Safety and Loss Prevention

Lessons Learned Database

Trevor Kletz famously observed that “Organisations have no memory. Only people have memory and they move on”. He also observed that “Accidents are not due to lack of knowledge, but failure to use the knowledge we have”.

This Lessons Learned Database (LLD) was inspired by these observations. Its purpose is simply to raise awareness of major incidents in the process industries, to promote the importance of root cause analysis and to catalyse cross-sector sharing of lessons learned and good practices. The infographic contained in the document below provides an overview of the main root causes of each incident and enables the user to quickly identify which incidents share common root causes across multiple process industry sectors. The document contains hyperlinks so the user can simply click on the incident name to directly access a 1-Page incident summary.

Download the Lessons Learned Database Infographic (PDF) >>

The 1-Page incident summaries provide a brief description of the event and highlight key points (including basic causes, critical factors, root causes and lessons learned) in addition to signposting users to the detailed investigation report and selected other pertinent reference materials. The following definitions were used in development of these 1-Pagers:

Near Miss is an undesirable event which, under different circumstances, could have resulted in a process safety incident.
Immediate Cause (or Basic Cause) is a sub-standard act or condition that led directly to the incident.
Critical Factor is an undesirable act or condition which, if eliminated, would have prevented occurrence or reduced the severity of the incident.
Root Cause (or System Cause) is an organisational failing that created circumstances or conditions enabling the incident to take place.

The IChemE Safety and Loss Prevention Special Interest Group hope you will find these resources helpful for teaching, revision, safety stand-downs, providing context for process hazard analysis (PHA) studies or helping justify projects to improve process safety performance at your manufacturing plant.

To celebrate IChemE's centenary year in 2022, a book of fifty-two of these incidents has been published, alongside commentary from a range of prominent IChemE members. This book is available in electronic format here. Note that this file uses internal links for navigation and also contains links to publicly-available incident investigation reports for those looking for more detailed information.

Another excellent way to learn from historic incidents is by using the IChemE Safety Centre's case studies. These include videos and training notes, and are available for purchase.