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From the Review Pages of the New Scientist : 5 June 1993

Safety and the short-term memory

Lessons from Disaster - How organisations have no memory and accidents recur

It was George Bernard Shaw who once wrote that: "Most discoveries are made regularly every 15 years". This could well be said of industrial accidents because when they occur we discover their causes and introduce specific measures to prevent them happening again. Then, in time, experienced individuals  leave the organisation taking their knowledge with them, the organisation as a whole forgets and, before long, conditions become ripe for another accident.

A good example of corporate failure to remember is the Kings Cross escalator fire in 1987, in which 31 people were killed and many more were injured. The immediate cause of the fire was a combination of a lighted match dropped by a passenger on an escalator, which set fire to an accumulation of grease and dust on the  running track. It wasn't however an isolated example: From 1958 to 1987 there was an average of 20 escalator fires a year, called "smoulderings" to make them seem less serious. Some had caused damage and passengers had suffered from smoke inhalation, but no one had been killed. Thus, little by little, the view grew within the organisation that no "smouldering" could become serious and fires were treated almost casually. It became the practice to call in the fire brigade only if it looked as if a fire might get out of hand. Recommendations made after previous fires were not carried out.

Lessons from Disaster - How organisations have no memory and accidents recur draws upon the wealth of experience of its author Trevor Kletz, formerly safety adviser to the Petrochemicals Divison of ICI. His  thesis is that it is not lack of knowledge that causes industrial accidents but mainly our failure to use the knowledge that is already available. Taking the process industry as the basis for many but not all of his examples, he shows how accidents may be repeated many times. He describes four serious accidents in the UK chemical industry which were repeated ten or more years later in the same company, though not always in the same part of it. "Organisations have no memory; only people have memories and they move on." He stresses the importance of learning and remembering the lessons of the past: looking back to earlier case histories to prevent future disasters. "Problems of all sorts, not just accidents, will recur less often if we publicise, discuss and record the actions taken in the past, remind people of them from time to time, do not make changes unless we know why the procedure or equipment was introduced..."

Kletz brings together a large number of carefully chosen case histories in his book and draws out the key lessons from each. Although he confines his attention mainly to one  industry, his message is of general application. There is an excellent chapter on safety management, that includes sections on hazard identification and assessment and on accident investigation. Another chapter considers ways of improving the corporate memory. The book is well written, illustrated and referenced. The book  will be of general interest to anyone with a concern for industrial safety and provides useful source of reference material for safety instruction. "Experience  is the best of schoolmasters, only the school-fees are heavy." wrote Thomas Carlyle the 19th Century Scottish historian. This book will help reduce the school-fees for safe plant operation considerably.

Antony Anderson

Lessons from Disaster - How organisations have no memory and accidents recur
Trevor Kletz
Published by the Institution of Chemical Engineers
Davis Building
165 - 171 Railway Terrace
Rugby, Warwickshire CV21 3HQ, UK
ISBN 0 85295