Heal

th&Saf
etyManagementLect
uri
ngResour
ce

f
or

Quar
ryi
ngRel
atedDegr
eeCour
ses

LECTURENOTES:

ACCI
DENTAETI
OLOGY

Obj
ect
ivesoft
hisSect
ion

 Toout
li
nehowacci
dent
sar
ecaused;

 Todemonst
rat
ether
oleofhumaner
rori
nacci
dentcausat
ion.

 Toout
li
nest
rat
egi
esf
orr
educi
nghumaner
ror
.
1.
0 Basi
cTheor
iesofAcci
dentCausat
ion
Acci
dentcausat
ionmodel
swer
eor
igi
nal
l
ydev
elopedi
nor
dert
oassi
stpeopl
ewhohadt
o
i
nvest
igat
eoccupat
ional
acci
dent
s,sot
hatsuchacci
dent
scoul
dbei
nvest
igat
edef
fect
ivel
y.

Knowi
nghow acci
dent
sar
ecausedi
sal
sousef
uli
napr
oact
ivesensei
nor
dert
oident
if
y
whatt
ypesoff
ail
uresorer
ror
sgener
all
ycauseacci
dent
s,andsoact
ioncanbet
akent
o
addr
esst
hesef
ail
uresbef
oret
heyhav
ethechancet
ooccur
.

TheDomi
noTheor
y

I
n1931,
thel
ateH.
W.Hei
nri
ch(
Hei
nri
chetal
,19801)pr
esent
edasetoft
heor
emsknownas
‘
theaxi
omsofi
ndust
ri
alsaf
ety
’.Thef
ir
staxi
om deal
twi
thacci
dentcausat
ion,st
ati
ngt
hat
t
‘heoccur
renceofani
njur
yinv
ari
abl
yresul
tsf
rom acompl
i
cat
edsequenceoff
act
ors,t
he
l
astoneofwhi
chbei
ngt
heacci
denti
tsel
f.
’

Al
ongsi
de,hepr
esent
edamodelknownast
he‘
domi
not
heor
y’ast
hisacci
dentsequence
wasl
i
kenedt
oar
owofdomi
noesknocki
ngeachot
herdowni
nar
ow.Thesequencei
s:-

I
njur
y,causedbyan;

 Acci
dent
,duet
oan;

 Unsaf
eactand/
ormechani
cal
orphy
sical
hazar
d,duet
othe;

 Faul
toft
hePer causedbyt
son, hei
r;

 Ancest
ryandSoci
alEnv
ironment
.

1
Hei
nri
chHW,Pet
ersonD&RoosN(
1980)
,Indust
ri
alAcci
dentPr
event
ion,5th Edi
ti
on,Mcgr
aw Hi
l
l,
NewYor
k

2
Theacci
denti
sav
oided,accor
dingt
oHei
nri
ch,byr
emov
ingoneoft
hedomi
noes,nor
mal
l
y
t
hemi
ddl
eoneorunsaf
eact
.Thi
stheor
ypr
ovi
dedt
hef
oundat
ionf
oracci
dentpr
event
ion
measur
esai
medatpr
event
ingunsaf
eact
sorunsaf
econdi
ti
ons.

Thef
ir
stupdat
eoft
heDomi
noTheor
ywaspr
esent
edbyBi
rd&Lof
tus[Hei
nri
chetal
,1980;
Bi
rd&Ger
mai
n,19862]
.Thi
supdat
eint
roducedt
wonewconcept
s;

 Thei
nfl
uenceofmanagementandmanager
ial
err
or;

 Loss,ast
her
esul
tofanacci
dentcoul
dbepr
oduct
ionl
osses,pr
oper
tydamageor
wast
ageofot
herasset
s,aswel
lasi
njur
ies.

Thi
smodel(
knownast
heI
nter
nat
ionalLossCont
rolI
nst
it
uteorI
LCImodel
)isshowni
nthe
f
igur
ebel
ow:

Thedomi
nomodelhasbeennot
edasaone-
dimensi
onalsequenceofev
ent
s.Acci
dent
sar
e
usual
l
ymul
ti
-f
act
oralanddev
elopt
hroughr
elat
ivel
ylengt
hysequencesofchangesand
er
ror
s’.Thi
shasl
edt
othepr
inci
pleofmul
ti
plecausat
ion.

Accor
dingt
oPet
erson3(
1978)
,behi
ndev
eryacci
dentt
her
eli
esmanycont
ri
but
ingf
act
ors,
causesandsub-
causes.Thet
heor
yofmul
ti
plecausat
ioni
sthatt
hesef
act
orscombi
ne
t
oget
her
,inr
andom f
ashi
on,
causi
ngacci
dent
s.So,
dur
ingacci
denti
nvest
igat
ions,
ther
eisa

2
Bi
rdFE&Ger
mai
nGL(
1986)
,Pr
act
icalLossCont
rolLeader
shi
p,I
nter
nat
ionalLossCont
rolI
nst
it
ute,
Loganv
il
le,
Geor
gia.
3
Pet
ersonD(
1978)
,Techni
quesofSaf
etyManagement
,2ndEdi
ti
on,
Mcgr
awHi
l
l

3
needt
oident
if
yasmanyoft
hesecausesaspossi
ble,
rat
hert
hanj
ustonef
oreachst
ageof
t
hedomi
nosequence.

Theacci
dentmodel
isi
nreal
i
tyanamal
gam ofbot
hthedomi
noandmul
ti
-causal
i
tyt
heor
ies,
suchast
hatshownbel
ow.

ROOTCAUSE BASI
CCAUSE I
MMEDI ATE I
NCI
DENT
(LackofCont
rol
) CAUSE LOSS
 causea   caused   causef 
 causeb  causee
 causec
  

Concl
usi
on

 Al
lacci
dent
swhet
hermaj
orormi
norar
ecaused,
ther
eisnosucht
hingasanacci
dent
al
acci
dent
!!

 Ver
yfew acci
dent
s,par
ti
cul
arl
yinl
argeor
gani
sat
ionsandcompl
ext
echnol
ogi
esar
e
associ
atedwi
thasi
ngl
ecause.

