The chair of the Health and Safety Executive has cast a spotlight on 1974’s Flixborough disaster, urging industry leaders to learn from past events.
Judith Hackitt, writing in her online blog, said debate still persisted around the precise causes of the explosion at Flixborough.
But she added: “The finding of the inquiry, and the generally accepted view, was that a ‘quick fix’ hastily installed bypass pipeline, which had been put in place to get the plant up and running after a reactor was taken offline, had ruptured.
“The resulting massive release of cyclohexane then exploded.”
Some forty years on, Ms Hackitt said it had never been more important for members of industry to take stock of the risks facing their site and act accordingly.
“One of the biggest challenges we face in the world of real health and safety – and preventing catastrophes – is getting people to recognise what could happen, and to learn from past events even if they have never been close to such a disaster themselves.
“All psychologists will tell you that “active” and “direct” learning is far more effective than the passive variety where you are told about what happened and the story is cascaded down.”
“So how do we learn effectively from past events?”
Ms Hackitt advised that the most effective way to learn from past events is by “reflecting on what happened” just as the world had done earlier in June “when we joined with the brave souls who returned to the Normandy beaches”.
But in the case of Flixborough, she added, the “real lesson for all of us is not to spend too long looking in the rear view mirror and pondering the detail of what did or did not actually happen”.
“The lessons of Flixborough are about management of change, proper engineering, human and organisational factors – big issues not detail.”
In learning from the past, industry must apply those lessons “more broadly” to mitigate a repeat of such devastating events, she said.
Remembering Flixborough
The devastation followed an explosion in the Nypro chemicals factory close to the village of Flixborough, England, on 1st June 1974. It killed 28 people and seriously injured 36, causing widespread damage well beyond the boundaries of the site.
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