Thursday, August 31, 2006

Allocating blame for cable car crash

Article on BBC site 18 July 2006. Provides more information about the Nevis Range cable car crash that injured 5 people.

I am interested by the language used by Mr Hinteregger from the operating company. Couple of quotes:

"there must have been human error as the safety systems worked as intended"

"the company was not "in charge" of allocating blame, as that was up to the investigating authorities."

Red-face spellchecker

Article from Reuters 26 July 2006

TextTrust is a company that sells a service checking web sites for spelling errors. Unfortunately they issued a news release with multiple errors. "It said commonly misspelled words included independent, accommodation and definitely, which were spelled independant, accomodation and definately."


Pitfalls of nuclear power

Book titled 'Nuclear Power Is Not the Answer' by Dr Helen Caldicott is summarised at this web site

Dr. Caldicott is President of the Nuclear Policy Research Institute. She has become "perhaps the world's leading advocate for the abolition of a technology too unsafe to be tolerated any longer."

Human error gets several mentions. See quotes below

"Many experts agree it's only a matter of when and where, not if, a devastating meltdown will occur in one or more of the 438 nuclear power plants located in 33 countries worldwide. It may result from human error, a plant owner's unwise or unsafe attempt to minimize operating costs, the Nuclear Regulatory Commission's (NRC) imprudent accession to industry pressure to allow 20 year operating extensions to plants designed to run only for 40 years, the effects of a tsunami or high enough magnitude earthquake in areas vulnerable to them or from a deliberate attack or internal sabotage."

"Every US power plant is moving into the old-age cycle" because no new ones have been built here since the TMI accident in Pennsylvania in 1979. As a result, the number of near-misses and near-meltdowns has increased mostly resulting from human error, aging equipment and inadequate maintenance and regulatory oversight. With the dangers so high and inevitable and the supposed benefits totally without merit, why would the leaders and residents of any community ever be willing to allow the construction or operation of a nuclear power plant near enough to them to destroy their lives should a catastrophic nuclear event happen as it surely will potentially at any of the world's nuclear plants.

Repetetive stress injuries (RSI)

Article "Exercise may be the rx for RSI" on 7 August 2006. Suggests the cost of RSI to US industry may be as much as $100 billion annually if direct and indirect costs of lost productivity and absenteeism are included.

Response to RSI is often to invest in expensive ergonomic equipment. However, there have been very few studies to evaluate their effectiveness. This article suggests ergonomic equipment is good for prevention, but pain killers and exercise are likely to be more effective once someone has got RSI.

As well as being generally fit, it is important to take 3 to 5 minute breaks every 20 to 40 minutes, and frequent 10 to 15 second 'micro breaks.' "You must get out of your chair a couple of times an hour."

Article online at,0,7236861.story?coll=la-home-health

Similar article at

Thumb ache from texting

Article in Guardian online on 15 August 2006.

Warns that sending lots of text messages can cause pain and swelling of tendons at the base of the thumb and wrist. It seems mobile phones are not designed with the capabilities of the thumb in mind, which is "not a very dextrous digit."

However, a reader has added comment. "Please tell me this is a joke article. I really hope there hasn't actually been serious research done" on this topic.

Blunders by NHS kill thousands of patients a year

Front page of Sunday Telegraph, 27 August 2006.

Quotes data from National Patient Safety Agency (NPSA) - "a total of 2,159 died after serious lapses in care by hospitals, family doctors' surgeries, ambulance trusts and in community and mental health care last year. A further 4,529 patients suffered severe harm because of avoidable mistakes." This is from a total of 500,000 reported patient safety incidents.

Apparently 165,135 people suffered harm while in NHS care. Of these
20,000 vulnerable patients managed to harm themselves whilst in care, with an unknown number committing suicide.
50,000 incidents involved patients being given the wrong medication
49,000 suffered errors during operations or other treatments
19,749 involved medical device failures
6,000 infection control incidents were reported.

We have to accept there will be a significant degree of under-reporting. The trouble is the NPSA do not seem to have any idea of what causes the errors, or make any evaluation of whether the risk is tolerable or not. It is a tragedy that people are harmed whilst in health care, but it will always happen. To evaluate the risk we need to at least have some understanding of what would happen if treatment had not been provided.

Meeting mixup

Had one of those heart stopping moments yesterday. It is the last week of the school holidays, and I had taken a day out from work to go out with the family. Mobile phone rings. It is one of my clients. He asks "are you nearly here?"

Now I have a meeting scheduled for the next day, which I point out. Reply is "no definitely today. The guy from the Netherlands has arrived to see you."

Anyway, turns out the email I received said the meeting was on Wednesday 31st. Should have said Wednesday 30th. What interests me is why I latched onto the date and the client latched on to the day, so that neither of us realised the error.

Being freelance, I don't tend to work a standard week. Work comes in small bursts, and I had recently been doing some work over the weekend. I don't have any particular reference points related to the day of the week, so probably consider the date more.

In contrast, when you have a 'proper job,' life is much more closely related to the Monday to Friday week. Hence, I can see that the day is of more interest.

Equally, when I got the phone message, I did wonder if I had made a mistake. I remember making a mental note that the meeting was on the last day of August, as a way of remembering. It would have been quite easy for me to have made this note for a meeting on the 30th, as I usually have to give some thought to which months have 30 and which have 31 days.

As it turned out we managed to cover everything important on the phone. I spent the day with the family and avoided a drive across country to go to the meeting.

Monday, August 28, 2006

Drowsy driving

According to this article

Loughborough university have tested how good sugar and caffeine are at keeping us awake. They conclude that a 'sugar rush' is not effective, and that to have "a drink that contains more useful amounts of caffeine and combine this with a short nap" is best. High sugar in caffeinated drinks seems to counteract the effect of the caffeine.

Egyptian train crash

Reported to have killed 'dozens' when one train went into the back of another. Human error is being cited as the cause, suggesting a driver passed a signal. Interesting to note that the head of the state railway authority was fired and his deputy suspended before the inquiry had reached any conclusions. It seems that the rail authority has been seen as being generally lenient regarding safety for some time, and there is motivation to maintain standard.

Sunday, August 13, 2006

Risk management - new guidance from HSE

I noticed this on the HSE home page a few weeks ago. At first it looked good, examples of how to do risk assessments. However, my view is that a fundamental aspect of risk management is that opportunities to remove hazards, followed by reducing hazards are taken before controls are considered. This seems to be completely overlooked in the examples provided.

I have written to HSE about this and received a reply saying they have debated this point internally and concluded that what they provide is a 'good enough' solution. I don't agree, especially with the ever increasing requirements for risk assessment including fire, stress, ATEX.

The new guidance is at