Given at DGIS VII in Chicago, September 2012

1. THE WHY WE DO THE THINGS WE DO
PETER MACKAY
HAZARDOUS CARGO BULLETIN

2. OR….
“WHAT’S THE WORST
THAT CAN HAPPEN….?”

3. ValuJet Flight 592
Everglades, Florida
May 1996

5. SOLAS

7. Torrey Canyon
March 18, 1967

8. Exxon Valdez
March 24, 1989

9. Costa Concordia
January 2012

10. Nypro cyclohexane oxidation unit,
Flixborough, UK
June 1, 1974

11. ICMESA chemical plant, Seveso,
Italy
July 10, 1976

12. Bhopal, India
December 1984

14. Los Alfaques campsite, Spain
July 11, 1978

15. Texas City, TX
March 23, 2005

16. Buncefield, UK
December 11, 2005

17. Bayamón, PR
October 23, 2009

18. IOC oil depot, Jaipur, India
October 29, 2009

19. CHEVRON REFINERY
PEMBROKE DOCK, UK
JUNE 2, 2011
FOUR DEAD

20. AKTAU, KAZAKHSTAN
OCTOBER 11, 2011
EIGHT DEAD

21. CARLSTADT, NJ, USA
NOVEMBER 7, 2011
NINE INJURED

22. ORICA
PORT KEMBLA, NSW, AUSTRALIA
DECEMBER 16, 2011

23. ODFJELL TERMINAL
ROTTERDAM, NETHERLANDS
JANUARY 25, 2012

24. STOLT VALOR
ARABIAN GULF
MARCH 15, 2012
ONE DEAD

25. Common themes:
- Taking short cuts
- Being „helpful‟
- “Why don‟t we try…”
- Commercial/time pressure
- Lack of/ineffective training
All 
Failure to follow procedure
Increased likelihood of something going wrong

26. In a high-hazard environment, ANY and
ALL operations can be SAFETY-
CRITICAL
So how do we get this message over?

27. PROCEDURES
Written, clear, rehearsed
CHECKLISTS
As an aide-memoire, not a box-ticking
process
TRAINING
To reinforce the message

28. peter@hazardouscargo.com
@TheMackay