Wednesday, June 28, 2006

Ship sinking - crew unable to use new technology

Article in Risk digest at summarises initial findings of inquiry into sinking of Queen of the North. Ship had a new computer based chart system. Crew did not know how to reduce the illumination level from the screen, which at night caused them problems. Their solution was to switch the display off.

Space probe error

According to an article at on June 14 2006 and recreated in the risks digest at engineers made a catastrophic error when they put together the Genesis space probe. Apparently they put in gravity switches in backward. These were supposed to deploy a parachute as the probe returned to earth, but instead it crashed to earth and was destroyed. Also, the makers skipped a critical pre-launch test and simply did a paperwork review. It is claimed this was partly due to severe financial constraints caused by competitive tendering process.

Tuesday, June 27, 2006

Handling uncertainty

Interesting article in May 2006 Chemical Engineer by Chris Beale.

includes Donald Rumsfeld's famous quote "There are known knowns. These are things we know we know. There are known unknowns. That is to say, things we know that we don't know. But there also unknown unknowns. These are the things we don't know we don't know."

Chris points out that people often interpret risk assessment as certainties, when this often far from the case. He proposes three levels of uncertainty.
1. Using established technology. Minimal uncertainty.
2. Incremental change. Risks considered to be similar to those already known. Use management of change but recognise there may be incorrect assumptions about impact of change.
3. Step changes to completely new product or process. Need to pilot and then scale up. Expect to uncover many gaps in knowledge.

The suggested yard stick for assessments is to consider if you assessed the risk using worst case data, would it change your recommendations for risk reduction measures? If yes, uncertainty could be critical and a cautious approach is required.

Perceptions of management commitment to safety

I come across it very often that people at the sharp end perceive that their managers, although saying the right things, are not really that interested in safety.

An article in May 2006 Chemical Engineer by Tom Woollard illustrates this. "Most easy to spot is the company executive who makes sure that 'health and safety is the first agenda item' and is adept with emergency exit briefings and the 'safety first' and 'people are our greatest asset' rhetoric; and yet is often seen speeding out of the car park, sales figures on the passenger seat, clutching their mobiles to their ears. These kinds of safety observations tend to travel quickly through the organisation whether or not they are recorded in the safety log book."

Tom relates this to failures in behavioural safety programs. This occurs either through lack of commitment or perceived sincerity. Often because the company has not got the right culture in place for the program to work effectively.

One solution, apparently, is to make sure people understand the importance of safety at work and at home. This supposedly starts to work at an emotional level.

I guess this can work, but as Tom says it is easy for them to be seen as gimmicks if done badly. I guess my concern is that the message become that risk is not acceptable, and it can quickly result in people not doing what they enjoy doing when out of work.

Speed cameras

I drove past the spot at the weekend where I picked up a speeding ticket a couple of years ago. It is in Caernarfon, North West Wales. The ticket said I was doing 42 mph in a 30 limit

The problem I have with is that at the time I thought I was in a 40 limit. OK, so I was still over that limit, but by a much lesser margin. The road where the camera is located chops and changes limits, and I would argue there are few visual clues (other than the signs at the change points) to inform you what limit you are in.

So I got a ticket, not for speeding to great excess, but for not noticing a change in speed limit. I really wonder how effective it has been at changing my behaviour or attitude, and hence has there been any improvement in the safety of my driving? The only major change I am aware of is that I now know to drive at 30mph on that particular stretch of road. Something I may do a handful of times per year.

I think this has parallels with what we talk about in industrial safety and human factors. If we take actions at face value we may make interventions that either have minimal or counter-productive affects. If we have too many rules and/or enforce them too rigidly the culture will change completely. Equally, if we are too lenient there will be consequences. I guess there is a balance to make, and we have to work continuously to make sure that balance is being achieved.

Thursday, June 22, 2006

Risk Aversion

Interesting article in RiskTec's quarterly newsletter Spring 06. See

There is great concern about risk aversion leading to crazy decisions. Reasons for this vary but fear of litigation, dogmatic implementation of policy without considering its suitability, belief that risk should be eliminated and simply using it as a conventient excuse are all noted.

A list of UK examples is provided

A 73 year old pensioner from Cardiff was ordered off a bus for carrying a tin of water-based emulsion paint.
Children at a London primary school have been banned from making daisy chains in case they pick up germs from the flowers.
Barmaids across Europe may be forced to cover up because of an EU directive on sun exposure.
A district council felled a line of conker trees to prevent youngsters from injuring themselves while gathering conkers.
A girl was banned from bringing sun cream into class during a heatwave in case it caused allergies in other pupils.
Two Christmases ago, a secondary school in Chipping Sodbury banned the wearing of tinsel to prevent any danger of strangulation.
Cakes baked by Radwinter WomenÂ’s Institute were banned from a hospital over fears they could present a health risk to elderly patients.
AA publicann from Taunton Deane was prevented from displaying hanging baskets on the front of the Ring of Bells pub by council officials concerned that some of the
flowers might spill onto the pavement, forcing pedestrians into the road.

Also, from and

Alabama state law prohibits a driver to be blindfolded while operating a vehicle.
In New Britain, Connecticut, it is illegal for fire trucks to exceed 25mph, even when going to a fire.
It is illegal in Singapore to drive within 50 metres of a pedestrian crossing the street.
In Evanston, Illinois, it is unlawful to change clothes in an automobile with the curtains drawn, except in case of fire.
In Luxembourg you must have window wipers but you are not required to have a windscreen.
Danish law stipulates no one may start a car while someone is underneath the vehicle.
A driver in Belgium who needs to turn through oncoming traffic has the right of way unless he slows down or stops.
In Thailand, the law requires you to wear a shirt while driving a car.
And finally, although the underlying reasons are unclear, spare a thought for the Swiss, who are not permitted to wash their car on a Sunday.

