Why cannot chemical accidents be prevented?
The same kinds of accidents occur time and again at production establishments handling dangerous chemicals. Can we not learn from previous accidents? Do we use appropriate accident investigation methods, and do we have enough co-operation in the investigation work? These were the topics studied by Tanja Heinimaa, Senior Adviser at the Finnish Safety and Chemicals Agency, in her licentiate thesis Improving the safety of Seveso establishments in Finland by developing the accident investigation process.
In Finland we have about 280 Seveso establishments, the total number in the whole EU being around 10,300. Seveso establishment denotes a production establishment dealing in handling and storage of dangerous chemicals, which involves a major-accident risk. Common legislation, including the Seveso Directive, has been passed in an attempt to improve safety at these establishments. In our country, the Finnish Safety and Chemicals Agency (Tukes) is responsible for supervising the safety at Seveso establishments. An average of 30 major-accidents occur at these establishments in Europe each year, Finland accounting for one of them.
In her licentiate thesis, Ms Heinimaa examined how to promote learning from accidents and accident investigation at Seveso establishments in Finland. The purpose of such learning is to prevent accidents and improve the safety at the establishments. The thesis addressed e.g. the methods and best practices used in accident investigation.
The accident investigation carried out on Seveso establishments is organised in different ways in various countries. In most countries, the entrepreneur conducts the investigation and submits the report to the authority for evaluation. On the basis of the report, the authority may request additional information, perform surveillance visits or impose requirements of various kinds. Depending on the incident, the Seveso authority may conduct an investigation of its own or participate as an expert in an investigation conducted by another party (often the Police). In Finland, authority investigation on Seveso accidents is attended to by Tukes. Among the other investigation parties can be the Safety Investigation Authority, the Radiation and Nuclear Safety Authority, the Police, rescue services, and occupational health and safety authorities in our country.
Although there is a great number of accident investigation methods, they are not systematically applied to in all organisations – neither are the latest methods known by all. The best known and most widely used methods are based on traditional safety thinking, with a focus on mistakes. The thesis presents a variety of accident investigation methods and best investigation practices.
“Different methods should be applied to at the various stages of the investigation process, particularly when investigating complex Seveso accidents, in order to ensure a high-quality, objective and adequately broad-based investigation. These methods would enable the investigation team to communicate efficiently and form a common view of the course of the accident and the underlying factors,” says Ms Heinimaa.
Best practices include:
- sufficient expertise and resources within the investigation team and a clearly defined goal
- well-functioning, confidence-based collaboration with the entrepreneur, the relevant authorities and other stakeholders
- systematic internal and external communication
- wide-ranging usage of accident investigation methods
- clear and logical conclusions based on investigations and tangible recommendations.
Although the leading idea of the thesis was the investigation of accidents involving the handling and storage of dangerous chemicals conducted by authorities, the results can certainly be used by other authorities, entrepreneurs and insurance companies in accident and near-miss investigations. The licentiate thesis may also be taken advantage of in education and training.
The Finnish-language thesis is available on Tukes' website: http://www.tukes.fi/Tiedostot/kemikaalit_kaasu/Onnettomuustutkinnan_vaikuttavuus_Seveso-laitoksilla.pdf
For more information:
Tanja Heinimaa, Senior Adviser, tel. +358 29 5052 657
e-mail: [email protected]