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Why major accidents are still occurring§
Paul R Amyotte1, Scott Berger2,3, David W Edwards4,5,
Jai P Gupta6, Dennis C Hendershot7, Faisal I Khan8,
M Sam Mannan9 and Ronald J Willey10
Major accidents happen in the process industries with relatively
low frequencies but extremely severe consequences. Harm to
workers and the public, loss of company property and other
assets, business interruption, and environmental degradation
are all possible outcomes of such events. This paper explores
the occurrence of major process accidents and offers
suggestions for their prevention according to seven core
concepts drawn from an analysis of the 1984 Bhopal tragedy: (i)
the creation of paradigm-enhancing organizations, (ii) inherently
safer design, (iii) awareness of the total cost of major accidents,
(iv) consideration of the broader societal and cultural aspects of
major accidents, (v) process safety culture, (vi) process safety
competency, and (vii) dynamic operational risk management.
Addresses
1
Department of Process Engineering & Applied Science, Dalhousie
University, Halifax, NS, Canada B3H 4R2
2
Former Executive Director (Retired), Center for Chemical Process
Safety (CCPS), New York, NY, USA
3
Vice President, AcuTech Consulting Group, USA
4
Granherne Ltd/KBR, Springfield Drive, Leatherhead KT22 7LH, UK
5
Visiting Professor of Safety and Loss Prevention, Loughborough
University, UK
6
Rajiv Gandhi Institute of Petroleum Technology, Ratapur Chowk, Rae
Bareli 229316, UP, India
7
CCPS Staff Consultant, Bethlehem, PA, USA
8
Department of Process Engineering, Memorial University, St. John’s,
NL, Canada A1B 3X5
9
Mary Kay O’Connor Process Safety Center, Artie McFerrin Department
of Chemical Engineering, Texas A&M University System, College
Station, TX 77843-3122, USA
10
Department of Chemical Engineering, Northeastern University,
Boston, MA 02115, USA
Corresponding author: Amyotte, Paul R (paul.amyotte@dal.ca)
Current Opinion in Chemical Engineering 2016, 14:1–8
This review comes from a themed issue on Process systems
engineering
Edited by Mahmoud El-Halwagi and Ka Ming Ng
For a complete overview see the Issue and the Editorial
Available online 27th July 2016
http://dx.doi.org/10.1016/j.coche.2016.07.003
2211-3398/# 2016 Elsevier Ltd. All rights reserved.
§
This paper is dedicated to the memory of Professor Trevor Kletz —
a visionary and a trailblazer, the likes of whom come in our midst only every few
centuries [8].
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Introduction
Major accidents in the process industries can be defined
as adverse events such as major leaks/releases, fires,
explosions or loss of structural integrity, leading to multi-
ple deaths and/or major damage to the environment or
property (adapted from Okoh and Haugen [1]). This is
the definition adopted in the current paper in which we
offer our thoughts on some of the reasons for the contin-
ued occurrence of these devastating incidents. (Our oc-
casional use of incident as a substitute for accident is in
accordance with our firm belief that these events are
neither unavoidable nor unpreventable.) As subsequently
described, the opinions expressed here are based largely
on a series of perspectives written around the time of the
30th anniversary of the Bhopal tragedy [2,3,4,5,6,
7,8,9]. Other resources (e.g., MKOPSC [10]) provide
information on process safety research and practice topics
that support our general argument.
The primary motivation for this paper is the moral/ethical
imperative of preventing major accidents in the process
industries. While there are strong financial, legal, societal
and reputational reasons for avoiding major accidents,
these pale in comparison to the need to do the right
thing. But what exactly is the right thing to do? Is it: (i)
eliminating all hazards because we cannot foresee every
combination of events that will result in significant loss, or
(ii) attempting to drive the frequency of major process
accidents to zero, or (iii) committing to not take on more
challenging risks than we can manage, even as we get
better at controlling major hazards, or (iv) developing
more rigorous process safety regulatory regimes (prescrip-
tive or performance-based), or . . .?
The answers to the above questions will of course
depend on who is responding. Rather than give eight
sets of answers from the eight authors of the current
paper — or attempt to achieve a set of consensus
answers from the group — we instead present our
answers to the question posed by the title of Silva’s
recent paper [11]: Why Are Major Accidents Still Occur-
ring? We recognize that these answers are personal and
are drawn from our individual experiences in industry
and academia. It is hoped, however, that our collective
opinions will stimulate additional thoughts on how to
prevent major process accidents. We consider these
opinions to be entirely consistent with Silva’s thesis
that loss of technical knowledge is an important con-
tributing factor to why a major accident occurs, with
Current Opinion in Chemical Engineering 2016, 14:1–8
2 Process systems engineering
such loss happening due to: (i) new technology (e.g.,
Macondo, Gulf of Mexico), (ii) inadequate training,
procedures and information (e.g., Three Mile Island,
USA), and (iii) failure to incorporate new knowledge
such as lessons learned (e.g., Fukushima, Japan) [11].
