Lessons from disaster: how organizations have no memory and accidents recur
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| Main Author: | |
|---|---|
| Format: | Book |
| Language: | English |
| Published: |
Rugby
Institution of Chemical Engineers
1993
|
| Subjects: | |
| Online Access: | Inhaltsverzeichnis |
| Physical Description: | VIII, 183 S. Ill., graph. Darst. |
| ISBN: | 0852953070 |
Staff View
MARC
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Record in the Search Index
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|---|---|
| adam_text | CONTENTS
PREFACE iii
FORETHOUGHTS viii
1. INTRODUCTION 1
2. ORGANISATIONS HAVE NO MEMORY 4
2.1 Isolation for Maintenance 4
2.2 Explosions in Buildings 10
2.3 Choked Vents 15
2.4 Pressure Vessels Opened by Operators 18
2.5 Improving the Corporate Memory 21
APPENDIX 2.1 — IT MUST NEVER HAPPEN AGAIN 24
3. ACCIDENTS OF THE COMING YEAR 27
3.1 A Tank will be Sucked in 27
3.2 A Trip will Fail to Operate 29
3.3 A Road Tanker will be Overfilled 31
3.4 A Man will be Injured while Disconnecting a Hose 31
3.5 A Road or Rail Tanker will be Moved before the Hose
has been Disconnected 32
3.6 The Wrong Pipeline will be Opened 33
3.7 A Heavy Oil Tank will Foam Over 34
3.8 A Pipe will be Damaged by Water Hammer 35
3.9 Must these Incidents Occur Again? 36
APPENDIX 3.1 — HOW STRONG IS A STORAGE TANK? 37
4. SOME OTHER FAILURES TO LEARN FROM THE PAST 41
4.1 Knowledge in the Wrong Place 41
4.2 Other Examples of Forgotten Knowledge 45
4.3 Loss of Skill 49
4.4 Two Fires and an Explosion in an Oil Company 53
4.5 Some Incidents on the Railways 56
4.6 Some Successes 58
v
5. WHY ARE WE PUBLISHING FEWER ACCIDENT
REPORTS? 62
5.1 The Present Position 62
5.2 Why should we Publish Accident Reports? 63
5.3 Why are we Publishing Fewer Accident Reports? 64
5.4 How can we Encourage the Transfer of Information? 67
6. WHAT ARE THE CAUSES OF CHANGE AND
INNOVATION IN SAFETY? 70
6.1 Isolation for Maintenance 70
6.2 Trip and Alarm Testing 74
6.3 Storage of Liquefied Petroleum Gas 76
6.4 High Integrity Protective Systems 81
6.5 Inherently Safer Design — a Slower Change 83
6.6 Other Springs of Action 85
6.7 How can we Encourage Change and Innovation? 88
APPENDIX 6.1 — A NOTE ON ASYMPTOTES 92
7. THE MANAGEMENT OF SAFETY 93
7.1 Policy 93
7.2 Whose Responsibility 1 94
7.3 Training. Instructions and Learning the Lessons of
the Past 96
7.4 Audits and their Limitations 96
7.5 Testing and Inspection 101
7.6 Identifying and Assessing Hazards 102
7.7 Accident Investigation and Human Error 106
7.8 Other Key Procedures 109
7.9 The Obvious 114
7.10 The Special Responsibilities of those at the Top 115
APPENDIX 7.1 — A FUTURE ACCIDENT REPORT 120
APPENDIX 7.2 — TRAIN DRIVER ERROR 122
APPENDIX 7.3 — A NOTE ON SPARK RESISTANT TOOLS 124
8. AN ANTHOLOGY OF ACCIDENTS 125
8.1 Reluctance to Rf.cognise that Something is Wrong 125
8.2 Labelling should be Clear and Unambiguous 127
8.3 Reassess Hazards from Time to Time 127
8.4 Watch Contractors Closely 128
vi
8.5 Do not Overload Supervisors 131
8.6 Do not Change a Design without Consulting the
Designer 132
8.7 What should we do with Safety Equipment that Stops
us Running the Plant? 133
8.8 Not all Trips are Spurious 134
8.9 It must be Safe as I m Following all the Codes1 136
8.10 Little Used Equipment becomes Forgotten 136
8.11 Crowd Control 137
8.12 Different People — Different Views 138
8.13 We can Learn from a Report even if its Conclusion is
Wrong 140
9. CHANGES IN SAFETY — A PERSONAL VIEW 143
9.1 Early Days 143
9.2 Changing Responsibilities 145
9.3 Safety Adviser 149
10. IMPROVING THE CORPORATE MEMORY 166
10.1 Spreading the Message 166
10.2 Discussions are Better than Lectures 167
10.3 Remembering the Message 170
10.4 Finding Old Reports 171
10.5 A Final Note 173
AFTERTHOUGHTS 175
INDEX 176
vii
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| isbn | 0852953070 |
| language | English |
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| physical | VIII, 183 S. Ill., graph. Darst. |
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| spelling | Kletz, Trevor Verfasser aut Lessons from disaster how organizations have no memory and accidents recur Trevor Kletz Rugby Institution of Chemical Engineers 1993 VIII, 183 S. Ill., graph. Darst. txt rdacontent n rdamedia nc rdacarrier Chemical industry Accidents Industrial accidents Sicherheit (DE-588)4054790-5 gnd rswk-swf Chemische Industrie (DE-588)4009848-5 gnd rswk-swf Chemische Industrie (DE-588)4009848-5 s Sicherheit (DE-588)4054790-5 s DE-604 HBZ Datenaustausch application/pdf http://bvbr.bib-bvb.de:8991/F?func=service&doc_library=BVB01&local_base=BVB01&doc_number=009280544&sequence=000002&line_number=0001&func_code=DB_RECORDS&service_type=MEDIA Inhaltsverzeichnis |
| spellingShingle | Kletz, Trevor Lessons from disaster how organizations have no memory and accidents recur Chemical industry Accidents Industrial accidents Sicherheit (DE-588)4054790-5 gnd Chemische Industrie (DE-588)4009848-5 gnd |
| subject_GND | (DE-588)4054790-5 (DE-588)4009848-5 |
| title | Lessons from disaster how organizations have no memory and accidents recur |
| title_auth | Lessons from disaster how organizations have no memory and accidents recur |
| title_exact_search | Lessons from disaster how organizations have no memory and accidents recur |
| title_full | Lessons from disaster how organizations have no memory and accidents recur Trevor Kletz |
| title_fullStr | Lessons from disaster how organizations have no memory and accidents recur Trevor Kletz |
| title_full_unstemmed | Lessons from disaster how organizations have no memory and accidents recur Trevor Kletz |
| title_short | Lessons from disaster |
| title_sort | lessons from disaster how organizations have no memory and accidents recur |
| title_sub | how organizations have no memory and accidents recur |
| topic | Chemical industry Accidents Industrial accidents Sicherheit (DE-588)4054790-5 gnd Chemische Industrie (DE-588)4009848-5 gnd |
| topic_facet | Chemical industry Accidents Industrial accidents Sicherheit Chemische Industrie |
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