Crisislab investigation into connection between Chemelot incidents

 
 
An investigation into nine incidents at Chemelot in 2015 found no direct connection between them. The study did reveal common factors that played a role in some of the incidents, however.

Crisislab was commissioned by the companies involved to study the nine incidents, all of which led either to the emergency services being called in or to nuisance for local residents. "We agree with Crisislab's findings," commented Geert Kastelijns, Director of Chemelot Site Permit B.V., which commissioned the study on behalf of the Chemelot companies involved. "Its approach has produced insights that will be of benefit to us."

Safety with a capital "S"
According to Crisislab, no one factor explains the incidents. Crisislab sees no sign of a relationship between the incidents and the insourcing of workers from abroad. Possible maintenance cutbacks are not the culprit, nor does the cause lie in there being more companies on the Chemelot site than in the past.  

While no direct relationship has been uncovered, the investigation revealed that a number of the incidents had factors in common. Some of these factors apply across the entire chemicals industry, including stricter standards that escalate occurrences into incidents. Before mid-2015, for example, there were no standards for discharging pyrazole. Crisislab also argues that complex and linked processes predictably lead to incidents. The final common factor is the constant tension between production and safety.
 
Crisislab also concluded that during everyday production, the companies involved are very concerned about safety with a small "s", i.e. safe working practices or worker safety. That means that safety with a capital "S", process-related safety, gets too little attention in everyday practice. Chemelot is also quick to display the risk-rule reflex; in other words, after every incident it has a strong tendency to introduce new procedures and techniques that only serve to raise the risk of new occurrences or incidents.

More specifically for Chemelot, Crisislab found that the applicable safety agreements between the companies focus more on worker safety and less on process safety in everyday practice, for example during maintenance work.

Caution about risk-rule reflex
The complexity and integration of activities on the Chemelot site have increased rather than decreased in recent years. The need to remain globally competitive has made that unavoidable. At the same time, the site's safety performance has improved, even though local residents may believe otherwise because the consequences of a number of incidents in 2015 were visible in the environs.

What steps will Chemelot take? "After reading the report, we are cautious about introducing all kinds of new measures," says Kastelijns. "We'd fall right back into the risk-rule reflex that way. We're first going to have a close look at Crisislab's findings and carefully consider which steps to take. We need to have a good understanding of what happened. One important area of concern is how we deal with process and installation safety."

Gert Jan de Geus had this to say: "I think the report was accurate in many respects. I see that we too are very concerned about personal safety but pay too little attention to the bigger Safety. That was a factor in both the fertilizer plant and the ammonia plant fires. To me, it confirms that we have to devote more attention to the big S."

Link to report: www.crisislab.nl/onderzoeksrapporten
More information: www.crisislab.nl.

 
   
 
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