Abstract

Abstract Lessons learnt from accidents are essential sources for updating state-of-the-art requirements in process safety. To improve this input in the Federal Republic of Germany in a systematic way, a central body for collecting and evaluating major accident and near miss events (ZEMA) was established in 1993. ZEMA is part of the Federal Environmental Agency (Umweltbundesamt, UBA). All events which are to be notified due to the German regulation on major accidents (Hazardous Incident Ordinance) are centrally collected, evaluated and documented by ZEMA. The bureau is also responsible for the dissemination of the lessons learnt to all stakeholders. This work is done in co-operation with the German Hazardous Incident Commission (Storfallkommission) and other national and international bodies. At the time being over 200 events from 1980–1997 are registered. For each event a separate data-sheet is published in annual reports, first started in 1993. In this paper, a summary evaluation on the events from 1993 to 1996 is presented and some basic lessons learnt are shown. The results from root cause analysis underline the importance of maintenance, detailed knowledge of chemical properties, human factor issues and the role of safety organisation, especially connected with sub-contractors. Keeping in mind that collecting information from major accidents is only a small amount compared with that from all the events which might be interesting to learn from, the recent plans for collecting minor accidents in Germany are reported.

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