title: How is it possible? Why didn't we do anything? A case history!
abstract: Two similar serious accidents occurred at a metal refining process installation within a 6-month time interval. The first one killed ten people, and the second accident one person. The accidents provide a typical case history of how a safety management system and a corresponding organisation could have prevented the occurrence of such an accident or, at least, have reduced its effects. The case is also interesting because it illustrates the physico-chemical complexities forming the root cause of the accidents.
authors.affiliation: TNO Defence Research, Schoemakerstraat 97, P.O. Box 6006, 2600 JA Delft, The Netherlands. pasman@do.tno.nl
authors.forename: H J
authors.initials: HJ
authors.lastname: Pasman
authors.forename: R
authors.initials: R
authors.lastname: Grollier Baron
mesh_terms: D000056:Accident Prevention; D000062:Accidents, Occupational; D002056:Burns; D004189:Disaster Planning; D005107:Explosions; D017809:Fatal Outcome; D006801:Humans; D008669:Metallurgy; D009026:Mortality; D012449:Safety