Which element of Process Safety Management does the Flixborough case highlight when ISD is ignored?

The Flixborough disaster underscores the critical importance of Management of Change (MOC) in the context of Inherently Safer Design (ISD). MOC is designed to ensure that any alterations to a process—whether related to equipment, technologies, procedures, or personnel—are adequately reviewed and assessed for potential safety implications before implementation.

In the Flixborough incident, modifications were made to the manufacturing process without a thorough evaluation of their safety impacts. These changes led to the use of an inadequate design that did not account for the new operating conditions, ultimately resulting in a catastrophic failure. This highlights how neglecting the MOC process can lead to unsafe situations, particularly when ISD principles are overlooked. Proper MOC practices would have involved risk assessment and reevaluation of the process changes to ensure that safety would not be compromised.

Understanding the role of MOC in effective Process Safety Management emphasizes that any changes, especially those that could fundamentally alter the safety of the process, must be carefully managed to prevent accidents like Flixborough.