 Thecausesofacci
dent
sar
eusual
l
ycompl
exandi
nter
act
ive.

4
2.
0 TheRol
eofHumanEr
rori
nAcci
dent
s
CommonQuot
ati
ons

“
Theact
ionsofpeopl
eaccountf
or96%ofal
li
njur
ies”–(
DuPont
)

“
80-
90%ofacci
dent
sar
eduet
ohumaner
ror
”(Hei
nri
chetal
,1980)

“
50-
90%ofacci
dent
saccor
dingtost
ati
sti
csar
eduet
ohumanf
ail
i
ngs”
–Kletz(
1990)

“Weseem tohavepassedtheerawher
etheneedwasforfurt
her
engi
neer
ingsafet
yguards….Whatwehavet
odoistocapturethe
4
HumanFactor”

I
ntr
oduct
ion

Al
thought
her
olet
hathumaner
rorpl
aysi
nacci
dentcausat
ionhasbeenaccept
edf
ormany
y
ear
s,i
tisonl
yrecent
lyt
hatal
otofconcer
tedef
for
thasbeenputi
ntodet
ail
edr
esear
chi
nto
humaner
rori
nacci
dent
s.

Dur
ingt
hepastt
wodecadest
heUKhassuf
fer
edal
argenumberoft
ragi
cdi
sast
ers.These
i
ncl
ude:

LondonUnder
groundFi
reatKi
ngsCr
oss(
1987) 31peopl
eki
l
led
Capsi
zeoft
heHer
aldofFr
eeEnt
erpr
iseFer
ry(
1987) 189peopl
eki
l
led
Rai
lCr
ashatCl
apham Junct
ion(
1988) 35peopl
eki
l
ledand500i
njur
ed.
Pi
perAl
phaOi
lRi
gExpl
osi
on(
1988) 167peopl
eki
l
led

Bey
ondt
het
echni
cali
ssuest
wocommonpoi
ntsemer
gedst
rongl
yfr
om t
hei
nqui
ri
esi
nto
t
heseacci
dent
s,whi
char
e:

 Thei
nfl
uenceofhumaner
rori
nthechai
nofev
ent
sleadi
ngt
otheacci
dent
;

 Fai
l
uresi
nthemanagementandor
gani
sat
ionofsaf
ety
.

Peopl
ecancauseorcont
ri
but
etoacci
dent
s(ormi
ti
gat
etheconsequences)i
nanumberof
way
s( 19995)
HSE, :

 Thr
oughaf
ail
ureaper
soncandi
rect
lycauseanacci
dent
.Howev
er,peopl
etendnott
o

4
Ri
mmi
ngt
onJ(
1993)
,DoesHeal
thandSaf
etyPay
?Saf
etyManagement
,Sept
ember
,p39-
62
5
HSE(
1999)
,Reduci
ngEr
rorandI
nfl
uenci
ngBehav
iour
,HS(
G)48,
HSEBooks

5
 makesucher
ror
sdel
i
ber
atel
y.Wear
eof
ten‘
setupt
ofai
l
’byt
hewayt
hatourbr
ain
pr
ocessesi
nfor
mat
ionbyourt
rai
ning,t
hrought
hedesi
gnofequi
pmentandpr
ocedur
es
andev
ent
hrought
hecul
tur
eoft
heor
gani
sat
iont
hatwewor
kfor
.

 Peopl
ecanmakedi
sast
rousdeci
sionsev
enwhent
heyar
eawar
eoft
her
isks.Wecan
al
somi
sint
erpr
etasi
tuat
ionandacti
nappr
opr
iat
elyasar
esul
t.Bot
hoft
hesecanl
eadt
o
t
heescal
ati
onofani
nci
dent
.

 Ont
heot
herhandwecani
nter
venet
ost
oppot
ent
ialacci
dent
s.Manycompani
eshav
e
t
hei
rownanecdot
esaboutr
ecov
eryf
rom apot
ent
iali
nci
dentt
hrought
het
imel
yact
ions
ofi
ndi
vi
dual
s.Mi
ti
gat
ionoft
hepossi
bleef
fect
sofani
nci
dentcanr
esul
tfr
om human
r
esour
cef
ulnessandi
ngenui
ty.

 Thedegr
eeofl
ossofl
i
fecanber
educedbyt
heemer
gencyr
esponseofoper
ator
sand
cr
ew.Emer
gencypl
anni
ngandr
esponsei
ncl
udi
ngappr
opr
iat
etr
aini
ngcansi
gni
fi
cant
ly
i
mpr
over
escuesi
tuat
ions.

TheTr
adi
ti
onal
ConceptofHumanEr
ror

Tr
adi
ti
onal
l
ythepr
omot
ionofsaf
etyhasbeenl
argel
yreact
ive,concent
rat
ingonacci
dent
i
nvest
igat
ionwi
tht
hepr
imar
yai
m ofav
oidi
ngr
epeatev
ent
s.I
npar
tthi
sar
osef
rom t
oo
si
mpl
eanappr
oacht
oacci
dentcausat
ionbasedont
heappar
enti
mpor
tancepl
acedont
he
conceptofasi
ngl
epr
imar
ycause;
eit
heranunsaf
eactoranunsaf
econdi
ti
on(
asar
esul
tof
t
hedomi
not
heor
y).I
fthef
ormerwer
ethecase,
responsi
bil
i
tywascl
earandbl
amecoul
dbe
appor
ti
oned.I
fthel
att
ert
henat
echni
calsol
uti
oncoul
dbesought
.Inpar
tthi
sal
soar
ose
f
rom t
hef
actt
hatar
eact
iveappr
oach,basedonasi
ngl
epr
imar
ycausewasal
soaneasy
appr
oacht
ohandl
e.

Taki
nga“
blame”appr
oacht
ohumaner
rori
nacci
dent
spr
ovi
desl
i
ttl
eofusei
nter
msof
f
utur
eacci
dentpr
event
ion.Forexampl
e,i
f amanmadeami
stakewhi
chr
esul
tedi
nan
acci
dentandwewor
kont
hebasi
sofa“
blame”appr
oacht
hent
her
ear
eonl
ythr
eeopt
ions
av
ail
abl
etous:

 Weacceptt
hathumaner
rori
sinev
itabl
e,shr
ugwershoul
der
s,t
ellhi
mtobeabi
tmor
e
car
eful
andcar
ryonasbef
orewi
thwerf
inger
scr
ossed.

