Learning lessons from incidents: A paradigm shift is overdue |
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| Institution: | 1. Mary Kay O’Connor Process Safety Center, Texas A&M University, College Station, TX, United States;2. Waldram Consultants Ltd., United Kingdom;1. Department of Chemical Engineering, Universiti Teknologi Malaysia, Johor Bahru, Malaysia;2. Centre of Hydrogen Energy, Institute of Future Energy, Universiti Teknologi Malaysia, Johor Bahru, Malaysia;3. Department of Biotechnology and Chemical Technology, Aalto University, Espoo, Finland;1. Delft University of Technology, The Netherlands;2. Amsterdam University of Applied Science, Aviation Academy, The Netherlands;3. Safety Science Group, Delft University of Technology, The Netherlands;1. Safety Science Group, Delft University of Technology, Faculty of Technology, Policy and Management, Jaffalaan 5, 2628 BX Delft, The Netherlands;2. ARGoSS, Faculty of Applied Economic Sciences, University of Antwerp, Prinsstraat 13, 2000 Antwerp, Belgium;3. CEDON, Faculty of Economics and Management, Campus Brussels, KULeuven, Warmoesberg 26, 1000 Brussels, Belgium;1. Nuclear Engineering Department, Technical University of Madrid, José Gutiérrez Abascal 2, 28006 Madrid, Spain;2. Modeling and Simulation Department, Nuclear Safety Council (MOSI CSN), Justo Dorado 11, 28040 Madrid, Spain |
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| Abstract: | Drawing on historical data we show that the international community of process engineers has not been good at learning lessons from their past accidents. We call for a paradigm change in the way we approach this and the creation of a single new, multi-national, multilingual accident database that is free at the point of use and that includes immediate and underlying causes as well as “lessons learned”. It must be user-friendly and provide links to key source documents. The purpose of this paper is to challenge those in authority, and with the power to do so, to make this happen. We give some preliminary views on what may be required. In countries that so choose this could include an element of compulsion to consult the database in specific circumstances and a sign-off procedure to verify that this has been done. |
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| Keywords: | Accidents Causes Incidents Lessons learned Database Multi-lingual Free access |
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