Bhopal clearly fits under item (ii) along with Three Mile
Island and many other incidents.
Background
In 2014, the corresponding author (PRA) — acting as
editor of the Journal of Loss Prevention in the Process
Industries — invited the other authors of this paper to
write a personal reflection on the Bhopal disaster [2].
These guest perspectives were published throughout
2015 and early 2016 [3,4,5,6,7,8,9]. The invitation
to submit the present paper to Current Opinion in Chemical
Engineering provided the impetus to review the perspec-
tives in their entirety for possible common themes. What
emerged from the analysis, though, was a set of unique
core concepts — that is, the single, most important point
from each of the Bhopal guest perspectives that could
help prevent major accidents in the process industries.
In addition to the efforts of the Journal of Loss Prevention
in the Process Industries, other process safety publications
have remembered Bhopal; see, for example: (i) volume 33
(issue 4, December 2014) of Process Safety Progress (in
particular, Murphy [12] and Murphy et al. [13]), (ii)
volume 97 (September 2015) of Process Safety and Envi-
ronmental Protection (starting with Edwards and Gupta
[14]), and (iii) issue 240 (December 2014) of Loss Preven-
tion Bulletin. In this latter publication, Essa [15] gives a
succinct summary of the technical details and human cost
of what happened at Bhopal: This issue of LPB commem-
orates the 30th anniversary of the world’s worst industrial
accident on record. The tragic incident happened at the Union
Carbide India Limited (UCIL) pesticide production plant in
Bhopal, India in the early hours of the 3rd December
1984. Many of us recall that this incident was caused by the
violent reaction between methyl isocyanate [MIC] and water,
which led to the release of approximately 40 tons of this highly
toxic gas into the atmosphere. This fateful release caused thou-
sands of deaths and hundreds of thousands of injuries, and an
unknown number to suffer continued physical and psychological
conditions. An on-going tragedy is that much of the site of the
incident remains contaminated and unremediated to this day
[15].
Hendershot [16] gives a timely reminder not only of
Bhopal, but also the human and property devastation
brought about by a series of explosions at a PEMEX
liquefied petroleum gas (LPG) terminal in San Juan
Ixhuatepec, Mexico just two weeks earlier (November
19, 1984). Readers interested in learning more about this
and other major process incidents are referred to Mannan
et al. [17] as well as several process safety books empha-
sizing case studies, including Sanders [18], Atherton and
Current Opinion in Chemical Engineering 2016, 14:1–8
Gil [19], Kletz [20], CCPS [21] and Mannan [22]. The
remainder of the current paper presents the previously
mentioned core concepts drawn from the Bhopal guest
perspectives [3,4,5,6,7,8,9]. These are given not in
order of priority, but simply in order of original publica-
tion.
Creation of paradigm-enhancing
organizations
Berger [3]: As I stood there in that godforsaken spot [Bhopal],
the call was clear. . .I am proud with how the CCPS [Center for
Chemical Process Safety] global community has grown and
how much all of us have accomplished. . .However, there is still
work to be done. . .
The formation of credible international organizations
dedicated to sharing process safety lessons and promoting
ongoing improvement in process safety technology and
management systems is central to the mission of avoiding
major process accidents. (We would be remiss to omit
mention of the broader-than-process-safety, worldwide
initiative driven largely by the Bhopal disaster — Re-
sponsible Care.1) In this respect we draw attention to
the Center for Chemical Process Safety (CCPS) and its
global efforts to disseminate information through avenues
such as symposia and conferences (e.g., the annual Global
Congress on Process Safety, in conjunction with the
AIChE Safety & Health Division). CCPS also produces
guidelines and concept books, and works to build com-
petency through educational packages, training courses
and certification. Berger [3] comments on the need for
implementation of CCPS’s Vision 20/20 which looks into
the not-too-distant future to demonstrate what perfect process
safety will look like when it is championed by industry; driven by
five tenets of culture, standards, competency, management sys-
tems and lessons learned; and enhanced by community passion
and four global societal themes (ccpsonline.org).
