Learning from past incidents lacks total recall

摘要

The August issue of SHP contained rather more accounts than usual of prosecutions following accidents. Yet, all the accidents reported were similar to those that have happened before. Accidents, it seems, are investigated, reported, filed - and then forgotten. The underlying cause of the explosion at Buncefield, for example, was that all the people and organisations involved in design, operations and maintenance were unaware of similar explosions - such as those in Newark, New Jersey in 1983, St. Herblain, France in 1991, Naples, Italy in 1995, and elsewhere.