Publikace: Three accidents in European dynamite production plants: An attempt to improve the external lessons learning
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Ferjenčík, Miloš
Dechy, Nicolas
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Three serious accidents occurred in three dynamite manufacturing plants within three European countries during a relatively short time period triggering the question of effective external learning. The article discusses the lessons for the prevention of accidents learned from retrospective comparative analysis. It advocates for a better process for learning lessons. It attempts to show how a two level approach to accident analysis may help to reveal a common deeper learning hidden under diverse routine lessons.
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Underlying cause, Root cause analysis, Lessons learned, Accident prevention, Explosion, Dynamite, hlubší příčina, analýza kořenových příčin, prevence havárií, exploze, dynamit