(165c) Latent Failures Hiding in Plain (Hind)Sight - an Incident Case Study

Hindsight often provides a crystal-clear view of an incident, allowing investigators to pinpoint a slew of root and causal factors that contribute to failures in process safety. However, achieving that clarity in real time, before incidents unfold, remains a significant challenge. This presentation aims to explore latent failures associated with a specific centrifuge fire incident, examining both the "historical" factors that initiated the risk years prior and the near-term causes leading to the event. A review of the incident's sequence of events will be conducted, focusing on how seemingly minor oversights can accumulate into substantial safety risks. The presentation will also discuss post-incident findings and critical lessons learned that can inform future practices. The insights gained from this incident will be contextualized within the broader framework of PSM with strategies highlighted for identifying hidden risks, and will emphasize the importance of internalizing these learnings across various organizational contexts. The implications extend beyond this singular case study, and by recognizing and addressing latent failures before they manifest as incidents, organizations can enhance their safety culture, improve risk awareness, and ultimately prevent future incidents.