Accidents and learning from accidents Group 4 Break-out session 1 Accidents and learning from accidents Group 4

Questions for discussion B1-1 REPORTING: Main Question: What is your legal requirement and trigger for reporting accidental initiations of explosions and pyrotechnics (and fireworks); quantity involved, consequence? How and to whom are they reported; centrally or locally? What proportion of significant incidents go unreported; i.e. reported by others such as the public? Are there differences between the explosives and the pyrotechnics/fireworks industries?   B1-2 INVESTIGATION: Main Question: Who investigates reported explosions; the company, your inspectors, specialists? Is there a legal obligation on companies to investigate their own explosions? Are investigations carried out independently or jointly? How are they carried out; tools, forensic investigation, technical and SMS failures? Do the investigations address underlying as well as the direct causes? B1-3 LESSONS LEARNED: Main Question: What are the most important lessons learned from explosives and pyrotechnics incidents in your country; technical, procedural, SMS and cultural? What are the lessons? How are these lessons shared with others; databases; company reports; safety bulletins – company internal, industry external, regulator; across the EU? How are these bulletins and information used; training, education?

B 1-1 Reporting Main Question: What is your legal requirement and trigger for reporting accidental initiations of explosions and pyrotechnics (and fireworks); quantity involved, consequence? You can take notes in this section:

B1-2 Investigation Main Question: Who investigates reported explosions; the company, your inspectors, specialists? You can take notes in this section:

B1-3 Lessons Learned Main Question: What are the most important lessons learned from explosives and pyrotechnics incidents in your country; technical, procedural, SMS and cultural? Procedural, SMS: 1. Training deficiencies, excess of confidence of personnel 2. Risk assessment deficiencies; trend to outsource the safety report to external consultant (the safety report is made by another company and they are maybe not aware of the SMS for the company) they do this for 3_ Size of companies: Bigger companies – upper tier are better controlled and better managed, small companies-family business has very low attitude to risk mange and SMS- Small companies are often not in Seveso so they have another attitude to regulations. They the need to earn money and can not follow all regulations. There are family companies and the persons working there are old and are doing explosives as they have always done. They don't know about new regulations. 4. Operative control : need to provide for a list of critical equipments and elements and link the critical equipment to the maintainance system-plan 7. Management of change, what permit do the company have for that. How do you know that you get the right product from the supplier? Work permit: not clear procedure and not adequate perfomed 8. exchange of lessons learned: In generall some countries have information meetings and seminars. We all need to be better! You can take notes in this section: Example: Accident that happend at a explosive plant. No enjuried, cost less than 1 miljon EU could come to the site the same day as the exident happend. Facieltie is willing to change there procedures. 4 different fecillities which are sparated from each other. The COE could answer at ewery question asked. They answerd about what happend and not wat was expected. 1. Training is important, access of confidence of personnel 2. Risk assessment and efficiencies 3. The safety report is made by another company and they are maybe not aware of the SMS for the country they do this for. Bigger companies hire persons for this and they are educated for this and have time to do this. Small companies, this is done in times now and then when you have time for it. 4. Operative control 5. List of critical equipment and elements 6. Link the critical equipment to the maintains system 7. Management of change, what permit do the company have for that. How do you know that you get the right product from the supplier? 8. Small companies are often not in Seveso so the have another attitude to regulations. They the need to earn money and can not follow all regulations. There are family companies and the persons working there are old and are doing explosives as they have always done. They don't know about new regulations. 9. In generall some countries have information meetings and seminars. We all need to be better!