System Safety Skeptic - Lessons Learned
"Effective system safety efforts require learning from failure"
From Terry Hardy and the "System Safety Skeptic" Blog, an article on the lessons learned from the chemical explosion at the 1999 Y-12 Plant in Oak Ridge, TN.
Lesson Learned: Analyses after accidents often show that clues existed before the mishap occurred. Such clues frequently take the form of anomalies observed during the life cycle of a project. An anomaly is an apparent problem or failure that occurs during verification or operation and affects a system, a subsystem, a process, support equipment, or facilities. Anomaly or problem reporting and corrective action, therefore, can play an important role in system safety analyses. An effective anomaly report and corrective action process not only allows for the reporting of problems, but also implements a closed-loop process for finding and fixing the root cause of a problem. In the case of this accident, if the near misses had been properly reported and analyzed, this accident may have been prevented.