Lessons from Disaster: How Organizations Have No Memory and Accidents RecurThis series of essays on safety and loss prevention is aimed at helping the process industries avoid accidents and improve its public image. The central message is the apparent inability of organizations to learn, and retain in the long term, the lessons drawn from accidents. Thus incidents of a similar type recur within the same company at intervals of a decade or so, as personnel involved move on to other jobs. |
Contents
2 | 15 |
5 | 21 |
3 | 27 |
6 | 33 |
4 | 39 |
2 | 45 |
4 | 53 |
2 | 63 |
2 | 94 |
6 | 102 |
8 | 109 |
1 A FUTURE ACCIDENT REPORT | 120 |
2 | 127 |
6888 | 131 |
11 | 137 |
2 | 145 |
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Aberfan accident reports Accidents in Industry audits bar gauge Bhopal BLEVE cause Chapter Chemical Engineers Clapham Junction corporate memory damage described discussed ethylene ethylene oxide example failed failure Feyzin Figure fire flammable Flixborough foreman happened hazardous materials Hazop Health and Safety Histories of Process HMSO hose human error hydrocarbons incident Industry Butterworths inherently safer designs installed Institution of Chemical isolation valves killed Kletz leak Learning from Accidents lessons liquefied liquid London look Loss Prevention no-one operators organisation pipe Piper Alpha pressure problems procedures Process Industry Process Plant Disasters protective equipment pump reactor realise recommendations relief valve Rugby safety adviser Safety Executive Section 2.1 senior managers serious accident slip-plates sodium chlorate someone source of ignition staff steam studbolts tanker technical temperature testing Trevor Kletz trips and alarms vapour vent vessel water hammer wrong