Page 36 - Serious Incident Prevention How to Achieve and Sustain Accident-Free Operations in Your Plant or Company

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Establish effective policy for other
More effective accountability sys-
Improve emergency plan, conduct
Training of maintenance personnel
tem for parts and fasteners re-
including inspection process
vessels to escort tankers
moved
Tanker allowed to veer off course
Low level of emergency pre-
Multiple causes including:
$5 billion (ordered September 1994)
Known Consequences Potential Preventative Probable Cause Actions Effective maintenance procedures, Screws missing from tail section Serious Incident Prevention drills and audit preparedness paredness: Paid to Alaska fishermen for Provide adequate emergency re- a) response barge too small and immediate losses: $287 M sponse equi
Punitive damages:
Loss of plane
Fatalities: 14
Incident Description A commuter plane went into a se- vere nosedive and crashed when a de-icer boot on the tail section apparently came loose during flight. Company officials con- firmed that 43 screws were re- moved from the tail section during maintenance and were not reinstalled, due to an oversight. A 987-foot tanker ran agrou

Location and Year (References) Texas USA 1991 (45) Alaska USA 1994 (46) Ohio USA 1990 (47)