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Accident investigation is like peeling an
onion or, if you prefer, a more poetic metaphor, the dance of the seven
veils. Beneath one layer of causes and recommendations, there are
other, less superficial layers. The outer layers deal with the
immediate technical causes while the inner layers are concerned with ways
of avoiding the hazards and with the underlying causes such as weaknesses
in the management system. Very often, only the outer layers are considered
and thus we fail to use all the information for which we have paid the
high price of the accident.
I am not suggesting that the immediate
causes of an incident are any less important than the underlying
causes. All must be considered if we wish to prevent further
accidents, as the examples will show. But putting the immediate
causes right will prevent only the last incident from happening again;
attending to the underlying causes may prevent many similar incidents.
Learning from Accidents in Industry will be
of interest to all those concerned with the investigation of accidents of
whatever sort, and all those who work in the process industries,
whether in design, operations, or loss prevention.
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Two simple incidents 2.
Protective system failure
3. Poor procedures and poor
management
4. A gas leak and explosion -- the
hazards of insularity
5. A liquid leak and fire -- the
hazards of amateurism
6. A tank explosion -- the hazards
of optional extras
7. Another tank explosion -- the
hazards of modifications and ignorance
8. Flixborough
9. Sevesco
10. Bhopal
11. Three Mile Island
12. Chernobyl
13. Aberfan
14. Missing recommendations
15. Three weeks in a works
16. Some pipe failures
17. Conclusion
Index
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