Lessons learned from Toulouse and Buncefield disasters: from risk analysis failures to the identification of atypical scenarios through a better knowledge management.

The recent occurrence of severe major accidents has brought to light flaws and limitations of hazard identification (HAZID) processes performed for safety reports, as in the accidents at Toulouse (France) and Buncefield (UK), where the accident scenarios that occurred were not captured by HAZID techniques. This study focuses on this type of atypical accident scenario deviating from normal expectations. The main purpose is to analyze the examples of atypical accidents mentioned and to attempt to identify them through the application of a well-known methodology such as the bow-tie analysis. To these aims, the concept of atypical event is accurately defined. Early warnings, causes, consequences, and occurrence mechanisms of the specific events are widely studied and general failures of risk assessment, management, and governance isolated. These activities contribute to outline a set of targeted recommendations, addressing transversal common deficiencies and also demonstrating how a better management of knowledge from the study of past events can support future risk assessment processes in the identification of atypical accident scenarios. Thus, a new methodology is not suggested; rather, a specific approach coordinating a more effective use of experience and available information is described, to suggest that lessons to be learned from past accidents can be effectively translated into actions of prevention.

First lessons of the Toulouse ammonium nitrate disaster, 21st September 2001, AZF plant, France.

A terrible explosion of ammonium nitrate, killing 30 people, occurred on 21st September 2001, in Toulouse, in AZF plant belonging to Grande Paroisse Company, TotalFinaElf Group. The manufactured chemicals in the plant were mainly ammonium nitrate, ammonium nitrate-based fertilisers and other chemicals including chlorinated compounds. The origins of the accident haven't found yet an agreement among investigators (company, justice). The aim of this paper is to provide abroad an overview of some lessons learnt on that accident, from many perspectives, following the national debates and parliamentary enquiry as well as the various technical accident investigations.