(81u) Analysing and Preventing the Recurrent Human Causes of Process Accidents: Application to Deepwater Horizon and Other Significant Incidents

As is often the case, human failures at the operational, design and safety management levels were significant contributors to the recent Deepwater Horizon incident. This paper analysis this and a number of other major incidents using a common framework to show that although incidents may appear to be unique, in fact they are the result of a limited set of recurring underlying causes that combine together to give rise to the serious consequences. If incidents and near misses are evaluated using tools that allow the identification and aggregation of these underlying causes, it is possible to identify recurrent patterns of causation, and to tailor prevention strategies and resources in the most cost-effective manner. The paper includes examples from nuclear power generation, and aviation in addition to oil and gas, to illustrate the generality and usefulness of this approach.