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Three speakers will use case studies to identify where leaders need to focus their attention in order to manage catastrophic incident risks, not just to ‘manage the business’.

Case studies will cover transport systems, and process industries – not all of which would appear to the casual observer to be ‘high-hazard’, but which, nevertheless, had high potential for loss.

Case study details:

Study A: Herald of Free Enterprise capsize, 1987

Although many people are aware of this catastrophic incident which occurred nearly 35 years ago, it merits revisiting to understand issues associated with leadership at all levels in an organisation and how this can affect performance. The speaker will describe the incident and some of the key lessons for organisation leaders across the lifecycle of equipment from design to operation and how these can be woven into organisational culture through the behaviours of those leaders.

Study B: Fatal Accident at a UK brewery, 2016

An incident at a large brewery: a team of contractors were removing an ammonia compressor when a huge ammonia leak occurred. One Refrigeration Engineer was killed almost instantly; a further 22 people were taken to hospital including emergency responders. The speaker will describe the incident and its aftermath then explore whether it was avoidable and whether good leadership could ensure it is not repeated.

Study C: Fatal explosion at chemical plant (Flixborough 1974) and a tank explosion at a material recovery plant (West Virginia, 2017).

Two maintenance procedures that went badly wrong because of non-robust safety systems and/or a lack of suitably qualified people.

The incidents will outline the events and their similarities.