2016 Gyenes IChemE Risk and safety management of ammonium nitrate fertilizers- keeping the memory of disasters alive

It is a common practice that, following a major accident, a thorough investigation is carried out with great involvement of experts in the field, creating reports and listing recommendations and lessons learned. Yet, history shows that there are difficulties in learning those lessons, in discovering the hidden remaining risk to anticipate some atypical scenarios 13or the next accident, or take on board the recommendations. Therefore, similar accidents reoccur from time to time with similar, but also new recommendations. However, some of the new recommendations in accident investigation reports do not take into account lessons learned or recommendations made from past accidents. Whatever the technical scenario involving AN16, some flaws are found in safety management, regulation, oversight and land use planning. The legislation may be modified and some standards are changed over the years but they are not implemented everywhere with the same pace and enforcement. The inherent risks of AN fertilizer are still high 14which require further regulation especially for small and medium enterprises. It may be a solution to introduce more hazard than risk based standards on the storage of AN fertilizers to prevent further accidents. This should then allow the storage of, for example, off-spec material and accidental contamination to be included in the requirements.  After an accident, the memory fades and people tend to forget some lessons or the momentum to implement corrective actions. As repeatedly stated by Trevor Kletz, “organisations have no memory, only people have”, it is therefore imperative that process safety experts have memory and remember these major events. Similar or new triggering initiators can happen everywhere, and therefore, learning from past mistakes remains a requisite to avoid a recurrence or the next disaster. Reducing exposure by reducing risk at source and vulnerability by using land use planning approaches remain parts of a global strategy.


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