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Keywords:

  • Incident investigation;
  • inherent safety;
  • domino loss causation model;
  • case study

Abstract

A methodology has been developed to enable the explicit use of the principles of inherent safety in an incident investigation protocol. The usefulness of this approach is demonstrated by application to the Westray coal mine explosion that occurred in Nova Scotia in 1992. This process-related disaster resulted in the deaths of 26 workers, destruction of the underground workings, and bankruptcy of the parent company. The purpose in presenting this case study is twofold: to validate the methodology and to identify the inherent safety considerations that could have prevented the incident. These findings have application beyond the realm of coal mining, extending well into the world of the chemical process industries. © 2004 American Institute of Chemical Engineers Process Saf Prog 23:197–205, 2004