Learning from major accidents involving dangerous substances

Abstract The Major Accident Reporting System (MARS) has been established by the Commission of the European Communities within the framework of the Implementation of the Council Directive 82/501/EEC on the Major Accident Hazards of Certain Industrial Activities (known also as the SEVESO or post-SEVESO-Directive). This system is operated in the JRC at Ispra site. Up to the end of 1991 a total of 121 accidents have been reported by the National Component Authorities in MARS. Accident reports have been analysed and accidents have been classified according to a number of parameters. This classification is useful in identifying priorities for improving safety. Both immediate and underlying accident causes have been identified for the vast majority of accidents notified and consequently lessons for preventing similar recurrences or mitigating accident consequences have been extracted. This analysis shows that the vast majority of the accidents notified could have been easily prevented by proper application of available knowledge. Managerial/organizational omissions and design inadequacies are the most dominant underlying causes. The experience from the operation of MARS is used for formulating proposals for more effective accident reporting procedures. Adoption by authorities and industry of common accident investigation and reporting procedures based on these proposals may enable the creation of a communication network among all parties interested in the safe processing, handling, transportation and storage of dangerous substances.