 Al
ter
nat
ivel
y,wecansayashewasr
esponsi
ble,weshoul
ddi
sci
pli
nehi
m,per
hapsev
en
sackhi
m.

 Thet
hir
dopt
ioni
sahal
f-
wayhousewher
ebywegi
vehi
mthebenef
itoft
hedoubtand
deci
det
hathemi
ghtneedr
etr
aini
ng.Howev
er,i
fal
lwehav
efoundoutaboutt
he

6
 acci
dentwast
hathewast
he“
cause”wehav
elear
ntnot
hingnewonwhi
cht
obaset
he
r
etr
aini
ng.Wewi
l
lal
mostcer
tai
nlyt
her
efor
eber
educedt
orepeat
ingt
het
rai
ningwhi
ch
weknowhasal
readyf
ail
ed!

Unf
ort
unat
elyt
hisi
sapr
ett
yreasonabl
edescr
ipt
ionoft
heappr
oacht
ohumaner
rori
n
acci
dent
sthathasexi
stedi
nmosti
ndust
ri
alor
gani
sat
ionsf
ory
ear
s.I
facci
dent
sar
etobe
pr
event
edi
nthef
utur
eiti
snousewhat
soev
ert
o“bl
ame”peopl
efort
hei
rmi
stakesunl
ess
wehav
eadet
ail
edunder
standi
ngofwhatcausedt
hemi
stakes.Onl
ybyunder
standi
ngal
l
t
hei
ssueswhi
chhav
ecaused(
orcoul
dcause)anacci
dentcanwei
dent
if
ythewayt
o
pr
eventf
utur
eacci
dent
s

Or
gani
sat
ional
&Manager
ial
Fai
l
ures

Ther
elev
anceofmanager
ialandor
gani
sat
ionalf
act
orshasbeengr
aphi
cal
l
yrev
eal
edi
nthe
i
nqui
ryr
epor
tsi
ntot
hemaj
ordi
sast
erst
hatoccur
redi
ntheUKatt
heendoft
he1980’
s.Pr
ior
t
othesedi
sast
ers,seni
ormanager
sofsuchor
gani
sat
ionspr
opoundedt
hepr
e-emi
nenceof
saf
et HSC,19936)
y( .Theybel
i
evedi
ntheef
fi
cacyoft
her
egul
ator
ysy
stem,i
ntheadequacy
oft
hei
rexi
sti
ngpr
ogr
ammesandi
ntheconf
idenceoft
heski
l
lsandmot
ivat
ionoft
hei
rst
aff
.
Thei
nqui
ryr
epor
tsr
evealt
hatt
hei
rbel
i
efi
nsaf
etywasami
rage,t
hei
rsy
stemsi
nadequat
e,
andoper
atorer
ror
sandv
iol
ati
onscommonpl
ace.Thei
nqui
ryr
epor
tsst
atedt
hatul
ti
mat
e
r
esponsi
bil
i
tyl
aywi
thcompl
acentdi
rect
orsandmanager
swhohadf
ail
edt
oensur
ethat
t
hei
rgoodi
ntent
ionswer
etr
ansl
atedi
ntoapr
act
icalandmoni
tor
edr
eal
i
ty.Mor
eov
ert
he
weaknesses wer
e so st
arkl
yrev
eal
ed wer
e notmat
ter
s ofconcer
ntot
he r
egul
ator
y
agenci
esbef
oret
heacci
dent
s.

Thebestwayt
ojust
if
ythei
mpor
tancewhi
chwaspl
acedont
hesepoi
ntsbyt
hev
ari
ous
i
nqui
ri
esi
stoconsi
deraser
iesofquot
ati
onst
akenf
rom t
heof
fi
cialr
epor
ts.Thef
ir
st
quot
ati
oni
stakenf
rom t
her
epor
tint
otheKi
ng’
sCr
ossf
ir
eont
heLondonUnder
ground7:

I
nqui
ryi
ntot
heKi
ng’
sCr
ossUnder
groundSt
ati
onFi
re

Manyoft heshor
tcomingsinthephysicalandhumanstateofaf
fair
sat
King’
sCrosson18Nov ember1987hadi nfactbeeni
denti
fi
edbeforeby
i
nternali
nqui
ri
esintoescal
atorfi
res.
..
..
Themanyr ecommendati
onshad
notbeenadequatel
yconsideredbyseniormanagers.
..
London
6
HSC(
1993)Or
gani
singf
orSaf
et,3rd Repor
y toft
heHumanFact
orsSt
udyGr
oupoft
heAdv
isor
y
Commi
tt
eeont
heSaf
etyofNucl
earI
nst
all
ati
ons,
HSEBooks.
7
Depar
tmentofTr
anspor
t(1988)
,Inv
est
igat
ioni
ntot
heKi
ngsCr
ossUnder
groundFi
re,
London:
HMSO

7
 Under
ground’sfai
l
uretocarr
ythr
ought
heproposalsresul
ti
ngfr
om
ear
li
erfi
res.
..
..
.wasafail
urewhi
chIbel
i
evecontr
ibutedtothedi
sast
er
atKi
ng’sCross.

Ihav
esaidunequi
vocal
l
ythatwedonotseewhathappenedonthe
ni
ghtof18November1987asbei
ngthefaul
toft
hoseinhumbleplaces.

Theset
wocomment
spl
acet
hepr
imar
yresponsi
bil
i
tysquar
elyonmanagementi
nact
ion
and/
ori
nef
fect
iveness i
nli
ghtofpr
evi
ous i
nci
dent
s whi
ch cl
ear
ly suggest
ed t
hata
cat
ast
rophi
cfi
rewi
thi
nanunder
groundst
ati
onwasi
ndeedpl
ausi
ble.Thi
sisshownqui
te
cl
ear
lyi
ntheconcl
usi
onst
othei
nqui
rywhi
chst
ate,
inpar
t:

I
nqui
ryi
ntot
heKi
ng’
sCr
ossUnder
groundSt
ati
onFi
re

Alt
houghIacceptthatLondonUndergroundbeli
evedt
hatsafet
ywas
enshr
inedintheethosofrai
lwayoperati
on,i
tbecamecleart
hatthey
hadablindspot.
..
.

