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PETER MACKAY HAZARDOUS CARGO BULLETIN THE WHY WE DO THE THINGS WE DO
PETER MACKAYHAZARDOUS CARGO BULLETIN
THE WHY WE DO THE THINGS WE DO
OR….
“WHAT’S THE WORST THAT CAN HAPPEN….?”
ValuJet Flight 592Everglades, FloridaMay 1996
SOLAS
Torrey CanyonMarch 18, 1967
Exxon ValdezMarch 24, 1989
Costa ConcordiaJanuary 2012
Nypro cyclohexane oxidation unit, Flixborough, UKJune 1, 1974
ICMESA chemical plant, Seveso, ItalyJuly 10, 1976
Bhopal, IndiaDecember 1984
Los Alfaques campsite, SpainJuly 11, 1978
Texas City, TXMarch 23, 2005
Buncefield, UKDecember 11, 2005
Bayamón, PROctober 23, 2009
IOC oil depot, Jaipur, IndiaOctober 29, 2009
CHEVRON REFINERYPEMBROKE DOCK, UKJUNE 2, 2011FOUR DEAD
AKTAU, KAZAKHSTANOCTOBER 11, 2011EIGHT DEAD
CARLSTADT, NJ, USANOVEMBER 7, 2011NINE INJURED
ORICAPORT KEMBLA, NSW, AUSTRALIADECEMBER 16, 2011
ODFJELL TERMINALROTTERDAM, NETHERLANDSJANUARY 25, 2012
STOLT VALORARABIAN GULFMARCH 15, 2012ONE DEAD
Common themes:
- Taking short cuts- Being ‘helpful’- “Why don’t we try…”- Commercial/time pressure- Lack of/ineffective training
All
Failure to follow procedureIncreased likelihood of something going wrong
In a high-hazard environment, ANY and ALL operations can be SAFETY-CRITICAL
So how do we get this message over?
PROCEDURESWritten, clear, rehearsed
CHECKLISTSAs an aide-memoire, not a box-ticking process
TRAININGTo reinforce the message
