High Integrity Systems and Safety Management in Hazardous Industries

1. Introduction

Part 1: High integrity safety instrumented systems

2. Design of high integrity safety instrumented systems
The safety lifecycle for the development of I&C systems
Reliability requirements for high-integrity systems
Hardware and software systems design
The ‘software problem’ and software quality management
Functional specification, traceability, and the ‘V’ model
High integrity software: setting up a software project
Techniques and measures to produce high-integrity software
I&C failure analysis techniques
Common mode failure
Case study: Ariane 5 failure, 1996
Case study: Forsmark, Sweden, 2006
I&C architecture
Case study: The I&C architecture for the European Pressurised Water Reactor
The selection of logic elements and vendors for high integrity safety systems
Quality management of software suppliers
Case study: A smart device with a hidden surprise
The potential for AI-based control systems for hazardous process plants


3. Cyber security
Stuxnet
APT1
Industrial control system architecture and cyber-attack


4. The human-machine interface
Introduction
A note on Pitot tubes
Birgenair 301, 6 February 1996
Aeroperu 603, 2 October 1996
A note on high altitude upsets and angle of attack
Air France 447, 1 June 2009
Synthesis


5. Some case studies of software and microprocessor failures
Introduction
Qantas Flight 72: a serious incident involving smart devices with mixed control and protection
Discussion of Qantas 72 incident
Uljin nuclear power plant, South Korea 1999
Kashiwazaki-Kariwa nuclear power plant, Japan 2001
North Sea pipe handling system fatal accident, 2008
Auto recalls for software faults
The Post Office/Fujitsu Horizon software system scandal


6. Managing the safety of ageing I&C
Introduction: the problem of ageing I&C equipment
Basic knowledge and understanding that must be retained by the operators
I&C lifecycle issues
Maintenance management
Maintenance planning
Procurement aspects
Key performance issues for ageing I&C equipment
Specific ageing failure mechanisms
Case study: Buncefield 2005

Part 2: The history of high-integrity technologies – pressure vessels and computers

7. Learning from ignorance: a brief history of pressure vessel integrity and failures
The Sultana disaster, Tennessee, 1865
Boiler explosions and developments in boiler technology during the first industrial revolution
The Cockenzie steam drum failure, 1966
Modelling the fracture of pressure vessels
The accuracy and reliability of non-destructive examination
Dounreay 1981 – safety valve testing on a steam drum
The SS Norway boiler explosion, Miami, 2003


8. The second industrial revolution: a brief history of computer development

Part 3: Safety management

9. Introduction: Organisation and safety culture
The Swiss Cheese model
The RAF Nimrod crash, Afghanistan, 2 September 2006
The meaning of safety in a military environment


10. Management systems to prevent or mitigate accidents
HSE management systems
Personnel recruitment and training
Safe working arrangements
Design engineering and safety functional requirements
Technical safety and technical risk assessments
Engineering changes and safety case changes
Accident and incident investigations
Emergency planning
Corrective action tracking
Synthesis


11. The human factor
Introduction
The Port of Ramsgate walkway accident, 1994
Saudia Flight 163: Human behaviour during crisis management
Conclusions


12. Hydrocarbon
Introduction
Processing
Pipeline rupture and fire, Washington State, 10 June 1999
Equilon Anacortes refinery coking plant accident, 25 November 1998


13. Offshore oil and gas: Piper Alpha and Mumbai High
The Piper Alpha accident and the Cullen Report
Offshore safety training
The Mumbai High accident, July 2005
#Piper Alpha and Mumbai High


14. BP: Introduction and the history of BP
BP Texas City refinery – prelude to the accident
The accident at BP Texas City
Aberdeen 2007 to 2009
The Macondo-Deepwater Horizon blowout, fire and oilspill, April to July 2010
The Macondo-Deepwater Horizon accident, 20 April 2010
So what went wrong?
Why did the blowout preventer fail to work?
Aftermath
Texas City and Macondo-Deepwater Horizon: Can any general conclusions be drawn about BP?


15. Chernobyl and Prelude: Tourism behind the Iron Curtain, 1984
Fukushima Generic technical requirements for all nuclear reactors
Stability and predictability of nuclear reactor behaviour
Nuclear reactor technology in the Soviet Union
The Chernobyl accident
Aftermath: Radiological and health consequences
Chernobyl: Indirect causes of the accident
The Great East Japan earthquake and tsunami, 11 March 2011
The accidents at Fukushima Daiichi
Major technical issues
Other lessons learned, cultural issues, and consequences for the nuclear industry and elsewhere
Radiological and health consequences
Common threads between Chernobyl and Fukushima: National cultural issues and the need for independent nuclear safety regulation


16. Toxic release
Introduction: Seveso, Bhopal, Mississauga, Sandoz
Accidents Toxic releases at DuPont Belle, 2010


17. Tragedies of the Commons
Introduction
The Great Stink of 1858
The Great London Smog of 1952
World population in the 21st century
Global warming in the 21st century Chapter 18. Conclusions
Some key themes in safety instrumented systems
Some key themes in safety management
Final words
Further reading


18. Conclusions


Appendix
1. Experience and judgment

2. Roger Boisjoly, the Challenger accident, and whistleblowing

3. Regulatory and political failings in the Boeing 737 Max accidents

4. Techa river contamination 1949-1951 and the 1957 ‘Kyshtym’ accident

5. Ammonium nitrate accidents