Ibeli
ev et hi
sar osebecausenooneper sonwaschar gedwi t
hov erall
responsi bil
i
tyforsafety.Eachdi r
ectorbeliev edhewasr esponsiblefor
safetyinhi sdivisi
on,butthatitcoveredpr incipall
ythesaf et
yofst aff.
Theoper ati
onsdi r
ector,whowasr esponsibl eforthesaf eoperationof
thesy stem, di
dnotbel ievehewasr esponsi bleforthesaf et
yofliftsand
escalator swhichcamewi thi
nt heengineer i
ngdi rector
’sdepartment .
Speciali
stsaf etystaf
fwer emai nlyinjuniorposi t
ionsandconcer ned
solel
ywi thsafetyofstaff.

Asi
mil
art
hemei
shi
ghl
i
ght
edi
nther
epor
tint
othecapsi
zeoft
heHer
aldofFr
eeEnt
erpr
ise8.
I
nthi
sdi
sast
ert
hemosti
mpor
tantsi
ngl
einci
dentl
eadi
ngt
otheacci
dentwast
hef
ail
uret
o
cl
oset
hebowdoor
sbef
oret
heshi
psetsai
l
.

Sev
eralMast
ersi
nthef
leethadr
aisedt
hei
rconcer
nont
hisi
ssuewi
thseni
ormanagement
wi
thi
nthecompanyasi
twasi
mpossi
blet
osee,f
rom t
hebr
idge,whet
hert
hedoor
swer
e
cl
osed.Ther
epl
i
esf
rom seni
ormanagementt
otheMast
ers’r
equest
sforanon-
bri
dge
war
ningsoi
ncensedt
heI
nqui
ryt
hatt
her
epor
tquot
esanumberofr
epl
i
esv
erbat
im,of
whi
cht
hisi
sone:

I
nqui
ryi
ntot
hecapsi
zeoft
heHer
aldofFr
eeEnt
erpr
ise

Dotheyneedanindi
cat
orl
ightt
otel
lthem whet
hert
hedeck
st
orekeeperi
sawakeandsober
?Mygoodness!!

Thesi
gni
fi
canceoft
hispar
ti
cul
arcommenti
snott
heamazi
ngcoi
nci
dencet
hatt
heman
r
esponsi
blef
orcl
osi
ngt
hedoor
swasi
nfactasl
eepatt
het
ime,butt
hati
tindi
cat
escl
ear
ly

8
Depar
tmentofTr
anspor
t(1987)TheHer
aldofFr
eeEnt
erpr
iseFor
mal
Repor
t,London:
HMSO

8
t
heat
ti
tudet
osaf
etyofSeni
orManagement
.Aser
iousconcer
nwi
thobv
iousl
yhor
rendous
i
mpl
i
cat
ions,hadbeenr
aisedbyseni
orandexper
iencedmember
soft
hest
affwhi
chcoul
d
hav
ebeenr
emedi
edatar
elat
ivel
yreasonabl
ecost
.Mor
egener
all
y,t
her
epor
tint
othe
capsi
zedr
awst
hef
oll
owi
ngconcl
usi
on:

I
nqui
ryi
ntot
hecapsi
zeoft
heHer
aldofFr
eeEnt
erpr
ise

Al
lconcer
nedinmanagement ,f
rom t
hemember softheBoar dof
Di
rect
orsdownt othejuniorsuperi
ntendents,weregui
ltyoffaul
tint
hat
al
lmustberegardedasshar ingresponsibi
l
ityforthef
ailur
eof
management.From thetoptot hebottom t
hebodycor poratewas
i
nfect
edwiththediseaseofsl oppi
ness.

Byi
mpl
i
cat
ionsuchacomment
,li
ket
hosequot
edf
rom t
heKi
ng’
sCr
ossRepor
tabov
e,i
s
l
ooki
ngbey
ondt
heev
ent
swhi
chi
mmedi
atel
ypr
ecededt
heacci
dentandhi
ghl
i
ght
ingt
he
oper
ati
onalci
rcumst
ancesandmanager
ialat
ti
tudeswhi
ch,
inef
fect
,pr
edi
sposedt
hecr
it
ical
ev
ent
s.

Exact
lyt
hesamepoi
nti
smadei
nther
epor
toft
hei
nqui
ryi
ntot
heCl
apham Junct
ionr
ail
ash9,
cr int
hiscasehowev
ert
her
epor
temphasi
sest
hepoi
ntmuchmor
especi
fi
cal
l
y:

I
nqui
ryi
ntot
heCl
apham Junct
ionRai
lCr
ash.

Thedirectcauseoft
heClapham Junct
ionacci
dentwasundoubt
edl
y
thewiri
ngerrorsmadebyMr .Hemmingwayinhisworki
ntheJunct
ion
“A”r
elayroom.
Lat
er,
ther
epor
tgoesont
ost
ate.
..
Theconceptofabsol
utesafet
ymustbeagospelspreadacr
osst he
wholeworkf
orceandparamountinthemindsofmanagement.Thev i
tal
i
mpor t
anceofthi
sconcept..wasacknowl
edgedti
meandagai ni
nt he
evi
dencewhichtheCourtheard.
..

But
,subsequent
lyi
tal
sost
ates.
.

Theconcernforsafetywasper mit
tedt oco-
existwit
hwor ki
ngpr act
ices
which.
..wereposit
ivelydangerous...Thebestofint
enti
onsr egardi
ng
saf
ewor ki
ngpracti
ceswasper mit
tedt ogohandi nhandwi t
ht heworst
ofi
nacti
oninensuringt hatsuchpracti
ceswereputintoeffect.

