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These bulletins are produced to provide practical lessons from major accidents and events that have occurred around the world. The variety of fascinating topics, both old and new, provide timeless lessons and valuable ideas. To comment on any bulletin, go to ERM's Risk and Safety blog: http://ircrisk.com/blognet
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- Tenerife Airport Disaster
- Lessons Learned Bulletin V4 No 3 Tenerife Airport Disaster
- On the morning of March 27, 1977, a small bomb was detonated at the Las Palmas airport on Gran Canaria Island. A terrorist group claimed that there was a second bomb, and the airport was shut down as a precaution. All incoming air traffic was relocated 90 kilometers (55 miles) away to the smaller Los Rodeos airport on Tenerife. Thereafter, a series of truly unfortunate events led to the worst accident in aviation history. The collision of KLM flight 4805 with Pan American flight 1736 resulted in the deaths of 583 people and the beginnings of a massive overhaul in the aviation industry that continues to this day.
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- Formula One's Darkest Day
- Lessons Learned Bulletin V4 No 2 Formula One's Darkest Day
- San Marino, Italy, 1994. Two men arrived to compete in the third race of the Formula One 1994 season. Roland Ratzenberger was in his first season of Formula One competition and was hoping to qualify for what would be just his second Grand Prix, while Ayrton Senna was a three-time World Champion who had already won 41 Grand Prix races, and was generally considered to be the best driver in the world. Tragically, neither would survive the week. Thanks in large part to safety measures instituted by the other drivers following this tragic weekend, theirs were the last Formula One-related driver deaths as of 2012. Their deaths carry important and striking safety lessons that are applicable across all industries and have likely saved countless lives in the last two decades.
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- The Charge of the Light Brigade
- Lessons Learned Bulletin V4 No 1 Charge of the Light Brigade
- "Forward, the Light Brigade!/Was there a man dismay'd? / Not tho' the soldier knew / someone had blunder'd / Theirs not to make reply / Theirs not to reason why / Theirs but to do and die / Into the valley of Death / Rode the six hundred."
In the 1850's, long-simmering disputes over control of resources and holy places in Eastern Europe finally erupted into war centered around the Crimean Peninsula. Britain, France, and the Ottoman Empire were allied against the Russian Empire. On October 25, 1854, the Light Brigade, a cavalry of almost 600 men, knowingly rode directly into a valley ringed on three sides by enemy troops. They were massacred by inescapable enemy fire. The Charge of the Light Brigade is still taught to military students and historians for its timeless and tragic lesson on the importance of interpersonal relationships and clear communications, and even today its lessons are applicable across all hazardous industries.
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- Human Factors
- Lessons Learned Bulletin V3 No 8 Human Factors
- Within safety critical industries there is a consensus of opinion that human factors have caused, or significantly contributed to, up to 90% of incidents and accidents. This is widely reported in the marine, transportation and aviation sectors but is equally true in the oil and gas sector. Human factors causes have featured in a number of high profile incidents in recent years, including the explosion and fire at Texas City in 2005, the leak of radioactive materials at the Thermal Oxide Reprocessing Plant at Sellafield (UK 2005), the Buncefield fuel depot explosion also in 2005, and most recently, the explosion and fire on the Deepwater Horizon drilling rig in 2010.
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- Starfish Prime
- Lessons Learned Bulletin V3 No 7 Starfish Prime
- In 1962, a U.S. government test caused a massive electromagnetic pulse that knocked out all of the electronics in Hawaii. that same test also disabled at least eight low-orbit satellites and created a radiation belt that encircled the Earth for years. This Cold War-er embarrassment is a tale of risk and repercussions that will not be easily forgotten.
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- Unlucky 13
- Lessons Learned Bulletin V3 No. 6 Unlucky 13
- The number 13 is notorious for being "unlucky." But is that really the case? In the last two centuries, there have been numerous accidents that involved the number 13, from freak volcano eruptions to massive coal mine disasters. Recent research into the number 13 and Friday the 13th has been conflicting but shows the importance of perception of risk.
