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Three accidents in European dynamite production plants: An attempt to improve the external lessons learning
Affiliation:1. University of Pardubice, Faculty of Chemical Technology, Studentska 573, 53210 Pardubice, Czech Republic;2. Club Heuristique pour l’Analyse Organisationnelle de la Sécurité Mas Saint-Sauveur, Route de Toreilles, 66430 Bompas, France;1. Center for Offshore Engineering and Safety Technology, China University of Petroleum, Qingdao, 266580, PR China;2. State Key Laboratory of Fire Science, University of Science and Technology of China, Hefei, 257061, PR China;3. Department of Environment and Safety Engineering, China University of Petroleum, Qingdao, 266580, PR China;1. Grupo de Diseño de Productos y Procesos (GDPP), Department of Chemical Engineering, Universidad de los Andes, Bogotá, Colombia;2. School of Management, Universidad de los Andes, Bogotá, Colombia;3. Centro para la Optimización y Probabilidad Aplicada (COPA), Department of Industrial Engineering, Universidad de los Andes, Bogotá, Colombia;1. Department of Mechanical Engineering, Indian Institute of Technology Patna, Bihta, Bihar, 801103, India;2. Division 2.2, Reactive Substances and Systems, Federal Institute for Materials Research and Testing (BAM), Unter den Eichen 87, 12205, Berlin, Germany;3. Department of Mechanical Engineering, Indian Institute of Technology Bombay, Mumbai, Maharashtra, 400076, India;1. School of Chemical Machinery and Safety Engineering, Dalian University of Technology, Dalian 116024, China;2. State Key Laboratory of Fire Science, University of Science and Technology of China, Hefei 230027, China;3. Department of Chemical System Engineering, School of Engineering, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8656, Japan;1. London South Bank University Explosion & Fire Research Group, 103 Borough Rd, SE1 0AA, UK;2. Honeywell Aerospace, Bunford Ln, Yeovil, BA20, UK
Abstract:Three serious accidents occurred in three dynamite manufacturing plants within three European countries during a relatively short time period triggering the question of effective external learning. The article discusses the lessons for the prevention of accidents learned from retrospective comparative analysis. It advocates for a better process for learning lessons. It attempts to show how a two level approach to accident analysis may help to reveal a common deeper learning hidden under diverse routine lessons.
Keywords:Underlying cause  Root cause analysis  Lessons learned  Accident prevention  Explosion  Dynamite
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