We learn more from accounts of accidents than from codes and standards
or exhortations to follow them. Incident reports are more likely to s
pur us into action. We are unlikely to read a code until an accident r
eport has shown us the need. This paper describes a number of accident
s, some old, some recent, which can teach us lessons of general intere
st It looks at the underlying causes as well as the immediate technica
l ones.