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- The Crash at Crush (1896)
- Lessons Learned Bulletin V3 No. 5 The Crash at Crush (1896)
- September 1896, 40,000 people gathered in a small Texas town to witness two locomotives deliberately engineered to have a head-on crash. What should have been a crowd-pleasing spectacle turned into a massive, casualty-filled embarrassment whose history has been preserved in books and songs as a lesson in risk management.
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- Storage Tank Fires Turn Fatal (2011)
- Lessons Learned Bulletin V3 No 4 Storage Tank Fires Turn Fatal Rev 0
- Two significant storage tank fires occured in Europe the week of May 30, 2011. Tragically, four people died and a fifth was left in critical condition. These fires were only two of ten such fires that have occured in the last three months and have left a string of costly damages and fatalities in their wake.
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- Special Edition: Bromwich Speaks at OTC 2011
- Bromwich Spoke at OTC May 2011 Rev 0 5-12-11
- At a lunch event at the 2011 Offshore Technology Conference, Michael Bromwich spoke about regulatory changes affecting deepwater drilling in the last year. Bromwich is Director of the Bureau of Ocean Energy Management, Regulation and Enforcement.
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- Software Glitch Maims, Kills Cancer Patients (1980s)
- Lessons Learned Bulletin V3 No2 Killer Software Rev 0
- Between 1985 and 1987, a computer program in a promising new linear accelerator delivered massive doses of radiation to six people in Canada and the United States, creating the worst medical accident in the history of linear accelerators.
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- Great Beer Flood of 1814
- Practical Lessons Bulletin V3 No1 Beer Flood Rev 0
- Picture it: A burst 610,000-liter beer vat that causes other vats to rupture resulting in about 1.5 million liters of beer flooding streets and homes, mowing down buildings, and killing in its wake. This 19th century event holds lessons for industry today.
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- International Regulators' Forum Considers Future Safety for Offshore Drilling
- Special Safety Bulletin Rev 1 12-29-10
- International Regulators' Forum met in October 2010 to consider what's next for offshore drilling safety. This bulletin summarizes some of those discussions.
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- Herald of Free Enterprise, 1987
- V2 No8 Practical Lessons Bulletin Rev 0 09-30-10
- Vacationers returning to the U.K. from holiday on the European continent did not suspect that they would soon be struggling for survival. The Herald of Free Enterprise is known as the worst maritime disaster involving a British registered ship in peacetime since 1919. The lessons learned can be applied across industries.
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- History Repeats Itself
- V2 No6 Practical Lessons Bulletin Rev 0 07-27-10
- "Those who cannot remember the past are condemned to repeat it." (Source: philosopher and novelist George Santayana). This bulletin briefly reviews several historical oil spills, all of which affected change for the future.
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- Embattled Safety Case of the RAF Nimrod XV230 (2006)
- V2 No5 Practical Lessons Bulletin Rev 1 06-30-10
- Despite their widespread use globally, safety cases are not infallible, as evidenced by the September 2, 2006, incident involving the Royal Air Force Nimrod XV230 spy plane that exploded over Afghanistan, killing 14 people.
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- Ammonium Nitrate Blast Killed Hundreds, Texas City (1947)
- V2 No4 IRC Practical Lessons Bulletin Rev 0 Apr 29, 2010
- Ammonium nitrate in a ship hold caused an explosion that devastated Texas City, Texas, in 1947. A direct cause was not determined. Hindsight suggests emergency response planning and understanding the hazards may have mitigated the damages.
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- LNG Explosion in Cleveland Levels One Square Mile (1944)
- V2 No3 LNG Blast (Cleveland 1944) Rev 1 033010
- October 20, 1944, a mid-day LNG leak at the East Ohio Gas Company led to explosions that leveled a neighborhood of one square mile, and left 130 dead. The cause was inherently unsafe design.
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- Tupras Refinery Rocked by Earthquake (1999)
- Vol 2 No 2 Tupras Refinery Rocked by Earthquake (1999) Rev 0 Feb 23 2010
- In 1999, the company’s largest refinery was in Korfez, just south of Izmit. It was designed and built with assistance from U.S. companies in 1961 (before current earthquake construction standards), and produced about 220,000 barrels per day—roughly one-third of Turkey’s total production of refined petroleum products. The earthquake damage at the Korfez refinery was so publicized and spectacular that it remains a subject of study yet today.
