Study of major accidents and lessons learned

Abstract

Government and private sector safety-related databases and other publisbed safety resources were studied to determine their relevance and to identify the major lessons learned from each product. Information sources studied include the National Response Center (NRC), the Accidental Release Information Program (ARIP), the Bureau of Labor Statistics (BLS), Census of Fatal Occupational Injuries (CFOI), Major Accident Reporting System (MARS), the Marsh & McLennan Annual Reviews (Marsh), and Safety and Loss Prevention Symposia (LPS). This paper appropriately references these sources of information to facilitate similar studies. We identified that: a) there are some problems with the government databases, b) even with these problems, some important information can be extracted, and c) descriptions of accidents are especially useful and educational. Some surprising and useful conclusions have also been developed; e.g., a) major accident performance is continuing to degrade, b) although PSM may be making a mark, something else is needed to improve industry's accident performance, and c) runaway reactions continue to be a significant cause of major accidents. Two case histories are summarized to support the conclusions and recommendations of this study. Recommendations concerning PSM and runaway reactions are included in this paper; that is: a) add "administrative controls" to PSM, and b) initiate more fundamental research in the area of short stopping runaway reactions.