Keeping the memory alive, preventing memory loss that contributes to process safety events


  • This article was presented at the 9th Global Congress on Process Safety in 2013. A copy of the original paper can be found on the CCPS website.


Recurring process safety events (PSEs) are a real concern to the energy industry. Contributing causes to these events are quite often very similar. It appears as though the learnings from past events are not retained in the memories of the workforce, setting the stage for accidents to repeat. Even with best practices available to prevent such recurring accidents, these events continue to happen again and again. It seems as if something is missing, in order to effectively use the knowledge gained from so many past disasters and near misses, to prevent further PSEs.

It was desired to develop a tool to aid ConocoPhillips Canada (CPC) in preventing memory loss that is contributing to PSEs. Some of the world's worst process safety accidents were reviewed to gather common learnings, and investigation reports of CPC past PSEs were analyzed to determine how prevalent the issue of memory loss is within the company. Best practices to prevent such memory loss were researched and found to be readily available, and yet for some reason, memory loss issues are very widespread. The cognitive sciences were looked to for an answer on how memories are developed and effectively retained. The field of education was researched, to determine how leading educators effectively teach learning to achieve high levels of memory retention. Through this the taxonomy table, a tool that has been used by educators to enhance teaching and learning for many years, was discovered. Then, effective safety communication methods that target memory retention were explored. All researched information was finally tied together, into a learning curriculum, consisting of various activities. These activities were constructed to advance the learning process toward an objective that had been carefully developed using the taxonomy table guidelines. This objective was “for the workers to integrate past process safety learnings to prevent future process safety events.” © 2013 American Institute of Chemical Engineers Process Saf Prog 33: 115–123, 2014