The 2nd Loop Project – Learning from Small Incidents

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 p...

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Main Author: Mats Lindgren
Format: Article
Language:English
Published: AIDIC Servizi S.r.l. 2025-06-01
Series:Chemical Engineering Transactions
Online Access:https://www.cetjournal.it/index.php/cet/article/view/15185
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author Mats Lindgren
author_facet Mats Lindgren
author_sort Mats Lindgren
collection DOAJ
description 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.
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spelling doaj-art-9df2147ab5204660899a6efd9b8ba8d72025-08-20T02:37:41ZengAIDIC Servizi S.r.l.Chemical Engineering Transactions2283-92162025-06-01116The 2nd Loop Project – Learning from Small IncidentsMats LindgrenThe 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.https://www.cetjournal.it/index.php/cet/article/view/15185
spellingShingle Mats Lindgren
The 2nd Loop Project – Learning from Small Incidents
Chemical Engineering Transactions
title The 2nd Loop Project – Learning from Small Incidents
title_full The 2nd Loop Project – Learning from Small Incidents
title_fullStr The 2nd Loop Project – Learning from Small Incidents
title_full_unstemmed The 2nd Loop Project – Learning from Small Incidents
title_short The 2nd Loop Project – Learning from Small Incidents
title_sort 2nd loop project learning from small incidents
url https://www.cetjournal.it/index.php/cet/article/view/15185
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