Accident Investigation 2009 Case study Using ISM Code in an Investigation Ships in Service Training Material A-M CHAUVEL

Accident Investigation The purpose of an accident investigation is to take action to prevent accidents from recurring. Examples of spectacular accidents Piper Alpha, TWA and Ocean Ranger Ships in Service Training Material A-M CHAUVEL

Accident Investigation It is very important to find causes of an accident in order to prevent bigger ones from taking place. There are several examples of companies that have gone bankrupt as a consequence of the physical damage resulting loss of production time after a major accident. By going through the debris after an accident we can often find traces of what caused the event. Ships in Service Training Material A-M CHAUVEL

Nuclear contamination THREE MILE ISLAND CASE Nuclear contamination Thursday 28 may 1979 USA Ships in Service Training Material A-M CHAUVEL

Three Mile Island March 28, 1979 A nuclear reactor at the Three Mile Island power plant near Harrisburg, Pa., suffers a partial core meltdown. The FDA immediately began radiation sampling of milk, fish and water within a 20-mile radius of the facility. FDA officials also arranged for the shipment of potassium iodide to protect citizens close to the plant had there been significant environmental leakage from the damaged reactor.   The radiation that did escape from the facility was low enough that use of the protective drug was not needed, and no food or other products were contaminated. Ships in Service Training Material A-M CHAUVEL

Three Mile Island The Accident There was nothing unusual about the early morning of March 28, 1979 at the Three Mile Nuclear Generating station. The weather was cold but not unusually so. But during routine maintenance, an automatically operated valve in the Unit 2 reactor closed when it should not have most likely due to either a mechanical or electrical failure. This shut off the water supply to the system that cools down the reactor core and prevented the steam generators from removing heat. Automated systems then shut down the reactor core. That should have been the end of the accident, but it was not. Ships in Service Training Material A-M CHAUVEL

Three Mile Island The Accident A misreading by one of the engineers on duty compounded with a series of equipment and instrument malfunctions led to a dangerous loss of water coolant from the reactor core. As a result, the reactor core was partially exposed, which led to some radioactive gases escaping into the containment section of the reactor building. Though some of this radiation was released into the surrounding area, no immediate deaths or injuries occurred. Ships in Service Training Material A-M CHAUVEL

Three Mile Island Control valve - On - 0ff When a small valve stuck open, cooling water escaped and the reactor core of TMI's Unit 2 began to melt. But at the time, nobody seemed to know what was going on. Ships in Service Training Material A-M CHAUVEL

Three Mile Island Nuclear plan dismantled Equipment Control room design errors Cooling pump failure Consignation error (signal ) Nuclear plan dismantled Error of comprehension of the situation Lack of training Incorrect recognition of the signal Steadiness in his decision Personnel Ships in Service Training Material A-M CHAUVEL

Three Mile Island Nuclear plan dismantled Ergonomic Human error Equipment Control room design errors Cooling pump failure 10.3 Ergonomic Consignation error (signal ) Nuclear plan dismantled Error of comprehension of the situation Lack of training Human error Incorrect recognition of the signal 6.5 Steadiness in his decision Personnel Ships in Service Training Material A-M CHAUVEL

Three Mile Island (After) In the following days "If the operators had been asleep that morning and not touched anything, the accident would have never happened.“ Harold Denton 20 years later Ships in Service Training Material A-M CHAUVEL

Collision of two trains A human error FLAUJAC CASE Collision of two trains Saturday 3 august 1985 Paris - Rodez Ships in Service Training Material A-M CHAUVEL

Flaujac Accident (Theory situation) 15:10 15:20 15:30 15:40 15:50 16:00 16:10 Roc Amadour local train Rodez-Brive 7924 Corail Paris-Rodez 6153 SA 29/06 to 07/09 7921 SF SA 6151 SA Gramat Flaujac Assier Fournel Figeac Ships in Service Training Material A-M CHAUVEL

Flaujac Accident (Actual situation) 15:10 15:20 15:30 15:40 15:50 16:00 16:10 Roc Amadour local train Rodez-Brive 7924 7921 SF SA 6151 SA 6153 SA Gramat 29/06 to 07/09 Flaujac Assier Fournel Corail Paris-Rodez Delay Figeac Ships in Service Training Material A-M CHAUVEL

Flaujac Accident Majors Causes - Train delay - No safety loops - Error of lecture - Diagram complexity - Information misunderstood - New job ( Stress ) - Procedure not followed Ships in Service Training Material A-M CHAUVEL

