Learning from Accidents, 3rd Edition

Contents......Page 5
Forethoughts......Page 7
Preface......Page 9
A note on the organisation of maintenance in the process industries......Page 10
Acknowledgements......Page 12
Introduction......Page 13
1 Finding the facts......Page 14
23.5 Signalmen’s errors......Page 0
3 The irrelevance of blame......Page 16
4 How can we encourage people to look for underlying causes?......Page 18
5 Is it helpful to use an accident model?......Page 19
7 Prevention should come first......Page 20
9 Other information to include in accident reports......Page 21
10 Precept or story?......Page 22
1.1 A small fire......Page 25
1.2 A mechanical accident......Page 29
2 Protective system failure......Page 34
2.1 The fuel......Page 36
2.3 The source of ignition......Page 37
2.4 First layer recommendations......Page 38
2.6 Third layer recommendations......Page 39
2.7 Other points......Page 41
3 Poor procedures and poor management......Page 44
3.6 Other comments......Page 50
4.1 Preventing leaks......Page 52
4.2 Minimising the effects of leaks......Page 55
4.3 Reducing the probability of ignition......Page 58
4.4 Incorrect knowledge......Page 59
4.5 Supercritical gases may behave like liquids......Page 61
4.6 Postscript......Page 62
4.7 Another explosion caused by the belief that ignition can be prevented......Page 63
5 A liquid leak and fire and the hazards of amateurism......Page 64
5.1 Prevention of the leak......Page 66
5.2 The source of ignition......Page 67
5.3 Minimising the effects of the fire......Page 68
5.4 The management experience and philosophy......Page 69
5.5 Consequential loss......Page 71
5.7 Other accidents due to unsupervised contractors......Page 72
5.8 The Heathrow tunnel collapse......Page 73
6.1 The fuel......Page 76
6.2 The air......Page 77
6.3 The source of ignition......Page 78
6.4 An unlikely coincidence?......Page 79
6.6 Training and inspections......Page 80
6.7 Other incidents......Page 81
6.9 Seeing the signal above the noise......Page 82
7.1 The control of plant modifications......Page 86
7.2 The vent was a relief valve......Page 87
7.3 The choking of the vent......Page 88
7.5 Could it have been a chemical explosion?......Page 89
7.6 The flame trap assembly......Page 90
7.8 Coincidences......Page 92
8 Flixborough......Page 95
8.1 Reduction of inventory......Page 98
8.2 The control of process modifications......Page 100
8.3 The control of plant modifications......Page 101
8.4 The need for suitably qualified staff......Page 102
8.6 Plant layout and location......Page 103
8.8 Public response......Page 106
8.10 The rebuilt plant......Page 108
8.12 Progress in implementing recommendations......Page 109
Appendix: Flixborough and the Tay Bridge......Page 110
9 Seveso......Page 115
9.1 How did the reactor get too hot?......Page 116
9.2 Why was there no relief system catchpot?......Page 117
9.4 Public response......Page 118
9.5 Other similar incidents......Page 120
10 Bhopal......Page 122
10.2 Plant location......Page 124
10.3 Why did a runway reaction occur?......Page 125
10.5 Joint ventures......Page 128
10.6 Training in loss prevention......Page 129
10.8 Public response......Page 131
11 Three Mile Island......Page 134
11.4 Following the rules is not enough......Page 138
11.6 Public response......Page 139
11.7 Must nuclear power stations be so hazardous?......Page 140
11.8 Measure directly what we need to know......Page 143
12 Chernobyl......Page 147
12.1 The reactor and the experiment......Page 148
12.2 The experiment goes wrong......Page 150
12.3 The lessons to be learned......Page 151
12.4 The need for inherently safer designs......Page 153
12.5 Public response......Page 154
12.6 Further reading......Page 155
13.1 A failure to learn from the past......Page 158
13.2 A failure to inspect adequately......Page 159
13.4 Personal responsibility......Page 160
13.6 Buffalo Creek......Page 163
13.7 Opuha dam......Page 165
14.1 A tank explosion......Page 167
14.2 The unforeseen results of technical change......Page 168
14.3 An explosion in a pumping station......Page 169
14.4 The collapse of the Dale Dyke dam......Page 170