Managing workplace transport risk

HSE have a proposed 'route map' out for consultation. It is important because 70 people were killed in accidents involving workplace transport in 2004/05

The route map is divided into four sections

1. Site layout and design
2. Vehicle selection and maintenance
3. Personnel matters
4. Management responsibilities

As it stands, my feeling is the document is weak and has a number of omissions. I think there is a fundamental problem because the causes of accidents is not made clear, so it not easy to see which of the proposed measures is likely to be most effective.

As with many things, my experience is that management of change is one of the most important elements, and it requires everyone working on a site to be aware of the risks of change. In particular new routes (including temporary and one-off), different vehicles, different activities and change to plant and equipment next to traffic routes can influence the risk.

I have sent some comments to HSE. You can do the same by going to

Thursday, June 08, 2006

Why most training doesn't work

Article in June 2006 Chemical Engineer about project management included a paragraph about why the 'obvious' answer for improving management is training, but that most proves to be ineffective.

It states that for an individual or team to improve they need to improve knowledge, attitudes, skills and habits. The vast majority of training concentrates on knowledge and skills. People may well gain these, but if they do not change their attitudes or habits there will be minimal affect. The problems are even worse if people do not think they need training (i.e. being sent on a mandatory course). Lack of confidence can also be an attitude problem that means people continue to avoid using the skill even after the training.

In my experience, most training is done 'on the job.' This has many benefits, but needs to planned, controlled and verified. Unfortunately planning, control and verification are usually only carried out for formal training events (e.g courses).

Good teams

Article in Appointments section of the Sunday Times on 4 June 2006.

Relating to football, with the World Cup on its way. "A team of champions doesn't make a champion team." From this the prediction is that smaller teams with reasonably well educated people who are highly driven by representing their country will do better (e.g. Croatia and Australia). Compare to bigger countries that often disappoint.

I find that the aging workforce is affecting team work in companies. Whereas there used to be a cross section of age and experience, this is no longer the case. In the past the young guys did the running around whilst the older ones could do the thinking. Now the middle agers are doing everything.

Tuesday, June 06, 2006

7 July 2005 - emergency plans

Final comments from the 7 July bombing response report. See previous posts.

The report suggests there was a lack of consideration of the individuals caught up in major or catastrophic incidents. Procedures tend to focus too much on incidents, rather than on individual and on processes rather than people. Emergency plans tend to cater for the needs of the emergency and other responding services, rather than explicitly addressing the needs and priorities of the people involved.

Part of the problem was that plans were developed in light of September 11th in New York where most people died and relatively few survived. This was opposite in London on July 7 when there were a great number of survivors to deal with. From this it was recommended that plans need to be recast on the needs of individuals involved in major catastrophes rather than the needs of emergency services. This will require a change of mindset from incidents to individuals and from processes to people.

7 July 2005 - technology

More from report of the 7 July bombing response report. See previous post.

Tim O’Toole, the Managing Director of London Underground is quoted in the report as saying a year before the event that “the big lesson for us is to invest in staff, rely on them; invest in technology but do not rely on it.”

I think this is an excellent insight. Equally it is interesting the report, having made this point, then talks at great length about having additional technology in preparation for such an event in the future. In particular, there were major problems with communication because mobile phone systems were overloaded and because emergency services could not communicate underground. I totally agree these were major weaknesses, but it seems likely that we need our emergency plans to work when technology is not available, and to use the technology when it is available to assist.

An interesting point is made about the ambulance service. They are now issuing key staff with pagers again. They had stopped doing this a couple of years ago because it appears that mobile phones do a better job. We are all starting to expect mobile phones to work reliably, but that can never be guaranteed with any technology.

7 July 2005 - emergency management

The report of the 7 July Review Committee has published it report examining how the multiple bombing in London were handled. It is available at

It states that one of the main problems was establishing exactly what had happened. There was very little communication from underground, where three of the bombs exploded, and much of the initial information was conflicting. Even once it was established what had happened, establishing the scale of the incident was very difficult. This was partly due to a procedural failure where each emergency service declared their own emergencies at each scene, whereas the first declaration of an emergency should have applied to all the services.

This seems fairly typical in my experience of emergency management. There is a general reluctance to declare an emergency. Although people do tend to start following the emergency procedure, the lack of formal declaration often causes delay and confusion.

I also wonder if a single command centre for all the emergency services would have been more effective. There seems to be political problems with the emergency services working together, which are simply beyond me. We want a combined response, and them have seperate control centres does not seem to help in any way.

Monday, June 05, 2006

Isambard Kingdom Brunel

We have just returned from a week's holiday in Bristol. Given that it is 200 years since Brunel was born and his strong links with the city, there was a lot about him in the various museums we visited and at the SS Great Britain (the first large iron hulled steam powered ship).

An interesting point made about Brunel was that he was not always successful. This demonstrated he was willing to take risks and usually learnt from his mistakes. It is suggested that this is how he was able to push technology so far.

I am concerned that we are tending to become more risk averse, but when we finally decide to do something we expect to it to be successful and rarely look back to see if we made mistakes that we can learn from. Some of Brunel's failures cost people's lives and caused companies to go bankrupt, but surely we should know enough about risk management now to take calculated risks and know the warning signs that mean we stop an endeavour before actual harm is experienced.