Flaujac Accident - 32 dead persons - 2 trains destroyed Management Train delay Equipment No safety loops - 32 dead persons - 2 trains destroyed New job ( Stress ) Personnel Information misunderstood Error of lecture Methods Diagram complexity Procedure not followed Ships in Service Training Material A-M CHAUVEL

Flaujac Accident As an investigator : Majors Causes As an investigator : Could you related the majors factors to the accident using a causes-effect diagram. Ships in Service Training Material A-M CHAUVEL

Flaujac Accident - 32 dead persons - 2 trains destroyed Management Equipment No safety loops Trains delay 8.3 - 32 dead persons - 2 trains destroyed Error of lecture Diagram complexity 6.3 6.4 6.4 6.5 Information misunderstood Procedure not followed New job ( Stress ) Personnel Methods Ships in Service Training Material A-M CHAUVEL

Physical Evidence Brazaville1989 170 people died Ships in Service Training Material A-M CHAUVEL

Collision of two aeroplanes TENERIFE CASE Collision of two aeroplanes Sunday 27 march 1977 Airport of Santa Cruz Ships in Service Training Material A-M CHAUVEL

Tenerife Accident Chronology of the event 16h 59mn 10 s PAA fly enter on the run way to take off on the west departure way. KLM fly is on the taxiway just behind the PAA fly. 17h 02mn 08s PAA fly enter the west departure gate. KLM fly pass the junction point C3 of the departure gate. 17h 05mn 44s KLM fly is at the end of departure gate ready to take off and request the authorisation to take off from the control tower. 17h 05mn 53s PAA pass the junction point C3. KLM received the authorisation to take off from the control tower. Ships in Service Training Material A-M CHAUVEL

Tenerife Accident Chronology of the event 17h 06mn 09 s KLM announce to the control tower that it will take off. 17h 06mn 19s PAA announce that he has not degage the departure gate. Immediately the control tower ask to KLM fly to stop the take off procedure until new information. KLM didn't ear the message. The control tower didn't ask confirmation of message. 17h 06mn 25s The control tower ask to PAA fly to inform them as soon as the departure gate will be free. 17h 06mn 30s PAA fly confirm to the control tower the message received. Ships in Service Training Material A-M CHAUVEL

Tenerife Accident Chronology of the event 17h 06mn 33s The KLM co-pilot who understand the message inform the pilot that “PAA didn’t leave the departure gate”. “Yes” affirm the pilot. 17h 06mn 49s Collision occur near the junction point C4. Ships in Service Training Material A-M CHAUVEL

taken in consideration Tenerife Accident KLM Take off PAA position Interpretation PAA not visible Heavy fog Authorisation Interpretation Inadequate wording Impatience of the pilot Stop order not followed Non respect of feed back procedure Reactors noises Tower control conversation not taken in consideration Pilot concentration on delay Hierarchical weight Radio Doubt on message Non insistence on message received Ships in Service Training Material A-M CHAUVEL

Tenerife Accident PAA moving Didn’t take exit N° 3 Interpretation of the tower message Ambiguity of the message Exit n°4 more easy Used of main runway Holidays period Commercial constraints Traffic turned to Santa Cruz Taxiway obstructed Emergency procedure Bomb explosion at Las Palmas Ships in Service Training Material A-M CHAUVEL

Tenerife Accident Majors Causes - Political crisis - Abnormal traffic - Heavy fog - Taxiway obstructed - Hierarchical authority - Wrong ground exit - 2 radio channels out of order - Airport Lighting system failure - Flight delay - Change in procedure - Order misunderstood - Procedure not followed - Pilot overconfident Ships in Service Training Material A-M CHAUVEL

Tenerife Accident As an investigator : Majors Causes As an investigator : Could you related the majors factors to the accident using a causes-effect diagram and ISM Code. Ships in Service Training Material A-M CHAUVEL

Tenerife Accident - 582 dead persons - 2 Boeing destroyed Environment Equipment Political crisis 2 radio channels out of order 10.3 Heavy fog Taxiway obstructed Lighting system failure - 582 dead persons - 2 Boeing destroyed Abnormal traffic 7.0 Hierarchical authority Wrong ground exit Change in procedure 5.2 5.2 8.3 Order misunderstood 7.0 6.4 Flight delay Procedure not followed Pilot overconfident Management Personnel Methods Ships in Service Training Material A-M CHAUVEL

