Accident Investigation Lessons Learned

IChemE Accident Database Reports about chemical incidents around the world from official government sources, the news media, and company reports 1980-Present Scope is beyond incidents reported to or investigated by regulatory agencies or first responders Contains lessons learned from 3,000 incidents Only one-fourth of the 12,000 incidents in the database contain lessonsdeamed information... 

Improve the accident investigation philosophy The philosophy and aim orientation of the accident investigation shall focus on improvement of safety and avoidance of accidents, analysis of the radical causes of the accidents, and learning of experiences and lessons. These measures serve as the important grounds for relevant department, industry and enterprise to formulate standards. Their implementation is supervised and tracked, so as to avoid reoccurrence of similar accidents. 

Accident investigation Organizations must conduct proper investigations to permit analysis of all accident events. This permits safety personnel to document (1) lessons learned, (2) take actions to prevent future events, (3) improve training, and (4) discipline drivers not following procedures. 

Investigate and communicate lessons learned from recent accidents throughout the company. 

Accident prevention depends to a large degree on lessons learned from accident investigation. We cannot argue with the thought that when an operator commits an unsafe act, leading to a mishap, there is an element of human or operator error. We are, however, decades past the place where we stopped there in our search for causes. Whenever an act is considered unsafe, we must ask why. Why was the unsafe act committed When this question is answered in depth it will lead us on a trail seldom of the operator s own conscious choosing. (56)... 

Every time a major change in the system or operational mode occurs, the system SMS should be reviewed to ensure that risks are properly addressed and identified. And make sure that through the closed-loop process, all lessons learned from accident investigations, hazard control verifications, and other learning are fed back into the SMS—thus ensuring a self-learning SMS. 

Unfortunately, accidents do happen. Chapter 11 helps you understand what to do when you must investigate an accident at your facility. It details how to set up the investigation team, investigate the accident, and document the results, lessons learned, and corrective actions. Companies and governments are learning the hard way the importance of how to communicate an accident to the public. This chapter tells you how to develop a crisis communication plan, common mistakes, and the dos and don ts of communicating with the public during an accident. 

Operator investigates all near misses, incidents, and accidents, and then identifies lessons learned and disseminates them to personnel within the company/organization, other operators, risk management commimity, and inspectors... 

Coordinating review and revision of existing JSAs to ensure appropriateness, reflect procedural changes, and incorporate lessons learned from work experience, including accident investigations or critiques... 

A very complete description of the accident, originating from internal as well as external, independent qualified documents or public investigation reports available from renowned institutes or companies such as CSB, NTSB, OSHA, TNO, INERIS, DNV, etc. Many recommendations and lessons to be learned are available. The coding has been done in an extensive way and an extensive abstract is available. 

In a nutshell, continued vigilance by the workers coupled with the use of personal protective equipment and unrelenting surveillance by the management remain the best remedy for prevention of accidents, be it explosions or fires. Further, we must learn a lesson from each accident but unfortunately this does not really happen [35]. The findings of the enquiries and investigations conducted do not yield meaningful results. The main reasons being ... 

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