Introduction of Speaker
Paul Gruhn
Safety Systems Specialist for >25 years
ISA Fellow
Member of ISA 84 & 101 committees
Developer & Instructor for ISAs courses on
Safety Instrumented Systems
Author of two ISA books
Developer of 1st commercial safety system
modeling software
Registered Professional Engineer in Texas
(and member of CSE exam team)
ISA 84 Expert
1
Accidents continue to happen
2
Even simple things can go horribly wrong
3
Its usually unforeseen combination of events
4
People must be competent & qualified
5
People must follow procedures
6
And even trained people make mistakes
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It only takes one slip-up
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Were not as indestructible as we think
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We cant think of every scenario
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Reuse of software is not always successful
Ariane 5 missile
Therac-25
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Near misses not followed up
12
Learn from past mistakes
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Lessons learned
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Questions / Discussion
15