Thi
sisanunequi
vocalst
atementt
hatwhi
l
etheacci
dentoccur
redasar
esul
tofspeci
fi
c
er
ror
sbyaspeci
fi
cindi
vi
dual
,ther
epor
tconsi
der
sthatt
hel
i
kel
i
hoodofsucher
ror
swas

9
Depar
tmentofTr
anspor
t(1988)I
nvest
igat
ion i
ntot
he Cl
apham Junct
ion Rai
l
way Acci
dent
,
London:
HMSO

9
i
ncr
easedconsi
der
abl
ybyt
heor
gani
sat
ionalandmanager
ialf
ramewor
kinwhi
chhi
swor
k
wasconduct
ed.

Theabov
ecomment
scanal
lbesummedupef
fect
ivel
ybyaquot
ati
onf
rom t
hei
nqui
ryi
nto
t
hePi
perAl
phaOi
lri
gfi
re10:

I
nqui
ryi
ntot
hePi
perAl
phaOi
lRi
gFi
re

Iam conv
incedf r
om theevi
dence..
.thatthequali
tyofsaf
ety
management. .
..i
sfundamentalt
ooff-shoresafet
y.Noamountof
det
ail
edregulat
ionsforsaf
etyimprovement scoul
dmakeupf or
def
ici
enci
esint hewaythatsafet
yismanaged.

Whatt
henar
ethegener
alconcl
usi
onswhi
chcanbedr
awnf
rom t
heabov
edi
sast
erswhi
ch
ar
ecommont
othev
ari
ousev
ent
swhi
l
eindependentoft
hespeci
fi
chazar
dsandr
isksi
n
whi
cht
heacci
dent
soccur
red?

I
nessencet
heycanbesummar
isedasf
oll
ows:

 Notoneoft
heseor
gani
sat
ionshad,
bef
oret
heacci
dent
s,anyser
iousr
eser
vat
ionsabout
t
hei
rsaf
etypr
ocedur
es,or
gani
sat
ion ormanagement
,yett
her
e wer
e cl
ear
lymany
pr
obl
emsofwhi
cht
heywer
enotawar
e.

 Er
ror
smade“
att
heshar
p-end”(
thei
mmedi
atecausesofanacci
dent
)mustbeseeni
n
t
hewi
dercont
extoft
heor
gani
sat
ionandmanagementcl
i
mat
einwhi
cht
heywer
e
commi
tt
ed.Addi
ti
onal
l
ymor
ethoughtneedst
obegi
vent
othedesi
gnofsy
stemsand
equi
pmentt
omi
nimi
set
hepot
ent
ialf
orhumaner
ror
.Bot
hoft
hesei
ssuesneedt
obe
gi
venmuchmor
eser
iousconsi
der
ati
oni
frepeat(
orsi
mil
ar)i
nci
dent
sar
etobeav
oided.

 Act
ionsspeakl
oudert
hanwor
ds.Thebestofwr
it
tensaf
etypol
i
cies,t
hemostdet
ail
ed
setofsaf
etyr
ulesandpr
ocedur
eset
c.ar
etot
all
ymeani
ngl
essunl
esst
heyar
eful
l
y
r
esour
ced,
rigor
ousl
yimpl
ement
edandkeptunderr
egul
arr
evi
ew.

 Commi
tment
,posi
ti
vesaf
etyat
ti
tudesandmot
ivat
iont
oget
herwi
thconst
antv
igi
l
ance
t
hroughoutt
heor
gani
sat
ion(
butl
edf
rom t
het
op)
,ar
eessent
ial
tohi
ghsaf
etyst
andar
ds.

 Youcannotr
elyonext
ernal
prescr
ipt
iont
oachi
evesaf
ety
.

10
Depar
tmentofEner
gy(
1990)ThePubl
i
cInqui
ryi
ntot
hePi
perAl
phaDi
sast
er,
(2v
ol)
,London:
HMSO

10
3.
0 Cl
assi
fi
cat
ionofHumanEr
ror
s
The t
erm ‘
human er
ror
’iswi
de and can i
ncl
ude a gr
eatv
ari
etyofhuman behav
iour
.
Ther
efor
e,i
nat
tempt
ingt
odef
inehumaner
ror
,di
ff
erentcl
assi
fi
cat
ionsy
stemshav
ebeen
dev
elopedt
odescr
ibet
hei
rnat
ure.I
dent
if
yingwhyt
heseer
ror
soccurwi
l
lul
ti
mat
elyassi
sti
n
r
educi
ngt
hel
i
kel
i
hoodofsucher
ror
soccur
ri
ng.

Thedi
sti
nct
ionbet
weent
hehandson‘
oper
ator
’er
ror
sandt
hosemadebyot
heraspect
sof
t
heor
gani
sat
ionhav
ebeendescr
ibedbyReason11(
1990)as‘
act
ive’
and‘
l
atent
’fai
l
ures.

Act
iveFai
l
ureshav
eani
mmedi
ateconsequenceandar
eusual
l
ymadebyf
ront
-l
inepeopl
e
suchasdr
iver
s,cont
rolr
oom andmachi
neoper
ator
s.Thesei
mmedi
atel
ypr
eceed,andar
e
t
hedi
rectcause,
oft
heacci
dent
.

Lat
entf
ail
uresar
ethoseaspect
soft
heor
gani
sat
ionwhi
chcani
mmedi
atel
ypr
edi
spose
act
ivef
ail
ures.Commonex
ampl
esofl
atentf
ail
uresi
ncl
ude(
HSE,
1999)
:

 Poordesi
gnofpl
antandequi
pment
;

 I
nef
fect
ivet
rai
ning;

 I
nadequat
esuper
visi
on;

 I
nef
fect
ivecommuni
cat
ions;
and

 Uncer
tai
nti
esi
nrol
esandr
esponsi
bil
i
ties.

Lat
entf
ail
uresar
ecr
uci
all
yimpor
tantt
oacci
dentpr
event
ionf
ort
wor
easons:

1.I
ftheyar
enotr
esol
ved,t
hepr
obabi
l
ityofr
epeat(
orsi
mil
ar)acci
dent
sremai
nshi
gh
r
egar
dlessofwhatot
heract
ioni
staken;

2.Asonel
atentf
ail
ureof
teni
nfl
uencessev
eralpot
ent
ialer
ror
s,r
emov
ingl
atentf
ail
ures
canbeav
erycost
-ef
fect
iver
out
etoacci
dentpr
event
ion.