Other organizations providing helpful information to the
worldwide process safety community include the: (i) Mary
Kay O’Connor Process Safety Center (Texas A&M Uni-
versity System) in College Station, TX and Doha, Qatar
(e.g., MKOPSC [10]), (ii) US Chemical Safety Board
(csb.gov), (iii) Canadian Society for Chemical Engineering
(e.g., CSChE [23]), (iv) UK Institution of Chemical Engi-
neers (e.g., Furlong and Collis [24]), (v) UK Health and
Safety Executive (e.g., HSE [25]), and (vi) European
Federation of Chemical Engineering Working Party on
Loss Prevention and Safety Promotion in the Process
Industries (e.g., De Rademaeker et al. [26]). These
bodies — and numerous others worldwide — have con-
tributed to the evolution of process safety through the
various advances shown in Figure 1. Here we have
updated previous versions of this graphic to reflect the
paradigm of knowledge management and communication
espoused in the current paper and by Silva [11]. Whether
or not the topical areas of emphasis identified in Figure 1
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Figure 1
Process Safety Level
Human Error/H
y Improvements
Technical Safet
1960 1970 1980
Year
Significant contributions to the evolution of process safety (updated from MKOPSC [10], De Rademaeker et al. [26] and Amyotte et al. [27]).
were introduced successively, it is clear that process safety
is based on engineering as well as the natural, manage-
ment and social sciences. Therefore, advances to over-
come organizational memory losses [8], such as the global,
open-access accident database advocated by Mannan and
Waldram [28], will be as important as engineering and
management system improvements.
Inherently safer design
Edwards [4]: . . .the only way to guarantee plant safety is to
eliminate the hazards, or if hazards are unavoidable, reduce the
size or keep people far enough away that they cannot be hurt.
It is difficult — some might say impossible — to argue
with the logic embodied in the above quote. Why then do
we often rush to implement add-on safety devices (both
passive and active) and develop procedural safety mea-
sures without first considering whether we truly need to
maintain such huge inventories of hazardous materials?
This was precisely the question posed by Trevor Kletz in
response to the 1974 major accident at the Nypro capro-
lactam plant in Flixborough, UK. He then proceeded to
demonstrate how to make process design and operation
inherently safer through a lifetime of publications and
presentations beginning with his seminal paper What You
Don’t Have, Can’t Leak [29], and culminating in the second
edition of his classic text [30]. Along the way, Trevor
introduced the process safety community to numerous
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Major accidents Amyotte et al. 3
unication
nagement/Comm
Knowledge Ma
Safety Culture
ment Systems
Safety Manage
E
Focus on HS
Management
uman Factors
1990 2000 2010
Current Opinion in Chemical Engineering
principles of inherently safer design (ISD), including the
four main ones shown in Table 1.
With respect to Bhopal, Edwards [4] illustrates the role
of ISD in eliminating/minimizing hazardous material
inventories and substituting alternative chemistry routes.
(See also Khan and Amyotte [32] for other ISD lessons
drawn from the Bhopal tragedy.) Edwards [4] further
describes how with motivation provided by the pioneer-
ing work of Trevor Kletz, he began to look at reaction
routes as the basis for assessing and ranking the inherent
safety of alternative chemical production routes (see, for
example, Edwards and Lawrence [33]). Today, ISD
remains an important topic of research, as evidenced
by a sampling of the current process safety literature
[34,35,36]. Particularly important are contributions from
industry showing the uptake of ISD by this sector [37].
Awareness of total cost of major accidents
Gupta [5]: If. . .family members and co-workers are also
apprised of events that lead to the continuing Bhopal tragedy,
the industry as a whole would be safer, the public happier, and
products cheaper since accidents cost a lot.
Perhaps major accidents would indeed be less likely to
occur if the true and total cost of such events was better
publicized and made known to all process industry ben-
eficiaries–the industry itself, government, academia and
the general public. Consider just the financial cost of the
Current Opinion in Chemical Engineering 2016, 14:1–8
4 Process systems engineering

Table 1

Inherent safety principles [31]

Principle Description
Minimization Use smaller quantities of hazardous materials when the use of such materials cannot be avoided. Perform a hazardous
procedure as few times as possible when the procedure is unavoidable.
Substitution Replace a substance with a less hazardous material (i.e., a completely new substance) or a processing route with
one that does not involve hazardous material. Replace a hazardous procedure with one that is less hazardous.
Moderation Use hazardous materials in their least hazardous forms (i.e., the same substance but in a safer formulation) or identify
processing options that involve less severe processing conditions.
Simplification Design processes, processing equipment, and procedures to eliminate opportunities for errors by eliminating excessive
use of add-on safety features and protective devices.

