Later that morning the plant management declared the incident over and work began to clean up the area. It was at
this point that the body of a company employee was discovered amongst the debris. She had been felled by the flying
shrapnel and died on the scene. Since she was a member of the plant’s emergency response team no one considered
her absence during the incident unusual. The company’s system of accounting for staff had failed as no one identified
that the employee was missing after the incident. Indeed several people who had the responsibility for accounting
for staff were unaware that this was their role in an emergency.Although internal company safety policies required
that plant-wide emergency drills be conducted at least once every three months, no such drill had been conducted in the facility for the 4 years prior to the incident