Abstract
The 2nd Loop Project was an analysis of approximately 200 process safety events at six companies, conducted by The Swedish Process Safety Association (IPS) during 2023. The objective was to evaluate the scope and quality of investigations, and to draw conclusions about the lessons learned. At each participating company, records from 30-40 process safety events from recent years were reviewed by a small group of safety specialists from the participating companies, led by the IPS director (this author). Most of the events were relatively minor LOPC's (loss of primary containment), challenges to barriers or malfunctioning barriers.
The main conclusion was that the process of learning from small incidents and near misses could be improved significantly. Regular reviews of incident reports, investigation results and resulting actions by process safety specialists and production staff together should be implemented or reinforced. Regarding common causal factors, it was concluded that poor design/construction often leads to cumbersome procedures and thereby invites human error, and that poor maintenance in aging plants often leads to leaks and malfunctioning equipment. It is proposed that these conclusions can be generalized to many companies in the process industry.