Ocean Ranger Tragedy (1982) 84 men died on the Ocean Ranger off Newfoundland. Located on the Hibernia field, 315 kilometers southeast of St. John's on the Grand Banks, the Ocean Ranger sank in the wild winter seas in one of Canada's worst marine disasters. Ships in Service Training Material A-M CHAUVEL

Ocean Ranger Testimony of the Government Inspector - An entire roughneck (drilling) crew of four to five men had quit over an injury to an inexperienced fellow worker. - Verbal abuse of the roughnecks by the driller was normal Ocean Drilling and Exploration Co procedure (The owner of the rig and in charge of its drilling crews). Verbal abuse was one of the causes of an accident in which a new worker on the drill floor lost two fingers when they were caught in an elevator. - Supervisors on the Ranger and other offshore rigs seemed to be cooperative with federal inspectors, but that there was a widespread feeling among ordinary crew members that they should keep quiet about problems on their vessels. The crew often seem to feel, rightly or wrongly, that they will lose their jobs if they give information to inspectors. It has been twenty-two years since 84 men died on the Ocean Ranger off Newfoundland. Located on the Hibernia field, 315 kilometres southeast of St. John's on the Grand Banks, the Ocean Ranger sank in the wild winter seas in one of Canada's worst marine disasters. In testimony before the Ocean Ranger Royal Commission, on December 15, 1982, the government inspector, who was last to survey the rig before it sank, had this to say: "An entire roughneck (drilling) crew of four to five men had quit over an injury to an inexperienced fellow worker, he said. Freeman's report said verbal abuse of the roughnecks by the driller 'was normal ODECO procedure.' Ocean Drilling and Exploration Co. was the owner of the rig and in charge of its drilling crews. Verbal abuse, Freeman alleged, was one of the causes of an accident in which a new worker on the drill floor lost two fingers when they were caught in an elevator. Freeman also testified that supervisors on the Ranger and other offshore rigs seemed to be cooperative with federal inspectors, but that there was a widespread feeling among ordinary crew members that they should keep quiet about problems on their vessels. 'The crew often seem to feel, rightly or wrongly, that they will lose their jobs if they give information to inspectors,' he said. Occasionally, they would volunteer information about the rigs, but usually with a request they not be identified, he said." (Canadian Press article) If the Ocean Ranger workers had been unionized, they would have had an effective health and safety committee that could have ensured that they had sound health and safety education and training. If they had been unionized, they would not have been afraid to speak out to a government inspector. They might be alive today if their concerns about safety had been acted upon. Ships in Service Training Material A-M CHAUVEL

Ocean Ranger Conclusion from Government Inspectors If the Ocean Ranger workers had been unionized, they would have had an effective health and safety committee that could have ensured that they had sound health and safety education and training. If they had been unionized, they would not have been afraid to speak out to a government inspector. It has been twenty-two years since 84 men died on the Ocean Ranger off Newfoundland. Located on the Hibernia field, 315 kilometres southeast of St. John's on the Grand Banks, the Ocean Ranger sank in the wild winter seas in one of Canada's worst marine disasters. In testimony before the Ocean Ranger Royal Commission, on December 15, 1982, the government inspector, who was last to survey the rig before it sank, had this to say: "An entire roughneck (drilling) crew of four to five men had quit over an injury to an inexperienced fellow worker, he said. Freeman's report said verbal abuse of the roughnecks by the driller 'was normal ODECO procedure.' Ocean Drilling and Exploration Co. was the owner of the rig and in charge of its drilling crews. Verbal abuse, Freeman alleged, was one of the causes of an accident in which a new worker on the drill floor lost two fingers when they were caught in an elevator. Freeman also testified that supervisors on the Ranger and other offshore rigs seemed to be cooperative with federal inspectors, but that there was a widespread feeling among ordinary crew members that they should keep quiet about problems on their vessels. 'The crew often seem to feel, rightly or wrongly, that they will lose their jobs if they give information to inspectors,' he said. Occasionally, they would volunteer information about the rigs, but usually with a request they not be identified, he said." (Canadian Press article) If the Ocean Ranger workers had been unionized, they would have had an effective health and safety committee that could have ensured that they had sound health and safety education and training. If they had been unionized, they would not have been afraid to speak out to a government inspector. They might be alive today if their concerns about safety had been acted upon. 84 men died They might be alive today if their concerns about safety had been acted upon. Ships in Service Training Material A-M CHAUVEL

PIPER ALPHA Destroyed by a fire Wednesday 6 July 1988 North Sea Ships in Service Training Material A-M CHAUVEL

Piper Alpha What was Piper Alpha? Piper Alpha was a large North Sea oil platform that started production in 1976. It produced oil from 24 wells. In its early life it had also produced gas from two wells. It was connected by an oil pipeline to Flotta and by gas pipelines to two other installations.

