Lessons Learned from Past Experience

This page seeks to inform you about what has been learned from previous incidents.  It is not a complete accident database but has been produced to assist those who wish to learn from past errors and oversights. This type of information used to be available in The Major Accident Database from the ICHEME but this is no longer maintained up to date.

It is not intended to ascribe blame to any individual or organisation but the descriptions are offered in an attempt to secure prevention of future accidents.  If anything causes offence or appears to have been misinterpreted then please let me know: peter@astriduk.co.uk

Some of these incidents are well known but nevertheless the root causes are not always remembered nor the lessons learned for new projects and current operations.

Not all of the entries are complete, it is intended to add more detail as time permits, especially where it is important to reference source material where it is not from first hand knowledge.  No responsibility can be taken for the material in external web sites nor the maintenance of the links.

Contents

Three Mile Island

Flixborough

HSE .  http://www.hse.gov.uk/comah/sragtech/caseflixboroug74.htm  

Wikipedia  http://en.wikipedia.org/wiki/Flixborough_disaster

Alternative Views: http://business.virgin.net/olwen.cox/pubs/FlixRevisit.htm and http://business.virgin.net/olwen.cox/pubs/Flixborough.htm

Seveso

Newark New Jersey

See p41 861lessonslearned.pdf

Bhopal

Grangemouth

HSE . http://www.hse.gov.uk/comah/sragtech/casebpgrang87b.htm

Wikipedia http://en.wikipedia.org/wiki/Grangemouth_Refinery

IChemE http://cms.icheme.org/mainwebsite/general251db29ef4116b1f.aspx?map=a9420ef94cbaaedd48f315ee799ea755

 

 

Chernobyl

Kings Cross Underground Fire

Railway Archive: http://www.railwaysarchive.co.uk/docsummary.php?docID=75

Piper Alpha

The Public Inquiry into the Piper Alpha Disaster, Cullen, The Honourable Lord, HM Stationery Office, 1990

Lees’ Loss Prevention in the Process Industries: Hazard Identification, Assessment and Control, ed. Mannan, S., 3rd edition, Elsevier Butterworth-Heinemann, 2005.

Learning from accidents, Kletz, T., 3rd edition, Gulf Professional Publishing, 2001.

FABIG: http://www.fabig.com/Accidents/Piper+Alpha.htm

Coode Island

Derbyshire

Pembroke Cracker

HSE: ‘The explosion and fires at the Texaco Refinery, Milford Haven, 24 July 1994: A report of the investigation by the Health and Safety Executive into the explosion and fires on the Pembroke Cracking Company Plant at the Texaco Refinery, Milford Haven on 24 July 1994’, ISBN 0 7176 1413 1, 1997.

    http://www.hse.gov.uk/comah/sragtech/casetexaco94.htm

See p43 861lessonslearned.pdf

Major Accidents since Flixborough (1974) http://www.hse.gov.uk/comah/lossprev.pdf

Ladbroke Grove Rail

Challenger

Longford

Ghlissengen

Toulouse

Buncefield

HSE http://www.hse.gov.uk/comah/buncefield/buncefield-report.pdf

  http://www.hse.gov.uk/comah/buncefield/final.htm

  http://www.hse.gov.uk/comah/buncefield/oneyear.htm

  http://www.buncefieldinvestigation.gov.uk/     

See p42 861lessonslearned.pdf

 

Texas City

See p44 861lessonslearned.pdf

 

Offshore semi-sub

 

Montara

Commission of Inquiry http://www.ret.gov.au/Department/Documents/MIR/Montara-Report.pdf

Australian Government http://www.ret.gov.au/Department/Documents/MIR/response-to-montara-inquiry-report.pdf

PTTEP Response http://www.ret.gov.au/Department/Documents/MIR/Montara-Response-Review.pdf

Macondo (Deepwater Horizon)

BP: http://www.bp.com/liveassets/bp_internet/globalbp/globalbp_uk_english/incident_response/STAGING/local_assets/downloads_pdfs/Deepwater_Horizon_Accident_Investigation_Report_Executive_summary.pdf

National Academy of Engineering and National Research Council:

                                         http://www.nationalacademies.org/includes/DH_Interim_Report_final.pdf

National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling

http://www.oilspillcommission.gov/

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