Macondo/Deepwater Horizon disaster in the Gulf of
Mexico, currently estimated at $50 billion and count-
ing–not to mention the significant shareholder value
erased. Gupta [5] gives an admittedly incomplete list
of 45 cost items for Bhopal in terms of human, environ-
mental and economic factors. A recent paper by Talarico
and Reniers [38] examines this issue by using cost-
benefit analysis to evaluate safety investments aimed at
reducing the risk from what they term high impact low
probability (HILP) accidents.
Gupta [5] also comments on the broad application of the
lessons from Bhopal to other endeavors such as construc-
tion, transport and medical practice. Here too, accident
costs can be both hidden and significant as illustrated for
building project contractors by Feng et al. [39] and for
other industry workers (including coal miners in China)
by Ma et al. [40].
Consideration of broader societal and cultural
aspects of major accidents
Willey [6]: . . .we as engineers need to consider more than the
impact of our engineering. We need to understand the cultural
aspects that surround our industrial site. . .cultural differences
that we will encounter as we begin practice as engineers. . . [that]
morale within a plant is nearly as important as having a
functioning relief system.
The pivotal role of societal and cultural factors in major
accident causation is addressed by Willey [6]. Support for
this core concept is provided in an earlier paper by Gupta
[41] who identified a number of factors affecting process
safety in developing countries. His list includes items
associated with the availability of resources, costs of
imported equipment, adequacy of training, management
and staff attitudes, regulatory regimes, and political and
bureaucratic interventions [41]. This list should clearly
not be viewed as applicable only to developing countries.
Willey [6] discusses other key lessons from Bhopal that
are also universally applicable — the principle of not
assigning blame when one is seeking the root causes of
an accident, and the ultimate responsibility of manage-
ment. These help explain the potentially fragile social
contract by which process industry companies generate
revenue, as illustrated by Figure 2 and the following
quote from Fung [44]: The future success of the chemical
industry will depend more on social license to operate than
technological advancement.
Process safety culture
Hendershot [7]: In general, the problem is not that we don’t
know what to do, but rather that we do not always actually do
what we already know how to do, and what we know we should
do.
From the viewpoint of risk-based process safety, the
above quote relates to the management system element
conduct of operations [45] and its subcomponent operational
discipline (which can be defined as displaying behaviors
within a system of checks and balances that help ensure that
things are done correctly and consistently [21]). The willing-
ness to operate process plants in a disciplined manner so
as to avoid major accidents is a direct reflection of the core
concept of process safety culture. Hendershot [7]
describes several key findings in this regard from the
BP North American Independent Safety Panel (the Baker
Panel, of which he was a member). The Panel examined
the impact of the safety culture and management systems
in BP North American refining operations on the condi-
tions contributing to the 2005 Texas City Refinery ex-
plosion. Findings included the importance of: (i) fostering
a good process safety culture, (ii) recognizing the differ-
ence between occupational safety and process safety, (iii)
recognizing that good occupational safety performance
does not ensure good process safety performance, and (iv)
developing appropriate leading and lagging metrics for
process safety performance. Relevant recent work
includes Strauch [46] on safety culture and accident
investigation, Azizi [47] on process safety performance
indicators, and Mize [48] on normalizing deviation.
The writings of Andrew Hopkins (e.g., [49,50]) are highly
recommended for those wishing to further their under-
standing of safety culture and its relation to major acci-
dent causation. Hopkins [49] gives a cultural roadmap for
process engineers that involves breaking safety culture
down into its components of just, reporting, learning and

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Figure 2
Two sides of a handout provided by a public interest group during the US Chemical Safety Board public meeting held on April 19, 2013 in relation
to the Chevron Richmond Refinery incident [42] (from Amyotte and Khan [43]).
flexible cultures. The idea of a learning culture is critical
to success in the process industries from at least two
perspectives: (i) the learning opportunities afforded by
major accidents [51], and (ii) the need for organizations
and corporations to remember these lessons [52]. Failure
to learn from experience within a plant, a company and an
industry is an all too common root cause identified in
incident investigation reports [7,53]. Readers whose
operations involve the potential for overfilling a process
vessel or storage tank are urged to also read I’ve Seen This
Movie Before [54], which deals with the 2009 CAPECO
incident in Puerto Rico [55].
Process safety competency
Mannan [8]: The organization has to hold each member
accountable and also provide resources to make the organiza-
tion successful.