Cl
assi
fyi
ngAct
iveFai
l
ures
I
nhi
scl
assi
fi
cat
ionofact
ivef
ail
uresReason(
1990)di
sti
ngui
shesbet
weeni
ntent
ionaland
uni
ntent
ionaler
ror
.Int
ent
ionaler
ror
sar
edescr
ibedasv
iol
ati
ons,whi
l
stuni
ntent
ionaler
ror
s
ar
ecl
assi
fi
edasei
thersl
i
ps/
lapsesormi
stakes.Theset
ypesofhumanf
ail
urear
eshowni
n

11
ReasonJ(
1990)HumanEr
ror
,Cambr
idgeUni
ver
sit
yPr
ess

11
t
hedi
agr
am bel
ow( 199912)
HSE, :

Sl
i
psandLapses:Theseoccuri
nrout
inet
askswi
thoper
ator
swhoknow t
hepr
ocesswel
l
andar
eexper
iencedi
nthei
rwor
k:

 Theyar
eact
ioner
ror
swhi
choccurwhi
l
stt
het
aski
sbei
ngcar
ri
edout
;

 Theyof
teni
nvol
vedmi
ssi
ngast
epoutofasequenceorget
ti
ngst
epsi
nthewr
ongor
der
andf
requent
lyar
isef
rom al
apseofat
tent
ion;

 Oper
ati
ngt
hewr
ongcont
rolt
hroughal
apsei
nat
tent
ionoracci
dent
all
ysel
ect
ingt
he
wr
onggearar
ety
pical
exampl
es.

Mi
stakes:Thesear
einadv
ert
enter
ror
sandoccurwhent
heel
ement
sofat
askar
ebei
ng
consi
der
edbyt
heoper
ator
.

Theyar
edeci
sionst
hatar
esubsequent
lyf
oundt
obewr
ong,al
thoughatt
het
imet
he
oper
atorwoul
dhav
ebel
i
evedt
hem t
obecor
rect
.Ther
ear
etwot
ypesof‘
mist
ake’(
HSE,
1999)
,rul
ebasedandknowl
edgebased:

 Rul
ebasedmi
stakesoccurwhent
heoper
ati
oni
nhandi
sgov
ernedbyaser
iesofr
ules.
Theer
roroccur
swhenani
nappr
opr
iat
eact
ioni
sti
edt
oapar
ti
cul
arev
ent

 Knowl
edgebaseder
ror
soccuri
nent
ir
elynov
elsi
tuat
ionswheny
ouar
ebey
ondy
our

12
HSE(
1999)
,Reduci
ngEr
rorandI
nfl
uenci
ngBehav
iour
,HS(
G)48,
HSEBooks

12
 ski
l
ls,bey
ondt
hepr
ovi
sionoft
her
ulesandy
ouhav
etor
elyent
ir
elyonadapt
ingy
our
basi
cknowl
edgeandexper
iencet
odeal
wit
hanewpr
obl
em.

Vi
olat
ions ar
e any del
i
ber
ate dev
iat
ion f
rom t
he r
ules,pr
ocedur
es,i
nst
ruct
ions and
r
egul
ati
ons,whi
ch ar
e deemed necessar
yfort
he saf
e oref
fi
cient oper
ati
on and
mai
ntenance of pl
ant or equi
pment
. Br
eaches i
n t
hese r
ules coul
d be
acci
dent
al/
uni
ntent
ional
ordel
i
ber
ate.

Vi
olat
ionsoccurf
ormanyr
easons,
andar
esel
dom wi
l
ful
act
sofsabot
ageorv
andal
i
sm.The
maj
ori
tyst
em f
rom agenui
nedesi
ret
oper
for
m wor
ksat
isf
act
ori
l
ygi
vent
heconst
rai
ntsand
expect
ati
onst
hatexi
st.Vi
olat
ionsar
edi
vi
dedi
ntot
hreecat
egor
ies:r
out
ine,si
tuat
ionaland
except
ional
(HSE,
1999)
.

Rout
ineVi
olat
ionsar
eoneswher
ebr
eaki
ngt
her
uleorpr
ocedur
ehasbecomet
henor
mal
wayofwor
king.Thev
iol
ati
ngbehav
iouri
snor
mal
l
yaut
omat
icandunconsci
ousbutt
he
v
iol
ati
oni
srecogni
sedassuch,
byt
hei
ndi
vi
dual
(s)i
fquest
ioned.Thi
scanbeduet
ocut
ti
ng
cor
ner
s,sav
ingt
ime.orbeduet
oabel
i
eft
hatt
her
ulesar
enol
ongerappl
i
cabl
e.

Si
tuat
ionalVi
olat
ionsoccurbecauseofl
i
mit
ati
onsi
ntheempl
oyeesi
mmedi
atewor
kspace
orenv
ironment
.Thesei
ncl
udet
hedesi
gnandcondi
ti
onoft
hewor
kar
ea,t
imepr
essur
e,
numberofst
aff
,super
visi
on,equi
pmentav
ail
abi
l
ity
,anddesi
gnandf
act
orsout
sidet
he
or
gani
sat
ionscont
rol
,suchasweat
herandt
imeofday
.Thesev
iol
ati
onsof
tenoccurwhena
r
ulei
simpossi
bleorext
remel
ydi
ff
icul
ttowor
ktoi
napar
ti
cul
arsi
tuat
ion.

Except
ionalVi
olat
ions ar
evi
olat
ions t
hat ar
erar
e and happen onl
yin par
ti
cul
ar
ci
rcumst
ances,of
tenwhensomet
hinggoeswr
ong.Theyoccurt
oal
argeext
entatt
he
knowl
edgebasedl
evel
.Thei
ndi
vi
duali
nat
tempt
ingt
osol
veanov
elpr
obl
em,
viol
atesar
ule
t
oachi
evet
hedesi
redgoal
.

