Today marks another anniversary of the BP Texas City Refinery explosion of March 23rd 2005.
There is no doubt that Incident Investigation reports provide valuable insight into the immediate and root causes of major accidents like this, however can you really digest & communicate all the key messages and apply the lessons which have been (painfully) learned?
The final CSB report was 341 pages long and inspired or instigated a number of related publications, including – perhaps most famously – ‘Failure to Learn‘ by Andrew Hopkins which (at 171 pages) is half as much again – undoubtedly invaluable but still quite a hefty read for time-poor stakeholders.
Learning is not necessarily the issue – it’s remembering/recalling those lessons just before they become relevant i.e. at the point of use (need) by frontline personnel, those who are interacting with hazardous materials or energy, who may benefit from taking a beat or pausing to reflect on what has happened in the past on the same or similar facilities.
Incidents Cards can be used to inform or remind personnel of related excursions, incidents or accidents with relative ranking of key information as well as QR code links to relevant material. These could be company or industry events that help facilitate discussions on the effects of loss of control.
Incident Infographics can be digitally connected to cards; capturing and communicating the key points on a single page using Barrier Failure Analysis (BFA) diagrams, they provide a simple, but powerful, summary of the progressive failure (or absence) of barriers which allowed a threat to escalate to the ultimate consequences.
BFA also provides depth of understanding, where the ultimate or proximate (Primary) cause(s) of the barrier failure are explained by (or traced back to) related (and sometimes remote) Secondary or root (Tertiary) causes or initiating events.
The individual barrier failure types are explained below:
These BFA diagrams and infographics can be created for company or industry incidents to represent the key points (times) in the incident where barriers were called upon to act but were unable to prevent the outcome.
Knowing (and remembering) WHAT failed, HOW it failed and WHY it failed and then addressing the causes at source, could help avoid history repeating itself.
Here’s a relevant & timely example for the incident on this date 17 years ago:
For more information on Incidents cards and/or Incident Infographics & Barrier Failure Analysis– please contact us.
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