Piper Alpha What happened ? On 6 July 1988 there was a massive leakage of gas condensate which was ignited causing an explosion which led to large oil fires. The heat ruptured the riser of a gas pipeline from another installation. This produced a further massive explosion and fireball that engulfed the Piper Alpha platform. All this took just 22 minutes. The scale of the disaster was enormous. 167 people died, 62 people survived..

Piper Alpha What caused the leak? It is believed that the leak came from pipe work connected to a condensate pump. A safety valve had been removed from this pipe work for overhaul and maintenance. The pump itself was undergoing maintenance work. When the pipe work from which the safety valve had been removed was pressurised at start-up, it is believed the leak occurred.

Piper Alpha Accident Supercharger Pump A Pump B Ships in Service Training Material A-M CHAUVEL

Piper Alpha Chronology of the event 3 July 6h 00 The gas treatment operation is stop for a maintenance reason. 15h 30mn The operation pass in operational mode n°1. 6 July The pump A start to knock. The chief engineer decide to make a revision, and switch to pump B. A work permit is issued signed by the head of production, the chief of safety and the shift supervisor. A copy of the work permit stay in the operating room. The electrical system is switch off, but the maintenance was not planned. Two sub-contracting technicians take this opportunity to make the maintenance operation on the security valve associate to the pump A. Ships in Service Training Material A-M CHAUVEL

Piper Alpha Chronology of the event 6 July A second work permit is issued according to the procedure. The valve is isolated by an operator. The technicians removed the valve and fix plugs on both side of the open canalisation. No obligation to test the water-tightness. The valve is bought to the maintenance shop, where the work is done. When finish just before 6PM, the crane was not available. The reinstallation job was postponed to the next day. The procedure in that case was follow and a copy of the work permit signed by the head of production, them suspended by the safety department until next day (Why?). This event should have been notified in the operating log book. Ships in Service Training Material A-M CHAUVEL

Piper Alpha Chronology of the event 6 July 18h00 Shift change. 21h50 Failure of Pump B. 21h53 The level of liquid in the pressure reducer increased, alarm signal start. 21h54 Report in operating room “the pump B will not start” 21h56 A low gas alarm start in the sector of the centrifugal compressor area Modules C. Two of three compressors failed. 21h57 A major gas alarm start in the sector of the centrifugal compressor. Ships in Service Training Material A-M CHAUVEL

Piper Alpha Chronology of the event 6 July 21h58 First explosion. Emergency activated in operating room. Smoke visible under the ceiling of the 68 floor. 10 to 30 seconds after the first visible flames a second explosion happened. 21h59 Crude oil from the main pipe accede from the area of extraction. Major damages happened in the operating room and maintenance shop. Safety light in service failed. 22h00 Operating room notice a major drop of crude oil in the pipe. The fire safety system didn’t worked. Piper Alpha send “Mayday” Ships in Service Training Material A-M CHAUVEL

Piper Alpha Chronology of the event 6 July 22h07 The radio leave it job because of the high temperature. 22h22 Colossal explosion. The platform intruded by a fireball and sacked by a explosion show an inclination of 45°. 23h00 The surface of the sea is burning all around the platform. 7 July 01h00 Piper Alpha collapsed. Ships in Service Training Material A-M CHAUVEL

Piper Alpha Majors Causes - Lack of qualified supervisors ( summer holidays ) - Fire protection system failure - Safety design error Safety design error - Maintenance procedure inadequate - Lighting safety system failure - Routine - Communication failure between shifts - Life boats unavailable - Non qualified assistants - Not regular operating procedure - Minimum manning requirements - Work permit procedure inadequate - Drills & exercises no formal practices Ships in Service Training Material A-M CHAUVEL

Piper Alpha As an investigator : Majors Causes As an investigator : Could you related the majors factors to the accident using a causes-effect diagram and ISM Code. Ships in Service Training Material A-M CHAUVEL

Maintenance procedure Communication failure Piper Alpha Management Equipment 6.2 Fire protection system failure Safety design error Lack of qualified supervisors ( summer holidays ) 10.3 Life boats unavailable Light safety system failure - 167 dead persons - 1 platform destroyed - environmental pollution Routine 8.2 6.7 7.0 6.2 Non qualified Not regular operating procedure Minimum manning requirements 10.1 10.3 Work permit procedure inadequate Maintenance procedure inadequate Drills & exercises no formal practices Communication failure between shifts Personnel Methods Ships in Service Training Material A-M CHAUVEL

