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                              18        Serious Incident Prevention



                                  The analysis of past serious incidents supports the contention of author
                              and petrochemical process safety expert Trevor Kletz, who states:


                                  It might seem to an outsider that industrial accidents occur because we do
                                  not know how to prevent them. In fact, they occur because we do not use
                                  the knowledge that is available. 49




                              References


                               1. J.  A. Davenport and E.M. Lenoir, “A Survey of  Vapor Cloud Explosions,
                                  Second Update,” Proceedings of the 26th Annual Loss Prevention Symposium,
                                  American Institute of Chemical Engineers (1992): 13–15.
                               2. Ibid.
                               3. D. Jackson, “Pampa Plant Deciding  When and  Whether It  Will Reopen,”
                                  Dallas Morning News, 16 November 1987, 1A, 4A.
                               4. G. Morris, “New Details Emerge as Carbide Fights OSHA Fine,” Chemical
                                  Week, 15 January 1992, 16.
                               5. “Missing Screws Caused ‘91 Commuter Plane Crash, NTSB Says,”  Dallas
                                  Morning News, 22 July 1992.
                               6. “Missing Wing Screws Cited in Aborted Flight,” Dallas Morning News, 23
                                  December 1992, 1A, 30A.
                               7. “Report on Fire at NC Food Plant Sent to Prosecutor,” Dallas Morning News,
                                  7 September 1991, 3A.
                               8. M. Reeves, “Clerk Turned Off Alarm, Official Says,” Dallas Morning News, 7
                                  March 1982, 1A, 7A.
                               9. T. J. Meyer, “Crane Collapse Kills 3, Hurts 1,” Dallas Morning News, 26 April
                                  1987, 1A, 28A.
                              10. D. Sharp, “Errors Renew the Call for Doctor Review,” USA Today, 27 March
                                  1995, 1.
                              11. H. Petroski, “Vanities of the Bonfire,” Professional Safety, July 2001, 20–24.
                              12. D. G. Mahoney, ed.,  Large Property Damage Losses in the Hydrocarbon-
                                  Chemical Industries, A Thirty-Year Review, 17th ed. (Risk Control Consulting,
                                  a division of J&H Marsh & McLennan Inc., formerly M&M Protection
                                  Consultants: 1997), 1–46.
                              13. Ibid.
                              14. Ibid.
                              15. Bureau of Labor Statistics, Census of Fatal Occupational Injuries, Industry by
                                  Year, 1992–1999.
                              16. Ibid.
                              17. U.S. Department of Transportation, Federal Railroad Administration, Rail Yard
                                  Accident Rate per 1 Million Switching Miles, 2000.
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