The Weekly Reflektion 16/2024

Do we at Reflekt talk too much about learning from Major Accidents and how improvements can be made to your operation without the devasting consequences of a disaster? Is it actually possible to talk too much about learning? We don’t think so and true to our word, here is our latest effort to prompt you to do something.

Do you win a consolation prize every time someone else has a Major Accident?

We were out at a concert last week and one of the singers sang a song called ‘The consolation prize’. It was a love song and told the story of a relationship that didn’t end so well resulting in the singer becoming single, again. Considering the way the singer put his soul into the song and the emotion created, it seemed to us very likely that this was a true story. So, what was the consolation prize, you may ask? First prize of course was a successful relationship and the couple still together. The consolation prize was what the singer had learned from the relationship and the break-up and using this learning to make sure that his next relationship would be a success. Sound familiar?

In last week’s Reflektion 15/2024 we considered how learning from the fire at Garnock Court in Irvine, Scotland could have been a factor in preventing the fire at Grenfell Tower in London, 2018.

In our Reflektions 30/2018 and 32/2018 we considered how the learning from the well control incident on the Bardolino well (UK) in 2009 could have been applied to prevent the Macondo well blow out (Gulf of Mexico) in 2010.

The failure of the high-level protection and overfilling of the distillation tower at Texas City refinery (USA) in March 2005 that caused an explosion where 15 people died could have been a useful learning to prevent the failure of the high-levelprotection on a fuel storage tank at Buncefield in December 2005 that led to the largest explosion and fire in the UK since World War 2.

The learning from the Paris Metro Fire in 1903 – 84 dead and the 20 fires a year on the London Underground between 1958 and 1987 would have been useful for prevention of the fire at the Kings Cross underground station that killed 31 people in November 1987. This was one of the incidents covered in our first Breakfast Seminar in April 2018.

Planes crash, ships capsize, refineries blow up, wells blow out, bridges collapse, dams burst etc. We investigate and we find the causes. We make recommendations for how these can be prevented. We change laws, rules, regulations and standards to embed the learning. Every so often, unfortunately, a new disaster pops up and inevitably there will one or more incidents that we could have learned from.

Everyone can ‘win’ a consolation prize in this Major Accident context. Irrespective of when it happened and where it happened there is no excuse for not learning. We live in aworld of global networks, search functions and easy access to information. Every company working with hazardous materials in hazardous locations with a potential for an incident that can have Major Accident consequences should have a Major Accident learning process. Do you?

Reflekt AS