The need for competency in process safety theory and
practice is not restricted to plant operators and system
designers; managers and corporate leaders must also well-
understand the risks intrinsic to the work they direct
[56,57]. Mannan [8] addresses the issue of broad-based
competency by commenting on specific requirements for
academia, industry, government and the public. He fur-
ther remarks that competent process safety performance
cannot be guaranteed solely by adherence to regulations,
which should be seen as minimum standards that can
provide motivation for improvement [8]; this view is
shared by Hendershot [58]. With respect to academia,
Mannan [8] advocates process safety education at
the undergraduate level for all engineering disciplines,
with specialization occurring at the graduate degree
levels (Master’s and PhD). Amyotte [59] has proposed
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Major accidents Amyotte et al. 5
Current Opinion in Chemical Engineering
educational determinants for an undergraduate process
safety course which include accreditation criteria (e.g.,
Canadian Engineering Accreditation Board, ABET, etc.),
regulatory body professional practice requirements, and
the resources made available by organizations such as
SAChE (Safety and Chemical Engineering Education).
With respect to industrial practice, the key to process
safety competency is a deep and thorough knowledge of
the physics and chemistry of the materials and processes
involved [7]; such knowledge is critical to the successful
implementation of inherently safer design principles [4].
Other competency requirements can be determined by
analyzing specific major accidents as done for BP Texas
City by Kidam et al. [60] in their development of a set of
plant design and accident prevention characteristics for
the process design lifecycle. Fyffe et al. [61] analyzed
60 CSB investigation reports and determined a number of
key issues (competencies) recommended for improve-
ment. The identified issues include process hazard anal-
ysis (PHA), which is a core process safety activity that
requires an effective competency management program
[62]. As a final comment, it is important to remember that
a management of change (MOC) program must account
for organizational as well as technical changes; personnel
changes such as replacing the incumbent in a position
affecting process safety must incorporate appropriate
evaluation of competencies [63].
Dynamic operational risk management
Khan [9]: . . .operation plays a key role in accident causation
and unwanted loss. Therefore developing methods to identify
and minimize risk during operation is a key way to prevent
accidents like Bhopal.
Current Opinion in Chemical Engineering 2016, 14:1–8
6 Process systems engineering
As the previous discussion on inherently safer design has
indicated, consideration of process safety early in the
design phase is key to preventing major accidents. Bhopal
and other incidents such as Flixborough and Seveso have
demonstrated the concurrent need for dynamic risk as-
sessment (DRA) as a component of the overall manage-
ment strategy for risk minimization during the operational
phase of a process plant [9,64].
DRA can be defined as a method that updates estimated
risk of a deteriorating process according to the performance
of the control system, safety barriers, inspection and main-
tenance activities, the human factor, and procedures [65].
Only a brief mention of this concept is made here because
Khan et al. have given a comprehensive overview of the
topic in another paper appearing in this volume [65].
Conclusion
With reference to the recent archival process safety
literature, we have described seven core concepts to
prevent major accidents in the process industries: (i)
the creation of paradigm-enhancing organizations, (ii)
inherently safer design, (iii) awareness of the total cost
of major accidents, (iv) consideration of the broader
societal and cultural aspects of major accidents, (v) pro-
cess safety culture, (vi) process safety competency, and
(vii) dynamic operational risk management.
Other process safety researchers and practitioners will
undoubtedly come up with different concepts or varia-
tions of those presented here. This pursuit should be
encouraged because no individual or group has all the
answers needed to ensure there will never be another
Bhopal. In searching for this knowledge, we would be
wise to heed the call for rigorous root cause analysis
expressed in the words of Trevor Kletz: For a long time,
people were saying that most accidents were due to human error
and this is true in a sense but it’s not very helpful. It’s a bit like
saying that falls are due to gravity [66].
Acknowledgement
The assistance of Yene Irvine in searching the process safety literature is
gratefully acknowledged.
References and recommended reading
Papers of particular interest, published within the period of review,
have been highlighted as:
 of special interest
 of outstanding interest
1. Okoh P, Haugen S: The influence of maintenance on some
selected major accidents. Chem Eng Trans 2013, 31:493-498.
2. Amyotte P: An editor’s perspective on giants and disasters. J
 Loss Prevent Process Ind 2014, 32:466-467.
This paper describes the initiation of the Bhopal guest perspective series.
3. Berger S: Guest perspective on Bhopal. J Loss Prevent Process
 Ind 2015, 33:311.
This paper is the first of the Bhopal guest perspectives on which the
current paper is based.
Current Opinion in Chemical Engineering 2016, 14:1–8
4. Edwards D: Guest perspective on Bhopal. Bhopal — how
 long does a disaster last? J Loss Prevent Process Ind 2015,
34:232-233.
This paper is the second of the Bhopal guest perspectives on which the
current paper is based.
