| Accident investigation: keep asking "why?". | |
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MedLine Citation:
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PMID: 16162391 Owner: NLM Status: MEDLINE |
Abstract/OtherAbstract:
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Finding the causes of an accident or operating problem and deciding what actions to take to prevent it happening again is rather like dismantling a set of Russian dolls (Fig. 1). Each time we ask "why?" (or a similar searching question) we find another cause besides the ones we have found already and another action (or set of actions) we can take to prevent similar accidents occurring again. Many investigators stop too soon. This occurred at Flixborough, at Bhopal and in the investigation of many lesser-known accidents. We are more likely to find the deeper causes and the more original actions if groups of people with wide interests and experience are able to take part in the investigations or discuss the investigation reports. We should never look at an accident report as "closing out" a problem. As we read it, we should ask ourselves, "what else could be done?" |
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Authors:
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Trevor A Kletz |
Publication Detail:
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Type: Journal Article Date: 2005-09-12 |
Journal Detail:
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Title: Journal of hazardous materials Volume: 130 ISSN: 0304-3894 ISO Abbreviation: J. Hazard. Mater. Publication Date: 2006 Mar |
Date Detail:
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Created Date: 2006-03-06 Completed Date: 2006-08-16 Revised Date: - |
Medline Journal Info:
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Nlm Unique ID: 9422688 Medline TA: J Hazard Mater Country: Netherlands |
Other Details:
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Languages: eng Pagination: 69-75 Citation Subset: IM |
Affiliation:
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Mary Kay O'Connor Process Safety Center, Chemical Engineering Department, Texas A&M University, TX, USA. t.kletz@lboro.ac.uk |
Export Citation:
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| MeSH Terms | |
Descriptor/Qualifier:
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Accident Prevention* Chemical Industry* Explosions* Great Britain Humans India Organizational Innovation Safety Management / organization & administration* |
From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine
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