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This Process Industries Division Event has been organised by the Process Industries Division Centres in the North West and Yorkshire Regions and the Aberdeen Area, part of the Process Industries Community

A short description of some lessons that have emerged from the fatal derailment at Carmont, Aberdeenshire, UK in 2020 will be followed by a panel discussion.

This webinar will focus on what it takes to move beyond a focus on what went wrong to understand why the situation occurred.

Significant resources have been applied by the Rail Accident Investigation Branch (RAIB) to the Carmont incident; lines of enquiry have covered how the incident occurred and also why the situation was not recognised before.  A report of the findings was issued in March 2022.

Organisations with catastrophic or process incident risks must monitor and manage those risks across the process lifecycle from design to eventual demolition – this includes gathering lessons through investigating unexpected situations and incidents with or without actual harm.

For maximum effect, those lessons should be applied as widely as possible; this requires investigators to uncover deep, systematic preconditions for incidents – identifying the systems where unnoticed faults allowed the incident to develop.

It is also important that lessons are easy to put into practice; this requires investigators to frame recommendations in clear, achievable terms.

The webinar will consist mostly of a panel discussion with panellists having experience in several fields. 

 What is seen as an ‘incident’ will be discussed and some of the important practices for investigation will be highlighted, with an opportunity for the audience to ask questions.

The audience will be asked to consider whether investigations where they work go far enough and to think about what would make lessons easier to enact in practice.

This is the fifth webinar in the series "Steal with pride: Learning Lessons for Success in Catastrophic Incident Prevention"