5. Gupta J: Guest perspective on Bhopal. J Loss Prevent Process
 Ind 2015, 34:233-234.
This paper is the third of the Bhopal guest perspectives on which the
current paper is based.
6. Willey RJ: Guest perspective on Bhopal. J Loss Prevent Process
 Ind 2015, 35:247-248.
This paper is the fourth of the Bhopal guest perspectives on which the
current paper is based.
7. Hendershot DC: Guest perspective on Bhopal. Why can’t we do
 better? Thoughts on the 30th anniversary of the Bhopal
tragedy. J Loss Prevent Process Ind 2015, 36:183-184.
This paper is the fifth of the Bhopal guest perspectives on which the
current paper is based.
8. Mannan MS: Guest perspective on Bhopal. J Loss Prevent
 Process Ind 2015, 38:298-299.
This paper is the sixth of the Bhopal guest perspectives on which the
current paper is based.
9. Khan F: Guest perspective on Bhopal. J Loss Prevent Process
 Ind 2016, 39:181-182.
This paper is the seventh of the Bhopal guest perspectives on which the
current paper is based.
10. Mary Kay O’Connor Process Safety Center (MKOPSC): Process
Safety Research Agenda for the 21st Century. A Policy Document
Developed by a Representation of the Global Process Safety
Academia (October 21–22, 2011, College Station, TX). College
Station, TX: Mary Kay O’Connor Process Safety Center, Texas
A&M University System; 2012.
11. Silva EC: Why are major accidents still occurring? Process Safe
 Prog 2016 http://dx.doi.org/10.1002/prs.11795. [in press].
This paper gives an alternate, although complementary, look at major
accident causation to the current paper.
12. Murphy JF: Editorial. The impact of Bhopal over thirty years of
process safety practice. Process Safe Prog 2014, 33:310-313.
13. Murphy JF, Hendershot D, Berger S, Summers AE, Willey RJ:
Bhopal revisited. Process Safe Prog 2014, 33:309.
14. Edwards D, Gupta J: Editorial. Process Safe Environ Protect 2015,
97:1-2.
15. Essa MI: Editorial. Lessons from Bhopal. Loss Prevent Bull 2014,
240:2.
16. Hendershot DC: Remembering two tragedies. J Chem Health
 Safe 2014, 21:37-38.
This paper gives a brief description of the PEMEX LPG explosions near
Mexico City which occurred two weeks before the MIC release at Bhopal.
It is important to learn the lessons from all major process incidents,
especially these two landmark events.
17. Mannan MS, Chowdhury AY, Reyes-Valdes OJ: A portrait of
 process safety: from its start to present day. Hydrocarbon
Process 2012, 91:55-62.
This paper gives the authors’ list of the top 10 worst process safety
incidents in history and describes the impact of these events on sig-
nificant improvements in process safety practice.
18. Sanders RE: Chemical Process Safety. Learning from Case
Histories. edn 3. Amsterdam, NL: Elsevier/Gulf Professional
Publishing; 2004.
19. Atherton J, Gil F: Incidents that Define Process Safety. Hoboken,
NJ: John Wiley & Sons; 2008.
20. Kletz T: What Went Wrong? Case Histories of Process Plant
Disasters and How They Could Have Been Avoided. edn 5.
Amsterdam, NL: Elsevier/Gulf Professional Publishing; 2009.
21. Center for Chemical Process Safety (CCPS): Recognizing
Catastrophic Incident Warning Signs in the Process Industries.
Hoboken, NJ: John Wiley & Sons; 2012.
22. Mannan MS: Lees’ Loss Prevention in the Process Industries. edn
4. Oxford, UK: Elsevier/Butterworth-Heinemann; 2012.
www.sciencedirect.com

23. Canadian Society for Chemical Engineering (CSChE): Process
Safety Management Standard. edn 1. Ottawa, Canada: Canadian
Society for Chemical Engineering; 2012.
24. Furlong A, Collis A: Chemical Engineering Matters. A Review of
IChemE’s Technical Strategy. Rugby, UK: Institution of Chemical
Engineers; 2012.
25. Health and Safety Executive (HSE): Reducing Risks, Protecting
People. HSE’s Decision-making Process. Norwich, UK: Her
Majesty’s Stationery Office; 2001.
26. De Rademaeker E, Suter G, Pasman HJ, Fabiano B: A review of
 the past, present and future of the European loss prevention
and safety promotion in the process industries. Process Safe
Environ Protect 2014, 92:280-291.
As the title implies, this paper reviews the evolution and future direction of
process safety research and practice. Written by key figures in the
European process safety community, the discussion is applicable glob-
ally.
