7th Joint EU/US Conference on OHS
Brussels 11-13 July 2012

Record of Deliberations of the Workshop on
Topic 4: The Prevention of Catastrophic Accidents

  1. The workshop did not attempt to define "catastrophic accident." The workshop focused on accidents that seriously injure many workers or members of the public, or have the capacity to do so. Workshop presentations demonstrated how such accidents often, but not always:
    • can extend beyond the workplace;
    • involve hazardous substances;
    • involve multiple system failures;
    • generate substantial public attention and media coverage.
  2. Databases, for example the EU's eMARS database required by the Seveso directives, and computer models, for example Storybuilder, developed and used in the Netherlands (both of which are available online)1 can be useful in analyzing the characteristics of catastrophic accidents. More attention should be given to the development of, access to, easy use and harmonization of appropriate databases and models, in both the United States and the European Union. It is important to ensure that these tools can be used by small and medium enterprises.
  3. Injury rates are not a good predictor of the risk of catastrophic accidents. However, near misses and process upsets are good predictors of catastrophic accidents caused by the same hazard types. Metrics for assessing catastrophic risks should capture data on such events.
  4. More attention should be given to the underlying organizational factors in accident investigation, models and metrics. Examples of organizational factors include whether decision-making is centralized or decentralized, how critical information is communicated, the availability of critical resources, the design of the work process, and the role of managers, workers and worker organizations, other employees and contractors in the safety program.
  5. Success in preventing catastrophic accidents occurs when the risks are thoroughly understood and effectively addressed at all levels of the organization. This can only be achieved by the development of routinely measurable, actionable and predictive indicators.
  6. Accident investigations, metrics, models and databases are useful only when their findings are applied to the workplace. This can be done through a process of writing, sharing and implementing "lessons learned."
  7. Risk assessment should begin by determining the hazards which could lead to a catastrophic accident. The next step is to determine the actual risk, which also takes into account the protective measures in place.
  8. Our common vision is the elimination of catastrophic accidents.
  9. An effective program for eliminating catastrophic accidents should include:
    • Comprehensive hazard identification and risk assessment;
    • To the extent feasible, the removal of the hazard and its replacement by inherently safer technology;
    • A system for monitoring and communicating critical information up and down the line in a clear and concise manner;
    • The rigorous root cause investigation of all accidents, near misses and process deviations and the application of the lessons learned to the prevention of future accidents;
    • A system for analyzing change and ensuring that the change does not increase the risk;
    • A system for ensuring that safety-critical maintenance is given priority, and for taking unsafe equipment out of service until it is fixed or replaced;
    • Regular safety audits, with follow-up;
    • A system for preventing fatigue among process operators and maintenance workers, where it exists;
    • The full involvement of workers and their organizations, and a role in the safety program for all persons on site;
    • Training in risk awareness and control for all on-site personnel;
    • The commitment and participation of the CEO and top-level managers;
    • The use of outside expertise where such expertise does not exist within the enterprise;
    • A system for ensuring the coordination and integration of contractors into the safety program;
    • An emergency response plan;
    • Additional measures where necessary.
    These elements should be included in the enterprise safety program and considered by the competent authority. It is especially important to ensure that the program can be adopted by small and medium enterprises, and understood by all concerned.
  10. The EU and US should continue to collaborate on the prevention of catastrophic accidents by:
    • The identification of available information resources;
    • The development and use of transatlantic databases;
    • International working groups on metrics and on small and medium enterprises, which would report at the next EU/US Conference;
    • Coordination with the OECD Working Group on Chemical Accidents;
    • Increased sharing of information on potentially catastrophic accidents and on lessons learned;
    • Increased sharing of information on good practices and successes

1 Currently https://emars.jrc.ec.europa.eu/ and http://www.storybuilder.eu