Judith Hackitt’s ‘Risk Assessment’ – Reflecting on the past for a safer future

Forty years ago this month I was nearing the end of my second year exams in Chemical Engineering at Imperial College. In those days we took all exams at the end of the academic year and it was a tough couple of weeks – we budding engineers always felt hard done to as our scientist peers had just four or five exams which were all over in a week. We had twice as many. Everyone else was out celebrating while we were all still locked away studying right to the end of term.

In that year though, 1974, every chemical engineer throughout the country, myself included, was preoccupied by something other than thoughts of exams or our long awaited end of year party as we stared with disbelief at TV and newspaper images of the devastation in Flixborough following the explosion in the Nypro chemicals factory there. It was difficult for us to take in that part of the industry we all aspired to work in had suffered a catastrophic incident which killed 28 people and caused widespread damage and injury well beyond the boundaries of the site.

Debate still persists around the detailed causes of the explosion at Flixborough but the finding of the inquiry, and the generally accepted view, was that a ‘quick fix’ hastily installed bypass pipeline, which had been put in place to get the plant up and running after a reactor was taken offline, had ruptured. The resulting massive release of cyclohexane then exploded.

Some readers will by now be saying “Yes, I remember that” if you do it means you’re a certain age – like me. The majority will be more likely to say “Yes, I remember being told about that”- which is very different.

One of the biggest challenges we face in the world of real health and safety – and preventing catastrophes – is getting people to recognise what could happen, and to learn from past events even if they have never been close to such a disaster themselves. All psychologists will tell you that “active” and “direct” learning is far more effective than the passive variety where you are told about what happened and the story is cascaded down. So how do we learn effectively from past events?

Most certainly by remembering them and reflecting on what happened – just as we all did last weekend when we joined with the brave souls who returned to the Normandy beaches 70 years on. But in the case of Flixborough the real lesson for all of us is not to spend too long “looking in the rear view mirror” and pondering the detail of what did or did not actually happen. The lessons of Flixborough are about management of change, proper engineering, human and organisational factors – big issues not detail. We all need to learn from the past, but apply those lessons more broadly, not just to stopping the very same thing happening again because the world has changed a lot in 40 years.

Article source: http://www.hse.gov.uk/news/judith-risk-assessment/reflecting-on-the-past-for-a-safer-future120614.htm