27. Amyotte P, Margeson A, Chiasson A, Khan F, Ahmed S: There is
no such thing as a black swan process incident. In Proceedings
of Hazards 24, IChemE; Edinburgh, UK (May 7–9): 2014.
28. Mannan MS, Waldram SP: Learning lessons from incidents: a
 paradigm shift is overdue. Process Safe Environ Protect 2014,
92:760-765.
This paper challenges decision-makers having the authority to effect
change to do just that — to facilitate development of a single new, multi-
national, multilingual accident database that is free at the point of use and
that includes immediate and underlying causes as well as lessons learned.
29. Kletz TA: What you don’t have, can’t leak. Chem Ind
1978:287-292.
30. Kletz T, Amyotte P: Process Plants. A Handbook for Inherently
Safer Design. edn 2. Boca Raton, FL: CRC Press/Taylor & Francis
Group; 2010.
31. Amyotte PR, Pegg MJ, Khan FI: Application of inherent safety
principles to dust explosion prevention and mitigation.
Process Safe Environ Protect 2009, 87:35-39.
32. Khan FI, Amyotte PR: How to make inherent safety practice a
reality. Can J Chem Eng 2003, 81:2-16.
33. Edwards DW, Lawrence D: Assessing the inherent safety of
chemical process routes: is there a relation between plant
costs and inherent safety? Process Safe Environ Protect 1993,
71:252-258.
34. Eini S, Abdolhamidzadeh B, Reniers G, Rashtchian D:
 Optimization procedure to select an inherently safer design
scheme. Process Safe Environ Protect 2015, 93:89-98.
This paper presents an optimization scheme for choosing among inher-
ently safer design options with consideration of both processing costs
and potential accident costs. The paper therefore demonstrates the
overlap between the seven core concepts presented here (in this case,
inherently safer design and awareness of the total cost of major acci-
dents).
35. Ahmad S, Hashim H, Hassim M: A graphical method for
assessing inherent safety during research and development
phase of process design. J Loss Prevent Process Ind 2016,
42:59-69.
36. Kidam K, Sahak H, Hassim M, Shahlan S, Hurme M: Inherently
safer design review and their timing during chemical process
development and design. J Loss Prevent Process Ind 2016,
42:47-58.
37. Center for Chemical Process Safety (CCPS): Inherently Safer
Chemical Processes. A Life Cycle Approach. Hoboken, NJ: John
Wiley & Sons; 2009.
38. Talarico L, Reniers G: Risk-informed decision making of safety
 investments by using the disproportion factor. Process Safe
Environ Protect 2016, 100:117-130.
This paper provides a review of cost/benefit methodologies for safety
interventions and proposes a risk-based decision-making formulation for
such investments.
39. Feng Y, Zhang S, Wu P: Factors influencing workplace accident
costs of building projects. Safety Sci 2015, 72:97-104.
www.sciencedirect.com
Major accidents Amyotte et al. 7
40. Ma Y, Zhao Q, Xi M: Decision-makings in safety investment: an
opportunity cost perspective. Safety Sci 2016, 83:31-39.
41. Gupta JP: Application of Dow’s fire and explosion index hazard
classification guide to process plants in the developing
countries. J Loss Prevent Process Ind 1997, 10:7-15.
42. US Chemical Safety Board (CSB): Final Investigation Report.
 Chevron Richmond Refinery. Pipe Rupture and Fire. Report No.
2012-03-I-CA. Washington, DC: US Chemical Safety Board; 2015.
This report describes the results of an incident investigation conducted by
the US Chemical Safety Board. It is typical of CSB investigation reports
and will serve as a good introduction for readers less familiar with this
organization. Attention is also drawn to the video accompanying the
report; the entire package of CSB videos is an invaluable training tool for
prevention of process incidents.
43. Amyotte P, Khan F: What do gas blows, iron dust
accumulations and sulfidation corrosion have in common?
Proceedings of Presentation, 15th International Symposium on
Loss Prevention and Safety Promotion in the Process Industries;
Freiburg, Germany (June 5–8): 2016.
44. Fung DT: Social license will trump technological
advancements in the chemical industry of the future. Can
Chem News 2013, 65:13.
45. Center for Chemical Process Safety (CCPS): Conduct of
Operations and Operational Discipline for Improving Process
Safety in Industry. Hoboken, NJ: John Wiley & Sons; 2011.
46. Strauch B: Can we examine safety culture in accident
 investigations, or should we? Safety Sci 2015, 77:102-111.
