Anatomy of a Disaster
Learning from experiences, especially catastrophic events…
view the report: ANATOMY OF A DISASTER
I worked at this facility many years prior to this tragedy (in 1991-1992 when it was Amoco Oil Company, when a coworker was burned while I was there, and one of my project efforts was to replace and repair a fire damaged portion of the facility (from a different incident than his accident)).
Dr. Evelyn Brown and I have used this 2005 event as case study in our courses…. “the largest and most comprehensive investigation in the history of the U. S. Chemical Safety Board.”