What went Wrong and Key lessons of this Major accidents .....

In last 30 to 40 years of span many major catastrophic disasters were reported in various countries. Let us focus on following few incidents:


 June 1974, Flixborough, England chemical plant explosion.

 January 1986, Space Shuttle Challenger explodes during launch.

 July 1988, Piper Alpha Oil Platform destroyed by fire and explosion.

 February 2003, Space Shuttle Columbia breaks up during re-entry

  March 2005, Texas City, Texas oil refinery explosion

What do these incidents, which were all major failures of complex technical systems, have in common? In all of them, what was the contributing factor identified as a problem after the investigation of these incidents?

What Went Wrong?
  In all above listed disasters, the incident investigations identified common problems in the organization’s “safety culture” as an important contributing factor.
  Lack of maintaining a sense of vulnerability and demonstrative leadership
. Since catastrophic accidents are not very common, it was easy to begin to believe by one and all that nothing bad can happen.
 Critical protective systems and procedures were not maintained or may be changed without proper understanding of the possible consequences.
 People become complacent, and have a false sense of security.
 Good operations and best practices were compromised.
 Lack of constant attention to the potentially catastrophic results of hazardous activities.

Key Learning: 
What is “safety culture”?
 “Culture is the way we do things around here”. Culture is a set of acceptable behaviours which is continually demonstrated by each and every employees of the organization. What do we allow and what we don’t allow to happen.
  Management should demonstrate a key leadership role in establishing a good safety culture in an organization and everybody must contribute.
 Make people of all discipline including contract worker aware and vigilant about the hazards of the materials and processes in the plant.
 Recognize and report “Near Miss” events to remind us of what could have gone wrong.

 Use incidents which occur in other facilities, to remind us of the possibility of similar problems at our plant.
  Always operate within safe operating limits, and established operating procedures. When this isn’t possible, communicate immediately to your supervisor.
 Use approved procedures (MOC) for authorizing changes to established procedures, including thorough risk evaluation and approval by knowledgeable authorities.
 Implement of all PSM operational elements and establish control mechanism for governance.
 Establishing and maintaining safety culture at work place can be achieved by strict adherence to “Operational Discipline” and employee involvement.