Examination of safety‐important characteristics of an electrostatic discharge tester for explosives

Technicians in laboratories and factories need the instruments and equipment which they use to be reliable, available, maintainable, and safe. In addition, sometimes an apparatus is also required to be foolproof. This article deals with the question of how the concept of foolproofness may be defined and tested. To clarify its meaning, the term “foolproofness” is compared with a similar concept—that of inherent safety. The article proposes a criterion describing acceptable foolproofness of an instrument, and a procedure which may be used to test whether the apparatus is acceptably foolproof. An example illustrates how the procedure to examine foolproofness may be applied. Selected parts of a case study show that the procedure is applicable to the analysis of scientific apparatus under development, and that it is able to provide the designer with reasonable results. It helps reveal the areas where the design of apparatus could be improved.

Reliability Testing of Assumptions about Hydrological Permeability of Drainage Paths in Dangerous Waste Storage Site

Two assumptions about development of hydrological permeability of drainage paths in a storage site were formulated. Validity of the assumptions was tested with the aid of system reliability analysis tools. The scheme of the drainage paths was converted into a graphical model suitable for the analysis. In order to identify the input data, geologists were asked to classify the possibility of creating a barrier for each predisposition type. Verbal characterizations were interpreted as point estimates of probabilities. Quantifications resulted in values that were in accordance with the assumptions. The testing confirmed applicability of the assumptions for safety assessment of the storage site.