1 3University of Huddersfield Repository

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1 1 3University of Huddersfield Repository Swuste, Paul, Groeneweg, Jop, Van Gulijk, Coen, Zwaard, Walter and Oostendorp, Yvette Van Three-Miles Island tot Piper Alpha Original Citation Swuste, Paul, Groeneweg, Jop, Van Gulijk, Coen, Zwaard, Walter and Oostendorp, Yvette (2015) Van Three-Miles Island tot Piper Alpha. Tijdschrift voor toegepaste Arbeidswetenschap, 28 (4). pp This version is available at The University Repository is a digital collection of the research output of the University, available on Open Access. Copyright and Moral Rights for the items on this site are retained by the individual author and/or other copyright owners. Users may access full items free of charge; copies of full text items generally can be reproduced, displayed or performed and given to third parties in any format or medium for personal research or study, educational or not-for-profit purposes without prior permission or charge, provided: 6 1 The authors, title and full bibliographic details is credited in any copy; 6 1 A hyperlink and/or URL is included for the original metadata page; and 6 1 The content is not changed in any way. For more information, including our policy and submission procedure, please contact the Repository Team at: E.mailbox@hud.ac.uk.

2 1 3Fullpaper VanThreeMileIslandtotPiperAlpha veiligheidsmanagement en veiligheidssystemen, een overzicht van Engels- en Nederlandstalige literatuur, Deel 2, de periode Inhoud Technische procesveiligheid Casus Shell Vraagstelling: Methode: Resultaten en conclusies: Abstract Method: Results and conclusions:

3 Methodenentechnieken

4 storing (Kemeny, 1979) Threemileisland

5 Algemenemanagementbenadering Arbeidsveiligheid

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8 Procesveiligheid, veiligheidstheorie 0 5n en veiligheidsmodellen Technische procesveiligheid

9 What you don t have can t leak

10 kans A i i i 6 9} 1 7 i i i B

11 Tight Coupling Delays in processing not possible Invariant sequences Only one method to achieve goal Little slack possible in supplies, equipment, 'personnel Buffers and redundancies are designed-in, deliberate Substitutions of supplies, equipment, 1 7personnel limited anq designed-in slack Loose Coupling Processing delays possible Order of sequences can be changed Alternative methods available Slack in resources possible Buffers and redundancies fortuitously available Substitutions fortuitously available Complex Systems Tight spacing of equipment Proximate production steps Many common-mode connections of components not in produi;tion sequence Limited isolation of failetl components Personnel specialization limits awareness of interdependendes Limited substitution of supplies and materials Unfamiliar or unintended feedback loops Many control parameters with potential interactions Indirect or inferential information sources Limited understanding of some processes (associated with transformation processes) Complex Systems Proximity Common-mode connections Interconnected subsystems Limited substitutions Feedback loops Multiple and interacting controls Indirect information Limited understanding 1 7 Summary Terms Linear Systems Equipment spread out Segregated production steps Common-mode connections limited to power supply and environment Easy isolation of failed components Less personnel specialization Extensive substitution of supplies and materials Few unfamiliar or unintended feedback loops Control parameters few, direct, and segregated Direct, on-line information sources Extensive understanding of all processes (typically fabrication or assembly processes) Linear Systems Spacial segregation Dedicated connections Segregated subsystems Easy substitutions Few feedback loops Single purpose, segregated controls Direct information Extensive understanding

12 resident pathogen in depth

13 skill-rule-knowledge

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15 We have third Veiligheidsmanagement en veiligheidsmanagementsystemen

16 trial without error resilience

17 high reliability Piperalpha

18 OntwikkelinginNederland

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20 Casus Shell

21 Discussieenconclusie DIRECTE FEEDBACK ENERGIEBRON COMPUTERSTURING PRODUCTIE voor 1800 WERKNEMER GRONDSTOFFEN 19 e eeuw WERKNEMER MACHINE GRONDSTOFFEN 2 e helft 20 e eeuw WERKNEMER COMPUTER MACHINE GRONDSTOFFEN

22 jaar theorie 0 5n 1 7 veiligheidsmanagement managementstromingen jaar groteongevallen theorie 0 5n,modellen, 1 7 i i i 1 7 veiligheidsmanagement managementstromingen

23 Literatuur

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27 Datum Plant/transport Chemicali 0 5n Gebeurtenis Gewonden-gew;doden- 6 9 Kosten milj$ H O

28 1 3Datum Plant/transport Chemicali 0 5n Gebeurtenis Gewonden-gew;doden- 6 9 Kosten milj$

29 1 3Datum Plant/transport Chemicali 0 5n Gebeurtenis Gewonden-gew;doden- 6 9 Kosten milj$ O H H