July 20, 2009 | Mark Paradies

Was Lack of “Knowledge & Understanding” and Poor Risk Analysis the Root Causes of a Fatal Explosion in Glasgow?

The BBC reports that Senior Judge Lord Gill has found that a 2004 blast that killed 9 people at ICI Plastics was caused by a pipe carrying liquid petroleum gas into the factory was “out of sight and out of mind”.

Other interesting quotes from the article include:

“In 2007, ICL Plastics and ICL Tech were fined a total of £400,000 for breaching health and safety laws.”

“The inquiry, which was held over two sessions in July and October last year, was told that the damaged pipework would have cost about £400 to replace.”

“After meeting with some of the families affected, Scottish Secretary Jim Murphy said: ‘What is clear from the report is that this disaster could and should have been avoided.’

“‘It lays out a litany of failings and it is imperative that we take on board Lord Gill’s recommendations for a better and more effective safety regime surrounding LPG installations to ensure an unnecessary and preventable fatal incident such as this never happens again.'”

Here are links to the …

Summary Report:

http://www.theiclinquiry.org/Documents/Documents/071609%20ICL%20INQUIRY%20SUMMARY%20PUBLIC%20RELEASE%207.pdf

The full report:

http://www.theiclinquiry.org/Documents/Documents/HC838ICL_Inquiry_Report.pdf

I haven’t had time for more than a cursory review of the reports. The analysis of the causes starts at about page 106 of the full report. There seem to be lot’s of causal factors and many chances to have prevented this accident. If you have time to review them. let me know what you think of their root cause analysis.

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Root Cause Analysis
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