Learning from Accidents – Reporting is not Enough

Abstract

The fire and explosion at the Nypro Works, Flixborough, UK in 1974 led to the setting up of a court of inquiry which reported in 1975. In the closing paragraphs of the report (Department of Employment, 1975) various lessons are listed as well as issues to be referred to other bodies. Two aspects are worth highlighting, as they have to a certain extent been lost in the mists of time. Firstly, “that the management structure should be so organised that the feedback from the bottom to the top should be effective.” This is not only to ensure that instructions are effectively carried out, but also that those responsible for certain tasks are competent, that top management has a clear understanding of the responsibilities and demands placed on individuals including the potential for overloading. The second issue which was raised, but referred to other bodies for urgent consideration, is that of the siting of offices, laboratories and the like well removed from hazardous plants and the construction of control rooms on block-house principles. This was then addressed further in their 2nd report to the UK’s Health and Safety Commission by the Advisory Committee on Major Hazards (HSC, 1979) On 23 March 2005 an explosion occurred at BP America’s Texas City refinery killing 15 workers and injuring 170 others. All of the fatalities occurred in a temporary office container located adjacent to the ISOM-plant, but not associate with the start-up operations of this plant. The lessons learned and conclusions drawn from the various investigations regarding the location of temporary buildings as well as the feedback within the management structure bear stark similarities to those of thirty years before. The fact that the analogy between the vulnerable buildings listed in the Flixborough report and the temporary buildings for contractors had not been drawn is an indicator of the limits of the learning achieved.This is not an isolated case, but has been repeated many fold. The chemical process world needs to make learning the lessons, i.e. taking action where appropriate, a fundamental aspect of process safety in the coming years.This paper shows examples of the failure to learn or limits of learning achieved in the past. It raises the need to establish learning organisations not only in the chemical processing industry, but also within public authorities and academia. It confirms the requirement that learning from accidents be firmly anchored in the safety management system and that leadership and corporate governance are essential to achieving this and preventing as far as possible the disasters of the past being repeated (be it in a modified form) in the future.