Overcoming the blame game to learn from major accidents: A systemic analysis of an Anhydrous Ammonia leakage accident

This article aims to demonstrate the need for changing the methods with which accidents are analyzed, if we truly wish to use what we uncover from them to learn and enrich our knowledge base of organizational management. The goal is to relinquish the broadly adopted and rather simplistic paradigm that accepts the search for human error and unsafe acts performed by workers, and produces “guilt diagnostics”. Instead, we use a systemic accident analysis methodology, based on the sociotechnical principle of understanding the real operating conditions in which accidents take place. In order to demonstrate the benefits of the theoretical framework, we compare the analyses of an Anhydrous Ammonia gas leakage accident in a fish processing plant using the traditional accident analysis model based on unsafe acts and the proposed systemic approach. The results favor the latter since it tends to be more reliable and offering useful recommendations to safety management processes, thus helping to prevent accidents, especially in complex systems.

► We examine a major Ammonia Anhydrate leakage accident in a fish processing plant.
► We compare the two methods used for the accident analysis.
► The methods are the search for unsafe acts/human error and a systemic approach.
► The systemic approach provide a much broader set of recommendations up to government level.