Industrial safety ordinance (ISO), implemented in Contra Costa County in 1998, and in the city of Richmond in 2000, expands on the California accidental release program (CalARP) and requires the consideration of inherently safer design (ISD). Identifying ISD-based corrective actions as part of incident investigations is an opportunity to consider ISD within the existing process safety management framework. The objectives of this work were to analyze corrective actions from ISO incident investigation reports with respect to the hierarchy of controls, to identify additional ISD-based corrective actions for an incident using the ISD bow tie protocol, and to develop additional ISD example-based guidance. Thirty incidents from 2001 to 2018 were analyzed, and 227 recommended corrective actions were documented and categorized according to the hierarchy of controls. An incident at the Tesoro Golden Eagle Refinery on September 15, 2004 was analyzed, and five additional ISD-based corrective actions were identified. This work suggests that using the ISD bow tie protocol and example-based guidance, in addition to ISD checklists and guidewords in incident investigations could help identify more ISD-based corrective actions.

中文翻译：

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Contra Costa 健康服务 (CCHS) 事件调查中的控制层级

1998 年在康特拉科斯塔县和 2000 年在里士满市实施的工业安全条例 (ISO) 扩展了加州意外释放计划 (CalARP)，并要求考虑本质安全设计 (ISD)。确定基于 ISD 的纠正措施作为事件调查的一部分是在现有过程安全管理框架内考虑 ISD 的机会。这项工作的目的是分析 ISO 事件调查报告中关于控制层次结构的纠正措施，使用 ISD 领结协议为事件确定额外的基于 ISD 的纠正措施，并开发额外的基于 ISD 示例的指南. 分析了 2001 年至 2018 年的 30 起事件，227 项建议的纠正措施被记录并根据控制层次进行分类。对 2004 年 9 月 15 日发生在 Tesoro Golden Eagle 炼油厂的事件进行了分析，并确定了另外五项基于 ISD 的纠正措施。这项工作表明，在事件调查中使用 ISD 领结协议和基于示例的指南，以及 ISD 检查表和指南，可以帮助确定更多基于 ISD 的纠正措施。