Chemical contamination Bhopal Chemical contamination Sunday 2 December 1984 INDIA Ships in Service Training Material A-M CHAUVEL A-M CHAUVEL - BUREAU VERITAS DNS-DCO

Bhopal Bhopal : population 800 000 600 km from Delhi Union Carbide : - Pesticides plan - 1000 workers including sub-contractors - Production : 1981 : 5200 tons 1982 : 2300 tons 1983 : 1650 tons - Turn over: 15 millions $ - Estimated loss of 4 millions $ per year. The accident started in the stock area of the methyl isocyanate ( MIC ) That day the equipment N° 610 contained 41 tons of MIC Delhi Bhopal Stainless steel Chloroform ( Water + MIC ) = Exothermic reaction Ships in Service Training Material A-M CHAUVEL

Bhopal On the night of the 2-3 December 1984 water inadvertently entered the MIC storage tank, where over 40 metric tons of MIC were being stored. The addition of water to the tank caused a runaway chemical reaction, resulting in a rapid rise in pressure and temperature. The heat generated by the reaction, the presence of higher than normal concentrations of chloroform, and the presence of an iron catalyst , produced by the corrosion of the stainless steel tank wall, resulted in a reaction of such momentum, that gases formed could not be contained by safety systems. Ships in Service Training Material A-M CHAUVEL

Bhopal As a result, MIC and other reaction products, in liquid and vapour form, escaped from the plant into the surrounding areas. There was no warning for people surrounding the plant as the emergency sirens had been switched off. The effect on the people living in the shanty settlements just over the fence was immediate and devastating. Many died in their beds, others staggered from their homes, blinded and choking, to die in the street. Many more died later after reaching hospitals and emergency aid centres. Ships in Service Training Material A-M CHAUVEL

Bhopal The factory was closed down after the accident. The early acute effects were vomiting and burning sensations in the eyes, nose and throat, and most deaths have been attributed to respiratory failure. For some, the toxic gas caused such massive internal secretions that their lungs became clogged with fluids, while for others, spasmodic constriction of the bronchial tubes led to suffocation. It is been estimated that at least 3,000 people died as a result of this accident, while figures for the number of people injured currently range from 200,000 to 600,000 people, with an estimated 500,000 typically quoted. The factory was closed down after the accident. Ships in Service Training Material A-M CHAUVEL

Bhopal The Bhopal disaster was the result of a combination of: legal, technological, organizational, and human errors. The immediate cause of the chemical reaction was the seepage of water (500 litres) into the MIC storage tank. The results of this reaction were exacerbated by the failure of containment and safety measures and by a complete absence of community information and emergency procedures. Ships in Service Training Material A-M CHAUVEL

Bhopal The long term effects were made worse by the absence of systems to care for and compensate the victims. Furthermore, safety standards and maintenance procedures at the plant had been deteriorating and ignored for months. A listing of the defects of the MIC unit runs as follows: - Gauges measuring temperature and pressure in the various parts of the unit, including the crucial MIC storage tanks, were so notoriously unreliable that workers ignored early signs of trouble. - The refrigeration unit for keeping MIC at low temperatures (and therefore less likely to undergo overheating and expansion should a contaminant enter the tank) had been shut off for some time. - The gas scrubber, designed to neutralize any escaping MIC, had been shut off for maintenance. - Even had it been operative, post-disaster inquiries revealed, the maximum pressure it could handle was only one-quarter that which was actually reached in the accident. Ships in Service Training Material A-M CHAUVEL

Bhopal - The flare tower, designed to burn off MIC escaping from the scrubber, was also turned off, waiting for replacement of a corroded piece of pipe. - The tower, however, was inadequately designed for its task, as it was capable of handling only a quarter of the volume of gas released. - The water curtain, designed to neutralize any remaining gas, was too short to reach the top of the flare tower, from where the MIC was billowing. - The lack of effective warning systems; the alarm on the storage tank failed to signal the increase in temperature on the night of the disaster. MIC storage tank number 610 was filled beyond recommended capacity; and the storage tank which was supposed to be held in reserve for excess MIC already contained the MIC. Ships in Service Training Material A-M CHAUVEL

