Reports on disasters
See also a page on Health & Safety Management Systems (HSEMS). Reading quality reports on disasters that get to the root cause helps the reader understand what an HSEMS needs to contain.
Health & Safety Executive (UK) Web site:
Here is a link to a page addressing 'Human and organisational factors in recent incidents'
One link is to an article on accident investigation
accident investigation - Petroleum Review 2008
Links are also provided to disaster reports that include the Texas City refinery and the Buncefield Oil Storage Depot explosions, both in 2005. No matter what line of business you are in you are should find something of relevance.
baker report summary recommendations
Department of Transport Investigation Reports on public transport major accidents (UK)
Located on Railways Archive website (March 2009)
Reports on rail and underground accidents in the 1980's
Kings Cross underground fire 1987
kings cross underground fire 1987 + bookmarks.pdf
Clapham Junction rail crash 1988
Clapham junction railway accident 1988.pdf
Quintinshill rail crash 1915.
Columbia space shuttle disaster (2003)
The reports can be found at the following website.
Civil engineering disasters
West Gate Bridge collapse during construction, Melbourne 1970
A study for engineering students is provided on the website at:
The document provides a good description of decisions and events leading up to the actions taken on the day of the accident.
West Gate Bridge Study for engineering students 1990
A more general UK paper providing an overview of learning from disasters and other problems with bridges
Proc ICE effect of bridge failure on UK technical policy and practice 2009
Healthcare Commission (now Care Quality Commission)
A world away from the oil industry but you may see similar themes emerging as in many other major disasters (it's my local hospital trust that was investigated following outbreaks of C.difficile)
To sum up - from the West Gate Bridge investigation but can be seen to have much wider relevance when a disaster is investigated deeply to find the root cause and contributing factors:
begat error … and the events which led to the disaster moved with the
inevitability of a Greek Tragedy.’
(Report of Royal Commission, VPRS 2591/P0, unit 14)
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