Learning from Accidents

An important principle in safety states that the causes of accidents are visible the day before the accident. These causes are visible to professionals who see deficiencies. This vision (knowledge or awareness) is developed by the study and development of accident and near-miss investigations. 

Every member of an investigation team learns about problems that precipitate accidents. This new knowledge helps every team member avoid similar situations in the future. If the investigation is appropriately reported, many others will also benefit. 

This concept is also important for reporting minor accidents or near misses. Minor accidents and near misses are excellent opportunities to obtain free chances to prevent larger accidents from occurring in the future. It is much easier to correct minor problems before serious accidents occur than to correct them after they are manifested in major losses. 

---

Drogaris, G. 1993. Major Accident Reporting System Lessons Learned from Accidents Notified. Elesevier Science Publishers,B.V., Amsterdam. 

Kletz, T. A. (1988). Learning from Accidents. Oxford, UK Butterworth-Heinemann. 

T. A. Kletz, Learning from Accidents, 2nd edition, Butterworth-Heinemann, 1994, Chapters. 

T. Kletz, Layered Accident Investigations, Hydrocarbon Processing (November 1979), pp. 373-382 and T. Kletz, Learning from Accidents in Industry (Boston Butterworths, 1988). 

Trevor Kletz, Learning from Accidents in Industry (Boston Butterworths, 1988). p. 153. 

Trevor A. Kletz, Learning from Accidents in Industry, 2d ed. (Boston Butterworth-Heinemann, 1994). Trevor A. Kletz, What Went Wrong Case Histories of Process Plant Disasters (Houston Gulf Publishing, 1985). 

This thesis is focused on the pro-active Sis in order to derive pre-accident warning signs and reactive Sis will not be addressed. However, this does not mean that the reactive Sis have no use as pre-warning signs. On the contrary, they contribute to the enhancement of the pro-active Sis by means of the lessons learned from accidents. 

Korvers P.M.W., Sonnemans P.J.M., Beek van P.C., 2003. Are accidents always unforeseeable - learning from accident analysis, Proceedings of the 37th Annual Loss Prevention Symposium, AIChE, New Orleans, pp. 483-492. 

Learning from Accidents in Industry, Keltz, T.A., London, Butterworths, 1998, p. 32... 

Trevor Kletz often described accident investigation with the story of peeling an onion. In the opening paragraph of Learning from Accidents in Industry, [6] Kletz states ... 

Kletz, Trevor A., Learning From Accidents in Industry, London Butterworth, 1988, pp. 1—23. 

Kletz, Trevor A., Learning From Accidents in Industry, ISBN 0-408-02696-0, Butterworths, London and Boston, 1988. The aims of this book are to show how we can learn more by analyzing accidents and to be better able to prevent similar accidents from occurring. It is another of Trevor Kletzs easy-to-read, informative books. 

---