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- Tale of a Semisub Explosion: Glomar Arctic II
- V2 No1 Glomar II Explosion (1982) Rev 0 01-11-10
- The 1982 explosion aboard the Glomar Arctic II is a typical story centered on temporary equipment and involving lack of procedures and training for operations, maintenance, and emergencies. Despite improvements in regulations and standards over the years, such events still occur all too frequently today. Comment on our blog: http://ircrisk.com/blognet/
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- Holiday Safety
- V1 No9 Holiday Safety Rev 1 11/30/09
- The number of injuries and deaths that occur November through December rises dramatically. IRC wanted to take this diversion from industrial accidents to remind you about safety at home and to wish you and yours a happy and safe holiday season.
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- 1976 Houston Ammonia Tanker Spill
- V1 No8 Ammonia Tanker Spill 1976 Rev 0 10/29/09
- The routine of a normal business day in Houston was suddenly in upheaval when a tanker truck carrying more than 7,000 gallons of ammonia crashed onto U.S. 59 from a freeway overpass. This busy intersection, enveloped by a toxic gas cloud, was near residential neighborhoods, major office buildings, and a new, upscale retail mall. Six died and nearly 200 others suffered severe injuries.
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- 1988 Ocean Odyssey Blowout
- V1 No7 Ocean Odyssey 1988 Blowout Rev 0 09/28/09
- It was in September 1988, as the North Sea oil and gas industry struggled under the shadow of the Piper Alpha incident, that the Ocean Odyssey had a blowout and ensuing fire. No doubt this was traumatic for the personnel. One man died. And the U.K. drilling industry suffered another blow.
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- 1989 Cormorant Alpha Explosion (07/30/09)
- V1 No6 1989 Cormorant Alpha Explosion Rev 1 (07/30/09)
- Less than a year after the Piper Alpha disaster in the North Sea, the Cormorant Alpha platform experienced an explosion. In an already tense climate, the event and lost production shook the U.K. drilling industry. This bulletin is based primarily upon an interview with an engineer who was on the Cormorant Alpha the day of the event.
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- 1999 Mont Blanc Tunnel Fire (06/30/09)
- V1 No5 1999 Mont Blanc Tunnel Fire Rev 0 (06/30/09)
- Toxic smoke and fire took 39 lives. Costs exceeded $500 million. Thirteen of 16 defendants were sentenced on charges of manslaughter. The fire's cause (ignition source) remains undetermined.
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- 2005 Mumbai High North Platform Fire (05/26/09)
- V1 No4 2005 Mumbai High North Explosion Rev 0 (05/21/09)
- The afternoon of July 27, 2005, a cook severing two fingertips began a series of events that lead to total destruction of the Mumbai High North platform, damage to other facilities, and 22 dead.
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- 2005 Buncefield: Largest Peacetime Explosion in Europe
- V1 No3 Buncefield 2005 Explosion Rev 0 (04/26/09)
- Registering at 2.5 on the Richter scale, the largest peacetime explosion in Europe was at Buncefield oil storage and transfer depot facility. No one died but 43 were injured and about 2,000 were evacuated. Damages were estimated at $1.5 billion.
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- 1914-17 Imperial Trans-Antarctic Expedition of Sir Ernest Shackleton
- V1 No2 Shackleton's Expedition Rev 0 (3/25/2009)
- Sir Ernest Shackleton and a crew of 27 set out to be the first to cross the Antarctic. Though Shackleton is lauded today for his leadership and compassion, the expedition failed. The crew spent two years stranded on the ice - fighting the elements, frostbite, and starvation - waiting for rescue.
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- 1984 Mexico City BLEVE Explosion
- V1 No 1 Mexico City Feb 26 2009 Rev 0 (2/26/2009)
- This unfortunate 1984 LNG terminal explosion demolished the facilities, killed hundreds, and injured thousands. Lessons learned apply today.
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