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                              74        Serious Incident Prevention



                                    Quality control deficiencies leading to installation of a pump incom-
                                    patible with process requirements.



                              A Systematic Process of Risk Identification


                                  Identifying and understanding significant risks for a major operation or
                              facility requires a comprehensive, systematic approach.  An effective
                              process for a petrochemical facility, for example, will generally require at
                              least the following:

                                    Input from operating, staff, and management personnel with opera-
                                    tional expertise
                                    Process hazard analyses
                                    A system for employees to report suspected deficiencies related to
                                    any aspect of the incident prevention process
                                    Management-of-change reviews
                                    Near-miss and accident investigations
                                    Field inspections
                                    Management briefings regarding specific serious-incident-related
                                    risks
                                    Networking through trade associations and safety groups
                                    Review of investigative reports for incidents experienced by other
                                    companies
                                    Evaluation and compliance with regulatory standards such as the
                                    OSHA Process Safety Management standard
                                    Evaluation of applicable statistical summaries and technical infor-
                                    mation regarding the causes of accidents
                                    Computer modeling or other evaluation of the range of consequences
                                    for potential incident scenarios

                                  Maintaining an adequate understanding of risks inherent in complex
                              operations is truly a neverending journey. The process requires perception,
                              attention to detail, dedication, and a keen thirst for knowledge. The disci-
                              pline and courage to challenge assumptions is critical. Experience confirms
                              that rather than “what you don’t know,” the real danger is often linked to
                              “what you think you know that isn’t so.” In traveling, the occasions where
                              we become lost tend to be those where we are certain of the proper route—
                              so certain that we fail to confirm the address or obtain directions. In oper-
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