In addition to addressing the question posed by the title of this paper, the
author (as a member of the US National Transportation Safety Board)
effectively writes on safety culture from a perspective that is broader than
just the process industries. The authors of the current paper believe it is
important for process safety researchers and practitioners to look outside
their own industry for lessons and guidance.
47. Azizi W: Predict incidents with process safety performance
 indicators. Chem Eng Prog 2016, 112:22-25.
This paper gives a succinct, practical overview of leading and lagging
process safety metrics for both barrier-based and tier-based approaches.
Readily understandable examples are given and the relative features of the
two approaches are compared.
48. Mize JF: How does ‘‘deviation’’ become ‘‘normal’’? Process
Safe Prog 2016 http://dx.doi.org/10.1002/prs.11803. [in press].
49. Hopkins A: Safety, Culture and Risk. Sydney, AU: CCH Australia
Limited; 2005.
50. Hopkins A: Failure to Learn. The BP Texas City Refinery Disaster.
Sydney, AU: CCH Australia Limited; 2009.
51. Goh YM, Tan S, Lai KC: Learning from the Bhopal disaster to
improve process safety management in Singapore. Process
Safe Environ Protect 2015, 97:102-108.
52. Throness B: Keeping the memory alive, preventing memory
loss that contributes to process safety events. Process Safe
Prog 2014, 33:115-123.
53. Hendershot D: Learning from experience revisited. J Chem
Health Safe 2014, 21:35.
54. Hendershot D: I’ve seen this movie before. J Chem Health Safe
 2016, 23:46.
On a narrow technical level, this paper deals with the issue of overfilling
process vessels and storage tanks. On a more widely applicable level, it
emphasizes the importance of learning from previous incidents and
remembering those lessons well into the future. The paper is also typical
of regular contributions by the same author to the Journal of Chemical
Health and Safety, each of which is relatively brief (one or two pages) and
practically oriented.
55. US Chemical Safety Board (CSB): Final Investigation Report.
Caribbean Petroleum Tank Terminal Explosion and Multiple Tank
Fires. Report No. 2010.02.I.PR. Washington, DC: US Chemical
Safety Board; 2015.
56. Taylor RH, van Wijk LGA, May JHM, Carhart NJ: A study of
 the precursors leading to ‘organisational’ accidents in
complex industrial settings. Process Safe Environ Protect 2015,
93:50-67.
Current Opinion in Chemical Engineering 2016, 14:1–8
8 Process systems engineering
This paper reviews 12 industrial incidents (process-related and otherwise)
with the aim of identifying organizational and cultural precursors. Inade-
quacies (i.e., lack of competencies) were found in diverse areas such as
leadership, communication and risk assessment.
57. Center for Chemical Process Safety (CCPS): Guidelines for
Defining Process Safety Competency Requirements. Hoboken,
NJ: John Wiley & Sons; 2015.
58. Hendershot D: Process safety: more to process safety than
regulations. J Chem Health Safe 2016, 23:37.
59. Amyotte PR: Process safety educational determinants. Process
Safe Prog 2013, 32:126-130.
60. Kidam K, Hussin NE, Hassan O, Ahmad A, Johari A, Hurme M:
Accident prevention approach throughout process design life
cycle. Process Safe Environ Protect 2014, 92:412-422.
61. Fyffe L, Krahn S, Clarke J, Kosson D, Hutton J: A preliminary
analysis of key issues in chemical industry accident reports.
Safety Sci 2016, 82:368-373.
62. Baybutt P: Competency requirements for process hazard
 analysis (PHA) teams. J Loss Prevent Process Ind 2015, 33:151-158.
Current Opinion in Chemical Engineering 2016, 14:1–8
This paper covers important aspects of PHA team competency require-
ments. Competency of personnel is defined in terms of qualification
requirements and performance standards; a competency management
program for PHA teams is described.
63. Wincek J, Sousa LS, Myers MR, Ozog H: Organizational change
management for process safety. Process Safe Prog 2015,
34:89-93.
64. Yang M, Khan F, Amyotte P: Dynamic risk assessment: a case
of the Bhopal disaster. Process Safe Environ Protect 2015,
97:70-79.
65. Khan F, Hashemi SJ, Paltrinieri N, Amyotte P, Cozzani V,
 Reniers G: Dynamic risk management: a contemporary
approach to process safety management. Curr Opin Chem Eng
2016, 14:9-17.
This paper describes the current state of knowledge with respect to
dynamic operational risk management and dynamic risk assessment
(DRA). A comprehensive reference list is provided.
66. Edwards D: Trevor Kletz: 1922–2013. Chem Eng 2013/
2014:60-61.
www.sciencedirect.com