IChemE – Lessons learned Database

Trevor Kletz famously observed that “Organisations have no memory. Only people have memory and they move on”. He also observed that “Accidents are not due to lack of knowledge, but failure to use the knowledge we have”. This Lessons Learned Database (LLD) was inspired by these observations. Its purpose is simply to raise awareness of major incidents in the process industries, to promote the importance of root cause analysis and to catalyse cross-sector sharing of lessons learned and good practices. The infographic contained in the document below provides an overview of the main root causes of each incident and enables the user to quickly identify which incidents share common root causes across multiple process industry sectors. The document contains hyperlinks so the user can simply click on the incident name to directly access a 1-Page incident summary.

Duiding score:

Duiding:

The 1-Page incident summaries provide a brief description of the event and highlight key points (including basic causes, critical factors, root causes and lessons learned) in addition to signposting users to the detailed investigation report and selected other pertinent reference materials.

Doelgroep(en):

• Beleidsmakers
• HSE managers
• Toezichthouders

Risicothema:

• Monitoring and Learning - Leren van Incidenten
• Risk | Control | Assurance - Algemeen