Professional Documents
Culture Documents
1
12.
Some Obstacles to Ge
Key points
2
12.
Some Obstacles to Ge
Vapours
Liquid
3
12.
Some Obstacles to Ge
4
12.
Some Obstacles to Ge
#6 similar, if not identical, accident recur at same site one year later,
suggesting that no lessons have been learned. Causes still not identified.
Record does not meet the most basic criteria for accident investigation.
11
12. Some Obstacles to Ge
12
12. Some Obstacles to Ge
13
12. Some Obstacles to Ge
14
12. Some Obstacles to Ge
15
12. Some Obstacles to Ge
16
12. Some Obstacles to Ge
17
12. Some Obstacles to Ge
Number of records
18
12. Some Obstacles to Ge
MARS
TAD
600
13,000
19
129
16
1 (2?)
11
Findings 1
value of info on past accidents
Our case example with bulk methanol storage has shown that some
of the data in some of the Short Reports in MARS have a number of
serious shortcomings. Causes are not identified and lessons
learned are left blank. The value of this information in the efforts
to prevent future methanol accidents is limited - but not nil.
Our case also demonstrates that even the most rudimentary data
on past accidents can be of value in accident prevention. Ironically,
it was the Short Report in MARS with the most meagre data that
gave inspiration to an accident causation hypothesis which
eventually proved useful. Also, the mere knowledge of past
accidents undermined the Companys assertion that it had no
knowledge of any prior accidents involving the bulk storage of
methanol.
19
12. Some Obstacles to Ge
20
12. Some Obstacles to Ge
21
12. Some Obstacles to Ge
22
12. Some Obstacles to Ge
23
12. Some Obstacles to Ge