Abstract
Finding the causes of an accident or operating problem and deciding
what actions to take to prevent it happening again is rather like
dismantling a set of Russian dolls. Each time we ask "why?" (or a
similar searching question) we find another cause besides the ones
we have found already and another action (or set of actions) we can
take to prevent similar accidents occurring again. Many investigators
stop too soon. This occurred at Flixborough, at Bhopal and in the
investigation of many lesser-known accidents. We are more likely
to find the deeper causes and the more original actions if groups
of people with wide interests and experience are able to take part
in the investigations or discuss the investigation reports. We should
never look at an accident report as "closing out" a problem. As we
read it, we should ask ourselves, "what else could be done?"
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