How is it possible? Why didn't we do anything? A case history

摘要

Two similar serious accidents occurred at a metal refining process installation within a six month time interval. The first one killed ten people, the second accident one person. The accidents provide a typical case history of how a safety management system and a corresponding organisation could have prevented the occurrence of such an accident or, at least, have reduced its effects. The case is also interesting because it illustrates the physico-chemical complexities forming the root cause of the accidents.