Lessons Learned from Toulouse and Buncefield Disasters: From Risk Analysis Failures to the Identification of Atypical Scenarios Through a Better Knowledge Management

The recent occurrence of severe major accidents has brought to light flaws and limitations of hazard identification (HAZID) processes performed for safety reports, as in the accidents at Toulouse (France) and Buncefield (UK), where the accident scenarios that occurred were not captured by HAZID techniques. The present study focuses on this type of atypical accident scenarios deviating from normal expectations. The main purpose is to analyse the examples of atypical accidents mentioned and to attempt to identify them through the application of a well known methodology such as the bow-tie analysis. To these aims, the concept of atypical event is accurately defined. Early warnings, causes, consequences and occurrence mechanisms of the specific events are widely studied and general failures of risk assessment, management and governance isolated. These activities contribute to outline a set of targeted recommendations, addressing transversal common deficiencies and also demonstrating how a better management of knowledge from the study of past events can support future risk assessment processes in the identification of atypical accident scenarios. Thus, a new methodology is not suggested, rather a specific approach coordinating a more effective use of experience and available information is described, in order to suggest that lessons to be learned from past accidents can be effectively translated into actions of prevention.