This work demonstrates the usefulness in using layer of protection analysis (LOPA) concept as an auxiliary technique in process safety incident investigations. It allows the investigation team to go further in causal analysis, by identifying and exploring the role played by each layer of protection in the incident, looking for “holes” as findings (causes) to use in the investigation process. This approach achieves better quality investigations, with more accurate lessons learned, and recommendations, as well as developing a clearer way to communicate what happened. This approach helps anyone who reads the incident report understand and learn about the process safety incident. Moreover, it provides a clearer way to communicate what happened, helping everyone who sees the incident report to understand and learn about how the process safety incident evolved from process deviation going thru the layers of protection up to the emergency response. At the same time, it shows what a process safety incident is in a much more suitable and understandable way, which emphasizes the process safety point of view, impacting in the organization process safety culture.

中文翻译：

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保护层分析作为过程安全事故调查中的辅助技术

这项工作证明了使用保护层分析 (LOPA) 概念作为过程安全事件调查中的辅助技术的有用性。它允许调查团队进一步进行因果分析，通过识别和探索每一层保护在事件中发挥的作用，寻找“漏洞”作为调查过程中使用的结果（原因）。这种方法可以实现更高质量的调查，获得更准确的经验教训和建议，并制定更清晰的方式来传达所发生的事情。这种方法可以帮助阅读事件报告的任何人了解和了解过程安全事件。此外，它提供了一种更清晰的方式来传达所发生的事情，帮助每个看到事件报告的人了解和了解过程安全事件是如何从过程偏差、保护层到应急响应演变的。同时，它以更合适和更容易理解的方式展示了过程安全事件是什么，强调了过程安全的观点，影响了组织的过程安全文化。