Incidents

Selected incidents are discussed on the individual Key Topics pages. However, some incidents contain so many human factors issues that they do not belong on a specific topic page. This section outlines several such incidents in some detail. I’ll update this section with more incidents when time allows. . .

The investigations into these incidents provide a good introduction to the breadth of human factors. By reviewing the lessons from these incidents you will gain an appreciation of a range of Key Topics, and the many inter-relationships between them. You may learn more about human factors from these incidents than from any textbook.

Complex systems such as oil, gas, chemical, nuclear, aviation, rail, healthcare and finance all have their own unique aspects. However, the human, management and organisational factors identified in these incidents are not so unique. All of these industries and complex systems have much in common – and therefore a great deal to learn from each other’s experiences.

These are not stories of Fluidised Catalytic Cracker Units, rocket boosters, isomerization (ISOM) units, independent high-level switches, Supplementary Cooling Pack (SCP) ducts or centrifuge feed tanks. They are stories of how clever and complex organisations sometimes fail.

BP Grangemouth petrochemical complex, May-June 2000

BP Texas City Refinery, March 2005

Buncefield oil storage depot, December 2005

RAF Nimrod XV230, September 2006

Space Shuttle Columbia, February 2003

THORP (Thermal Oxide Reprocessing Plant), April 2005