Plenaria [107] Lectura Plenaria (Salón RENOIR) S. BERGER - Lecciones que la Industria Química Debería Aprender de las Pérdidas de los Transbordadores Espaciales Challenger y Columbia Fecha: Miercoles, 17:30 - 18:30, Renoir Room (Ground Floor - San Miguel Palace) Dr. Scott BERGER Director CCPS AIChE New York, USA ABSTRACT: As the complex technical and managerial discipline of process safety has matured, our ability to analyze and assert control over adverse outcomes has reached to deeper and deeper levels. At first, we sought to assess blame on the parties causing accidents: the operator who didn’t follow procedure, the engineer who chose the wrong material of construction, or the supervisor who botched the work safety permit. Later, we learned to question management systems; were the procedures in fact possible to follow, was the engineer given enough time and resources to choose the correct material, or did the supervisor received adequate training? Over the years, we have also seen numerous examples of failures on an even deeper level, at the level of organizational culture. This did not come into clear view until the final months of 2003, with the completion of the Columbia Space Shuttle Accident Investigation. A group of CCPS representatives began meeting to see what learning might be applied to the chemical and petroleum industries from the Board’s findings. Almost immediately, this group began to see examples where a weakened process safety culture had contributed to historical chemical incidents, such as Flixborough, Bhopal, and Piper Alpha. This lead to further evaluation, and ultimately the creation of this lecture. Volver a Matriz de Sesiones