Lat
entFai
l
ures
Lat
entf
ail
uresar
ethef
act
orsorci
rcumst
anceswi
thi
nanor
gani
sat
ionwhi
chi
ncr
easet
he
l
i
kel
i
hoodofact
ivef
ail
ures.Consi
dersomeexampl
esofl
atentf
ail
uresi
nrel
ati
ont
othe
exampl
eacci
dent
sgi
venear
li
er:

13
 Ki
ng’
sCr
ossUnder
groundSt
ati
onFi
re

Thel
atentf
ail
uresher
eincl
uded:

Whi lesev er
almi norescalat orfi
reshadoccur r
edpr evi
ouslyandhadbeen
i
nv estigated,apparentlynoonei ntheorganisati
onseriouslyconsi
deredt hef actthat
amaj orescalatorfi
rewasapossi bil
it
y-consequent l
y,astheinqui
rystates, l
itt
le
effectiveacti
onhadbeent akenont hewarningspr ov
idedbyt heminorfires.Similarl
y
thei nquiryal
sor eport
edt hattherewereser i
ousflawsinthemanager ialand
organi sati
onalresponsibilit
iesandaccount abil
i
tyforsafetywithvi
rtuall
yallaspect s
oft heor gani
sationthinkingpassengersaf etywassomeoneel se’
sresponsi bil
it
y.

Theexi
stenceoft
hese,andot
hersi
mil
ar,l
atentf
ail
ureswi
thi
ntheLondonUnder
ground
oper
ati
onsi
gni
fi
cant
lyi
ncr
easedt
hepr
obabi
l
ityofamaj
orescal
atorf
ir
e,wi
thhi
ndsi
ghti
t
wasal
mostamat
terofwhenr
athert
hanwhet
her
.Iti
sal
soappar
ent
,assuggest
edabov
e,
t
hatunl
esst
her
emedi
alact
ion t
aken encompassed t
heseor
gani
sat
ional
/management
l
atentf
ail
ures,t
hatar
epeatev
entwasl
i
kel
yfor
,qui
tesi
mpl
y,t
hemaj
ori
nfl
uenci
ngf
act
ors
woul
dhav
eremai
nedi
npl
acet
opr
edi
sposeasi
mil
arev
ent
.

TheCapsi
zeoft
heHer
aldofFr
eeEnt
erpr
ise

amongt
hel
atentf
ail
uresi
nvol
vedher
ear
ethef
oll
owi
ng:

I
twasi mpossibleforanyonetoont hebri
dgetoseewhetherthebowdoor shad
beenclosedpriort
oset t
ingsailandalt
houghther
ewer eorgani
sati
onalprocedures
i
npl acetheOffi
cerinchargewas, ef
fect
ivel
y,wor
kingonthebasisof“fai
th”rat
her
thananymor epositi
vefeedbackofinformati
on.

Thisdesignl
atentfai
lurewascompoundedbyt heatti
tudeofthesenior
managementi nthememosi nreplytoarequestf
oranon- br
idgewar ni
ngdev i
ce
(quotedearl
i
er).Foraformalrequestconcerni
ngamaj orsafet
yissue,from aseni
or
operati
onalmanager,tobetreatedinsuchawaycl ear
lyindi
catesthatther
ewas
apparentl
yveryli
tt
lecredi
bil
i
tygiventopotenti
alsafet
yissues.

Ov
er180l
i
veswer
elostl
argel
yasar
esul
tofl
atentf
ail
uresbyt
heshi
p’sdesi
gner
swho
ov
erl
ooked,ori
gnor
edt
hepot
ent
iali
mpl
i
cat
ionsofbr
idgeof
fi
cer
snotbei
ngabl
etobe
cer
tai
nthatt
hebow door
swer
ecl
osed,compoundedbyt
hef
actt
hatseni
ormanagement
al
soappar
ent
lyconsi
der
edt
hei
ssuet
obeofl
i
ttl
econcer
n.

Ot
herl
atentf
ail
ures,
commoni
nindust
ryar
e:

At
ti
tudest
oSaf
ety
:Thesaf
etycul
tur
eofanor
gani
sat
ioni
sest
abl
i
shed,i
npar
t,byt
he

14
at
ti
tudest
osaf
etyshownbymanagementandsuper
visor
yst
aff
.Unl
essmanager
sleadby
exampl
eandv
isi
blydemonst
rat
ethei
rcommi
tmentt
osaf
ety
,noamountofhar
dwor
kint
he
pr
epar
ati
onandest
abl
i
shmentofr
ulesandpr
ocedur
esandi
npr
ovi
dingt
rai
ningwi
l
lhav
e
anyl
ast
ingef
fect
.

Rul
es & Pr
ocedur
es:Rul
es and pr
ocedur
es pr
ovi
de t
he f
ramewor
kupon whi
ch saf
ety
assur
ancei
sbui
l
tandar
ecl
aimedt
obeef
fect
ivecont
rolmeasur
es.Howev
ert
hisi
sli
tt
le
mor
ethananassumpt
ionr
athert
hanapr
ovenr
eal
i
ty.St
udi
eshav
eshownt
hatsaf
etyr
ules
andpr
ocedur
esar
eof
ten:

 Wr
it
tennegat
ivel
y,concent
rat
ingonshoul
dnotbedoner
athert
hanonwhatshoul
d
bedone;

 I
mpr
act
ical
;

 I
nconf
li
ctwi
thot
herr
ules

Tr
aini
ng:Wi
thi
ntr
aini
ng pr
ogr
ammes,l
i
ttl
e consi
der
ati
on i
s gi
ven t
o ev
aluat
ing i
ts
ef
fect
iveness.I
tcannotbeassumedt
hatbysi
mpl
yat
tendi
ngat
rai
ningcour
semeanst
hat
onei
sadequat
elyt
rai
ned.Ot
hercommonpr
obl
emswi
tht
rai
ningpr
ogr
ammesi
ncl
ude:

 Hazar
dawar
enessi
sof
tenassumedr
athert
hant
rai
ning;

 Tr
aini
ngshoul
dconcent
rat
eonwhati
ssaf
e,r
athert
hanunsaf
e,whatt
odo,r
ather
t
hanwhatnott
odo.

 Tr
aini
ngi
snotal
way
sconsi
stentwi
tht
her
ulesandpr
ocedur
es.

