Learning from Accidents

Introduction Two simple incidents Protective system failure Poor procedures and poor management A gas leak and explosion - The hazards of insularity A liquid leak and fire - The hazards of amateurism Another tank explosion - The hazards of optional extras Flixborough Seveso Bhopal Three Mile Island Chernobyl Aberfan Missing recommendations Three weeks in a works Some pipe failures Piper Alpha The King's Cross underground railway station fire Clapham Junction - Every sort of human error Herald of Free Enterprise Some aviation accidents Invisable hazards Signals passed at danger Longford: The hazards of following fashions The Gresford colliery explosion Green intention, red result Looking beyond violations Keeping an open mind Secondhand software: The Therac story. Conclusions Epilogue: Myths on incident investigations - widely held beliefs that are not wholly true.

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