ORGANISATIONS had no memory in relation to industrial accidents. Only people did, and they moved on, the Southern Health Board conference on chemical emergencies has been told.
Mr T.A. Kletz, a consultant to the chemical industry in the UK, said the record of accidents in the workplace showed that with the passage of time and changes in staff, recommendations made after the original accidents were either forgotten or not passed on to other parts of the organisation.
He told the conference in Cork yesterday: "After about 10 years most of the staff on a plant have changed. No one can remember why equipment was installed or procedures introduced, and someone keen to cut costs or improve efficiency - both very desirable things to do - asks `Why are we following this time consuming procedure?' or `Why are we using this unnecessary equipment?'"
Describing some recent industrial accidents, Mr Kletz said that in all cases human errors were made. The correct procedures were not followed, or one shift failed to inform another of changes that had been made in plant and equipment.
To improve the corporate memory, Mr Kletz added, steps should be taken to ensure awareness of past accidents and the prevention of future ones. He suggested that in every instruction, code and standard, an account should be made of how and why an accident occurred because of failure to follow guidelines.
Old as well as recent accidents should be described in safety bulletins and newsletters and discussed at safety meetings, and there should be regular checks that recommendations made after accidents were being followed.
He added that equipment should never be removed before the reason for its installation was known, and a procedure should never be abandoned before the operative knew why it was introduced.
Better retrieval systems should be devised so that the reason for past accidents could be found more readily.
"Few companies make full use of the computerised information systems that are available, and even where there is a system few employees seem to use it. If such a system is to be widely used, it must be available at every desk. It will not be used if we have to walk to the library and/or consult an information scientist," Mr Kletz said.
Few courses covered past accidents, although suitable training data were available. Employees at all levels, from operators to senior management, should be involved in regular safety discussions at which slides, photographs and details of accidents are available, Mr Kletz concluded.