Learning from Accidents

Accident investigation is like peeling an onion. 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 avoiding the hazards and with weaknesses in the management system. 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 an accident. This book aims to show, by analysing accidents that have occured, how we can learn more from them and thus be better able to prevent them occuring again. Looking at a wide range of accidents from the trivial to major disasters and covering the process industries, nuclear industry and transportation, the author analyses each accident in a practical and non-theoretical fashion and summarises each with a chain of events showing the prevention and mitigation which could have occured at every stage. At all times the book emphasises cause and prevention rather than human interest or cleaning up the mess. The chapter on Piper Alpha has been especially written for the book by Brian Appleton, one of the technical assessors of the official enquiry. Anyone involved in accident investigation and reporting of whatever sort and all those who work in industry, whether in design, operations or loss prevention will find this book full of invaluable guidance and advice.