Incident investigation and analysis
The folly of ‘paper safety’ – lessons from the Nimrod review
On 2nd September 2006, RAF Nimrod XV230 was on a routine mission over Helmand Province in Southern Afghanistan when, only minutes after completing air-to-air refuelling, she suffered a catastrophic mid-air fire which led to the total loss of the aircraft and the death of all 14 on board. Following the initial investigation by the Board of Inquiry which reported on the probable cause of the accident, a broader independent review was instigated in late 2007.
Six steps for successful incident investigation
Organisations investigate business upsets because they are required to by law or their own company standards, or the public or shareholders expect it. But, whatever the motivation, the goal is to identify why the incident happened and to take action to reduce the risk of future incidents.
Accidents waiting to happen
Why do things go wrong? A relatively simple question, but one that is fundamental to the risk management of any organisation. Whether it is the computer failure that delays the payroll, prescribing the wrong medication, an object falling from height or a fire in a warehouse, the chances are that at some point there was a human involvement that could have been better managed.
Texas City refinery explosion: findings from the Independent Safety Review Panel
On March 23, 2005, the BP Texas City refinery experienced one of the most serious U.S. workplace disasters of the past two decades, resulting in 15 deaths, more than 170 injuries, and significant economic losses. During the startup of an isomerisation unit, the associated raffinate splitter tower was overfilled and overheated. A substantial volume of hydrocarbon liquid and vapour were forced into an adjacent blowdown stack, rapidly exceeding its capacity. Ignition of the resulting vapour cloud caused an explosion that extended to nearby temporary trailers.
If only Daedalus had known about Tripod
Even the first documented aviation accident, the death of Icarus, warrants some re-evaluation from time to time. Traditionally, his death is blamed on his recklessness.