Kegworth Plane Crash 1989 Passengers crew thought captain

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Kegworth Plane Crash 1989 • Passengers & crew thought captain saw left & right

Kegworth Plane Crash 1989 • Passengers & crew thought captain saw left & right differently – no-one thought to challenge • Knowledge based error – level of training for new plane brought into question; using trial & error to find what instruments did • In emergency fell back on well learnt behaviour, not suitable for new design, e. g. one of instruments could have shown problem not considered as on old plane was unreliable • Rule based error – pilot applied set of rules to finding problem engine and appeared to work • Distracted by questions from ground control • Perception of risk – did not consider all options as plane could fly on 1 engine – loss of 1 engine not thought serious • Pilots not attuned to new design – nothing to draw attention to draw eyes to small display showing danger

Herald of Free Enterprise ferry capsize 1987 • Crew working 24 hr shifts; assistant

Herald of Free Enterprise ferry capsize 1987 • Crew working 24 hr shifts; assistant bosun asleep after normal duties – closing bow doors peripheral duty • “Own job” culture – bosun saw doors open but not his job to close • Crew used to workplace and did not perceive risk • Wrong priorities - speed of turnaround more important than safety. Money not spent on safety features, e. g. bow door indicators on bridge • Routine violation – sailing with bow doors open became routine though against rules. Appeared to be , or was, condoned by management

Piper Alpha oil platform explosion 1988 • Knowledge based errors – personnel not trained

Piper Alpha oil platform explosion 1988 • Knowledge based errors – personnel not trained in policy & procedures; decisions taken from poor knowledge base • Misperception – production priority over safety • Routine violations – breaking rules of PTW became common – reinforced by management condoning overtly or covertly (turning blind eye) • Organisation’s negative H&S culture – managers did not have authority to make safety decisions that could lose revenue • Previous problems not remedied • No one person to take control in emergency • Personnel followed what training they had & went up to living accommodation (and died) • Those saved had not followed training & had gone downwards to sea

Ladbroke Grove train crash 1999 • Negative H&S culture of organisation influences individual •

Ladbroke Grove train crash 1999 • Negative H&S culture of organisation influences individual • Knowledge based error – driver did not have required knowledge/experience to adjust behaviour on approaching signals – not aware it was “black spot” • Working at rules level as had not had time to develop skill/knowledge of job • Complexity of signals at junction – could have concentrated on route and not signal

Glenridding Beck schoolboy drowned 2002 • • • Serious errors of judgement by party

Glenridding Beck schoolboy drowned 2002 • • • Serious errors of judgement by party leader Some shortcomings in checking procedures Some shortcomings in LEA arrangements for educational visits Misunderstandings between LEA & school as to certain responsibilities Heads can delegate H&S functions – need to clearly define responsibilities & establish lines of accountability Good practice to review H&S procedures in light of reported incidents All schools should have someone acting as focal point for H&S with clearly defined responsibilities & been provided with effective training & resources Monitoring important to ensure compliance & needs to cover activities and H&S management systems as well as sites – check compliance with risk assessments / safe operating procedures, Should be seen as supportive Good practice for school governing bodies to receive evidence from monitoring by school & LEA showing both what has been done & what could be better – aim continuous improvement H&S considerations should feature in performance monitoring, staff appraisal / development Favourable OFSTED reports on school trips not confirmation of safe practice and no substitute for thorough risk assessment

Milford Haven explosion & fire 1994 • Control valve being shut when control system

Milford Haven explosion & fire 1994 • Control valve being shut when control system indicated open • Inadequate maintenance of plant & instrumentation – inadequate control systems and faulty actuator/valve, sensors • Modification of plant carried out without assessment of potential consequences • Control panel graphics did not provide necessary process overviews • Excessive number of alarms in emergency reduced effectiveness • Poor plan layout; human factors / ergonomic issues in control room • Wrong priorities – keeping plant running when should have been shut down • Inadequate emergency operating procedures / training

Chernobyl reactor explosion 1986 • Gross violations of operating rules & regulations during test

Chernobyl reactor explosion 1986 • Gross violations of operating rules & regulations during test • Knowingly ignored regulations to speed test completion • Lack of knowledge of nuclear reactor physics & engineering, experience & training • Key systems switched off • Developers of reactor plant considered combination of events impossible & did not allow for creating of emergency protection system capable of preventing events leading to disaster, e. g. intentional disabling of emergency protection system plus violation of operating procedures • Primary cause – extremely improbable combination of rule infringement plus operational routine allowed by staff