14.5 Look for what is not said......Page 172
15 Three weeks in a works......Page 174
15.1 The accidents......Page 175
15.2 General comments......Page 186
15.3 Conclusions......Page 187
Appendix: An example of a well-written accident report......Page 188
16.1 Why are pipe failures important?......Page 191
16.2 Some pipe failures that could have been prevented by better design......Page 192
16.3 Some pipe failures that could have been prevented by better inspection during or after construction......Page 195
16.4 Some pipe failures that could have been prevented by better operations......Page 202
16.5 An unusual pipe failure......Page 203
16.6 Conclusions......Page 204
17 Piper Alpha......Page 208
17.1 The initial explosion......Page 210
17.3 The gas fire......Page 212
17.4 Fire-fighting......Page 213
17.5 The accommodation block......Page 214
17.7 Lessons from the disaster......Page 215
17.8 Conclusion......Page 218
18.1 The immediate causes......Page 219
18.2 The underlying causes......Page 221
18.3 Was there no watchdog?......Page 223
18.4 Did the report go too far?......Page 224
18.5 Conclusions......Page 225
19.2 Why was there no checking?......Page 232
19.3 Communication failures......Page 233
19.4 Failures to learn from the past......Page 234
19.5 Other comments......Page 235
20.1 The immediate causes......Page 238
20.2 The weaknesses in design......Page 239
20.3 The weaknesses in management......Page 240
20.4 Learning the lessons of the past......Page 242
20.5 Was the Herald typical of marine standards?......Page 243
21.1 The R101 airship disaster (Figure 21.1)......Page 246
21.2 The Comet crashes (Figure 21.2)......Page 248
21.3 The Munich crash (Figure 21.3)......Page 250
21.4 The Trident Crash at Heathrow (Figure 21.4)......Page 252
21.6 The Zagreb mid-air collision (Figure 21.6)......Page 254
21.7 The Tenerife ground collision (Figure 21.7)......Page 256
21.8 The Chicago DC-10 crash (Figure 21.8)......Page 258
21.10 Challenger......Page 260
22.1 A building collapse......Page 265
22.3 Other building collapses......Page 267
22.4 Other unseen hazards......Page 268
23 Signals passed at danger......Page 271
23.1 Blaming the driver......Page 272
23.2 Reducing SPADS by better engineering etc.......Page 274
23.4 The Southall railway accident......Page 277
24.1 The background......Page 279
24.2 Ignorance of the hazard......Page 281
24.3 Management re-organisation and its results......Page 282
24.4 Safety in Exxon and Esso......Page 283
24.6 Similar problems elsewhere?......Page 284
25.1 The background......Page 287
25.2 The inquiry......Page 288
25.3 The reasons for the explosion......Page 289
25.4 Conclusions......Page 291
26.1 Explosions in compressor houses......Page 293
26.2 Vent collection systems......Page 294
26.3 Replacements for halogenated hydrocarbons......Page 296
26.4 Some miscellaneous examples......Page 299
26.6 Conclusions......Page 300
27 Looking beyond violations......Page 303
27.1 What happened?......Page 304
27.3 Lessons for other industries......Page 305
27.4 BNFL: The wider context......Page 307
28.1 Failure of a steam main: what happened and why?......Page 309
28.2 Second thoughts......Page 310
28.4 Sinking of a North Sea floating rig......Page 311
29.1 Background......Page 315
29.2 The incidents......Page 316
29.4 Other lessons from these incidents......Page 317
29.5 Another incident due to second-hand software......Page 318
29.6 Second-hand hardware......Page 319
30.1 Effective prevention lies far from the top event......Page 320
30.3 Testing and inspection of protective equipment......Page 322
30.5 The need for hazard and operability studies......Page 323
30.6 Better management......Page 324
30.7 How far should we go in bringing old plants up to modern standards?......Page 326
30.8 Human error......Page 329
30.9 Emphasise actions, not causes......Page 331
30.10 A final note......Page 332
Appendix 1 Some questions to ask during accident investigations......Page 337
Accident classification......Page 338
Appendix 2 Myths on accident investigation......Page 340
Appendix 3 Further reading......Page 347
Afterthought......Page 348
Index......Page 349