Description:
Accidents in the process industry continue to occur, and we do not seem to be making much progress in reducing them (Venkatasubramanian, 2011). Postmortem analysis has indicated that they were preventable and had similar systemic causes (Kletz, 2003). Why do we fail to learn from the past and make adequate changes to prevent their reappearance? A variety of explanations have been offered; operators' faults, component failures, lax supervision of operations, poor maintenance, etc. All of these explanations, and many others, have been exhaustively studied, analyzed, “systematized” into causal groups, and a variety of approaches have been developed to address them. Even so, they still occur with significant numbers of fatalities and injured people, with significant disruption of productive operations and frequently extensive destruction of the surrounding environment, both physical and social.