Bhopal Majors Causes - Lack of qualified supervisors - Total lack of safety culture - Cut on maintenance programme - Under qualified subcontractors - No emergency plan - Reduction of quality control personnel - Safety rules violation - Budget restrictions - Lack of maintenance on safety equipment - Lack of training - Safety valve failure - No plug for isolation of the system - Lack of knowledge of the process Ships in Service Training Material A-M CHAUVEL

Bhopal Consequences - More than 2 300 dead Persons - 170 000 contaminated - Environmental pollution Ships in Service Training Material A-M CHAUVEL

Could you identify some deviations from the requirements Bhopal Using ISM Code : Could you identify some deviations from the requirements Ships in Service Training Material A-M CHAUVEL

Causes - Effect Diagram Tuna Ships in Service Training Material A-M CHAUVEL

Bhopal Management Methods - more than 2 300 dead persons - 170 000 contaminated - environmental pollution Personnel Equipment Ships in Service Training Material A-M CHAUVEL

Management Methods 2.1 8.1 3.3 6.2 2.2 10.2 10.1 4.0 - more than Total lack of safety culture 2.1 8.1 3.3 6.2 No quality control Lack of qualified supervisors 2.2 10.2 10.1 4.0 No emergency plan Budget restrictions - more than 2 300 dead persons - 170 000 contaminated - environmental pollution No maintenance programme Safety rules violation Unqualified subcontractors 6.4 6.6 6.3 Lack of maintenance on safety equipment Lack of training 10.2 7.0 Safety valve failure No plug for isolation of the system Lack of knowlege of the process Personnel Equipment Ships in Service Training Material A-M CHAUVEL

Bhopal Ships in Service Training Material A-M CHAUVEL

Other Accident Causation Ships in Service Training Material A-M CHAUVEL

Other Accident Causation Kings Cross Fire (1987) 31 died - Discarded cigarette - Accumulation of rubbish - Poor housecleaning practice - Wooden escalator - Failure of fire fighting equipment - Lack of emergency training - Poor safety culture Ships in Service Training Material A-M CHAUVEL

Other Accident Causation Herald of Free Enterprise (1987) 189 died - Failure to close bow doors - No checking/reporting system - Commercial pressures - Internal friction - Disease of sloppiness Ships in Service Training Material A-M CHAUVEL

Other Accident Causation Clapham Junction (1988) 35 died & 500 injured - Signal failure - Incorrect maintenance - Degradation of working practices - Training problems - Communication problems - Poor supervision - Excessive working hours - Failure to learn lessons Ships in Service Training Material A-M CHAUVEL

Non respect of a procedure Most of the major accidents have for origins Error of diagnosis Late decision Ambiguous communication Misinterpretation of a signal Non respect of a procedure or regulation Ships in Service Training Material A-M CHAUVEL

Before Starting AN ACCIDENT INVESTIGATION IN SHIPPING INDUSTRY Ships in Service Training Material A-M CHAUVEL

? Grounding Stranding (21%) Foundered (44%) Fire Explosion (16%) Ships lost Contact (1%) Collision (12%) ? A - M CHAUVEL - BUREAU VERITAS

? Grounding Stranding (21%) Foundered (44%) Fire Explosion (16%) Ships lost Contact (1%) Collision (12%) ? Adverse weather High speed Technical circumstances Stress Social hierarchy on board Speed Practices Fatigue Poor planning Management deficiencies Training Reduction of crew Defective equipment Design Blind eyes to procedures Lack of attention Communication failures Careless overconfidence Error of judgement Excessive speed A - M CHAUVEL - BUREAU VERITAS

independent investigator ? Why do we need an independent investigator ? The benefits of good accident investigation Apart from achieving the ultimate goal of preventing a recurrence of the same or similar accident, effective accident investigation can provide many benefits to an organisation, including;  Identifying out-moded operational methods  Improvements in the work environment  Increased productivity due to modification of equipment and machinery  Improvements to operational and safety procedures  Improved safety awareness Ships in Service Training Material A-M CHAUVEL

Ghislengien Belgium July 30 2004 LNG Pipeline Explosion

Ghislengien Gas explosion in bleu : ( Declarations of the Fluxys management ) Pipeline Environment Development of the industrial zone Bad condition Material ( meets International standards) Pressure too high Flooded risk area Consolidation work of the underground (under the standard) Explosion : 16 dead 120 Injured Quality control procedures Denied need for evacuation of the area ? (Respected) Gates closed only after the explosion External threat Procedures Management Ships in Service Training Material A-M CHAUVEL