Posts Tagged "Acidente potencial"

October 16, 2017 – Today the U.S. Chemical Safety Board released an eight minute safety video entitled “Fire in Baton Rouge” detailing the CSB’s Key Lessons stemming from the 2016 fire at the ExxonMobil Refinery that seriously injured four workers. The CSB’s latest video includes a new four minute animation explaining the events leading up to the incident.

Link to video:

Link to Investigation Information Page:

The fire occurred when operators inadvertently removed bolts that secured a piece of pressure-containing equipment to a type of valve known as a plug valve. When the operators then attempted to open the valve, it came apart and released flammable isobutane, which formed a vapor cloud that quickly ignited. In the video, Chairperson Vanessa Allen Sutherland said, “During our investigation, the CSB learned that the operators attempting to open the plug valve were following accepted practices within the refinery. Our safety bulletin addresses the need for companies to be vigilant with their safety hazard and risk mitigation analyses. The management of safety is critical to the protection and safety of workers and integrity of facility operations.”

The CSB is issuing Key Lessons to address the shortcomings revealed by the investigation:

1. Evaluate human factors – interactions among humans and other elements of a system – associated with operational difficulties that exist at a facility in relation to machinery and other equipment, especially when the equipment is part of a process covered by the Occupational Safety and Health Administration’s Process Safety Management (PSM) standard. Apply the hierarchy of controls – a method of evaluating safeguards to provide effective risk reduction – to mitigate the identified hazards.

2. Establish detailed and accurate procedures for workers performing potentially hazardous work, including job tasks such as removing an inoperable gearbox.

3. Provide training to ensure workers can perform all anticipated job tasks safely. This training should include a focus on processes and equipment to improve hazard awareness and help prevent chemical incidents.

Chairperson Sutherland said, “The safety management practices outlined in our bulletin could have prevented the fire in Baton Rouge. We urge companies to share and implement our key safety lessons at their facilities in order to prevent future injuries and property damage.”

For more information, contact Communications Manager Hillary Cohen at or by phone at 202.446.8094.

Source: CSB

O Fim de Piper Alpha

O fim de Piper Alpha foi resultado de uma série de falhas sistêmicas que culminou na morte de 167 pessoas, perda de bilhões de dólares e destruição total da plataforma. O acidente ocorreu em 6 de julho de 1988 após uma série de explosões e incêndios.

Piper Alpha era uma plataforma situada no mar do Norte a aproximadamente 200 km a noroeste de Aberdeen, na Escócia. Localizada em águas de até 144 m de profundidade.

As lições aprendidas no acidente de Piper Alpha podem ser aplicadas para a exploração de hidrocarbonetos offshore, como também em outros setores industriais.



This paper outlines how important is to have an efficient Training Matrix in Chemical and Petrochemical companies. To ensure high performance in Process Safety, it is essential to have teams highly trained ready to take action and make great decisions. The high level of human performance is an important aspect of any training program. Process Safety goes beyond of compliance with minimum requirements of legal policies. An efficient Process Safety Management (PSM) can assure both high performances in preventing Process Safety Incidents and saving money for the company. To have a PSM program as described, companies have to define what their employees need to know to perform their specific roles successfully and how deep they need to go in each subject. In other words, it is important to have a Tridimensional Training Matrix. Skills development should take place in all parts of an organization, but not everyone needs to know everything deeply.

Focusing on continuous improvement in the processes, companies need to define the proficiency level of their employees in different positions and roles, as well as the applicability of knowledge acquired in training in each position/role. It is also important knowing the difference between positions and roles. A role can be performed by different positions, for instance, a Process Engineer (position) could be the Process Safety Focal Point (role). Knowing this is important to set the mandatory competences for positions and critical roles in Process Safety and preventing to overwhelm some employees with lots of roles decreasing their productivity. A Tridimensional Training Matrix is composed by positions/roles, trainings/courses and proficiency levels. The combination of these three dimensions leads to an effective and lower cost training program. It is also important to define which trainings in which proficiency levels could be taken on the Online Basis to reduce costs with classroom trainings.

Finally, it is also important to define when the training should be taken, if it is a new employee training or a refresh one which needs to be taken in a specific time interval. In conclusion, creating a Tridimensional Training Matrix is complex and challenging, but having this tool will improve the performance of the employees and the entire company.


Normalmente quando pensamos em um artigo, pensamos em uma publicação em revista técnica, jornais, ou congressos acadêmicos.

Desta vez pensei em quebrar um pouco estas regras, investidas de uma formalidade embora direcionado para um meio técnico, vou aplicar forma e linguagem diferentes para tratar de um assunto, que via de regra é extremamente formal e até mesmo de cunho jurídico.

A Ética e a Responsabilidade em caso de um acidente de processo grave.


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