Equi
pmentdesi
gn&Mai
ntenance:l
i
mit
ati
onsi
nthest
andar
dofer
gonomi
csappl
i
edt
othe
desi
gn oft
heequi
pment
/pl
anti
ncr
easet
her
iskofhuman er
ror
.Whi
l
sti
tisusualt
o
associ
atedesi
gnl
i
mit
ati
onswi
thuni
ntent
ionaler
ror
s,i
.e.sl
i
ps&mi
stakes,poordesi
gns
al
socr
eat
east
rongmot
ivat
ionf
oroper
ator
stov
iol
atesaf
ewor
kingpr
ocedur
es.

Concl
usi
onofSect
ion

 HumanEr
rori
smor
ethanoper
ator
/pi
l
oter
ror
.Ev
ery
onecanmakeer
ror
snomat
terhow
wel
ltr
ainedandmot
ivat
edt
heyar
e.

 I
tisusef
ult
odi
sti
ngui
shbet
weenact
iveandl
atentf
ail
ures.Act
ivef
ail
uresar
ethose

15
 handsonoper
atorer
ror
sthati
mmedi
atel
ypr
ecedeanacci
dent
.Lat
entf
ail
uresar
ethe
f
act
orsorci
rcumst
anceswi
thi
nanor
gani
sat
ionwhi
chi
ncr
easet
hel
i
kel
i
hoodofact
ive
f
ail
ures.Lat
entf
ail
uresl
i
ehi
ddenunt
ilt
heyar
etr
igger
edatsomet
imei
nthef
utur
e.

 I
nthe domi
no t
heor
yorchai
n descr
ibed ear
li
eri
nthe cour
se act
ivef
ail
ures ar
e
anal
ogoust
othei
mmedi
atecauseandl
atentf
ail
uresanal
ogoust
otheunder
lyi
ngorr
oot
cause.

16
4.
0 St
rat
egi
esf
orReduci
ngHumanEr
ror
Reduci
nghumaner
rori
nvol
vesf
armor
ethant
aki
ngdi
sci
pli
nar
yact
ionagai
nstani
ndi
vi
dual
.
Ther
ear
ear
angeofmeasur
eswhi
char
emor
eef
fect
ivecont
rol
sincl
udi
ngt
hedesi
gnoft
he
equi
pment
,job,
procedur
esandt
rai
ning.

Act
ionsf
orov
ercomi
ngAct
iveFai
l
ures

Sl
i
psandLapses

Desi
gni
mpr
ovementi
sthemostef
fect
iver
out
eforel
i
minat
ingt
hecauseoft
hist
ypeof
humaner
ror
.Forexampl
e,t
ypi
calpr
obl
emswi
thcont
rol
sanddi
spl
ayst
hatcauset
hist
ype
ofer
rori
ncl
ude:

 Swi
tcheswhi
char
etoocl
oseandcanbei
nadv
ert
ent
lyswi
tchedonorof
f;

 Di
spl
ayswhi
chf
orcet
heusert
obendorst
ret
cht
oreadt
hem pr
oper
ly;

 Cr
it
ical
displ
aysnoti
ntheoper
ator
sfi
eldofv
iew;

 Poor
lydesi
gnedgauges;

 Di
spl
ayswhi
char
ecl
utt
eredwi
thnon-
essent
ial
inf
ormat
ionandar
edi
ff
icul
ttor
ead.

Mi
stakes
Tr
aini
ng,f
ori
ndi
vi
dual
sandt
eams,i
sthemostef
fect
ivewayf
orr
educi
ngmi
staket
ype
human er
ror
s.The r
isk oft
hist
ype ofhuman er
rorwi
l
lbe decr
eased i
fthe t
rai
nee

17
under
standst
heneedf
orandbenef
it
sfr
om saf
epl
ansandact
ionsr
athert
hansi
mpl
ybei
ng
abl
etor
eci
tet
hest
epspar
rotf
ashi
on.Tr
aini
ngshoul
dbebasedondef
inedt
rai
ningneeds
andobj
ect
ives,andi
tshoul
dbeev
aluat
edt
oseei
fithashadt
hedesi
redi
mpr
ovementi
n
per
for
mance.

Vi
olat
ions
Ther
eisnosi
ngl
ebestav
enuef
orr
educi
ngt
hepot
ent
ialf
ordel
i
ber
atedev
iat
ionsf
rom saf
e
r
ulesandpr
ocedur
es.Theav
enuesf
orr
educi
ngt
hepr
obabi
l
ityofv
iol
ati
onsshoul
dbe
consi
der
edi
nter
msoft
hosewhi
chr
educeani
ndi
vi
dual
smot
ivat
iont
ovi
olat
e.These
i
ncl
ude:

 Under
-est
imat
ionoft
her
isk

 Real
orper
cei
vedpr
essur
efr
om t
hebosstadoptpoorwor
kpr
act
ices;

 Pr
essur
efr
om wor
k-mat
est
oadoptt
hei
rpoorwor
kingpr
act
ices;

 Cut
ti
ngcor
ner
stosav
eti
meandef
for
t

Addr
essi
ngLat
entFai
l
ures
Theor
gani
sat
ionmustcr
eat
eanenv
ironmentwhi
ch:

 r
educest
hebenef
itt
oani
ndi
vi
dual
from v
iol
ati
ngr
ules.

 Reducest
her
iskofanoper
atormaki
ngsl
i
ps/
lapsesandmi
stakes.

Thi
scanbedonebyi
dent
if
yingandaddr
essi
ngl
atentf
ail
ures.

Exampl
esofl
atentf
ail
uresi
ncl
ude:

 Poordesi
gnofpl
antandequi
pment
;

 I
mpr
act
ical
procedur
es,

 I
nef
fect
ivet
rai
ning;

 I
nadequat
esuper
visi
on;

 I
nef
fect
ivecommuni
cat
ions;
and

 Uncer
tai
nti
esi
nrol
esandr
esponsi
bil
i
ties.

Oneoft
hepr
inci
palway
sofsy
stemat
ical
l
ydoi
ngt
hisi
sthr
oughaheal
thandsaf
ety
managementsy
stem.Thi
sist
hesubj
ectoft
henextt
opi
car
eai
nthi
scour
se.

18