Project Report
earning lessons from accidents is a fundamental principle in preventing technological accidents and mitigating their effects. In 1982, recognising the paramount importance of this principle, the first EU Seveso Directive created a mechanism for sharing of lessons learned from chemical accidents among Member States by establishing the Major Accident Reporting System (MARS) managed by the European Commission’s Joint Research Centre (JRC). Through MARS (now called eMARS), EU competent authorities provide information on the sequence of events leading to a chemical accident, so that authorities and operators around the EU, and even the world, can learn from the event. The lessons learned are extracted from a report generated by (what should be) a thorough and systemic investigation to identify direct causes and underlying factors. Chemical accidents tend to have complex causality such that investigation and analysis requires a methodical approach to sort through causality that has several dimensions and interlinkages. Therefore, choosing an accident analysis methodology, or methodologies, to use in the investigation is fundamental to obtaining reliable and useful results. This decision requires understanding the strengths and weaknesses of various methodologies and selecting the optimal tool or tools, given the objectives of the investigation, the nature of the accident, and the limits of available resources.
To help provide support to such decisions, and with the view to improving reports of major accidents in eMARS, the JRC organised the Accident Analysis Benchmarking Exercise (AABE) with volunteers from a cross-section of competent authorities, researchers, and industry experts to explore a number of accident analysis methods and compare their usefulness in revealing direct and underlying causes from selected chemical accidents. The objective of the first part of the AABE was to compare the results produced by application of different methods to analyse a defined set of accidents and evaluate the use of the methods against agreed criteria. The second phase of the exercise was intended to use the experiences of the analysts in this process to create a tool that might be support a wide range of experts, who are expert in process safety but not necessarily in accident analysis methods, to produce or review accident investigation reports. This document summarises the activities and results of the first phase of this project and the direction proposed by the group for the second phase.
ALLFORD Lee;
WOOD Maureen;
2021-03-29
Publications Office of the European Union
JRC123513
978-92-76-28605-9 (online),
978-92-76-28604-2 (print),
1831-9424 (online),
1018-5593 (print),
EUR 30564 EN,
OP KJ-NA-30564-EN-N (online),
OP KJ-NA-30564-EN-C (print),
https://publications.jrc.ec.europa.eu/repository/handle/JRC123513,
10.2760/08034 (online),
10.2760/080539 (print),
