Learning lessons

The investigation of the refinery tank explosion that killed 4 persons is underway. A BBC news item mentions the following:
"Maintenance work had been carried out on a 730 cubic metre storage tank which exploded on Thursday evening, damaging an adjacent vessel.Dr Ivan Vince, a safety, health and environmental specialist at ASK Consultants told BBC Radio Wales that the investigators will look at two types of causes.
"The first part of the investigation is narrowing it down to exactly what happened and what were the immediate causes," he said. It could be some time before the cause of the explosion is known."Then the route cause investigation looks at the bigger picture like the safety management systems, the adequacy of the training and procedures in general or deeper, the status of the safety culture, the working environment in general."I have never come across a situation where there have not been lessons to be learnt. The problem is lessons are learnt but then forgotten when personnel change."
The last statement is highly significant. Organisations should implement and sustain a process safety knowledge management system.Otherwise, as people change, their knowledge goes with them.
Read the article in this link