Thursday, April 30, 2009

Report shows human error almost led to aircraft crash

Article from 3 Newsin New Zealand, 30 April 2009

Emirates Airbus A340, which had originated in Auckland, was forced to make an emergency landing at Melbourne Airport after its tail struck the runway while taking off. Flight data shows the plane's wheels were still on the ground 115 metres past the end of the runway and two antennas and a strobe light were hit as the plane struggled into the air.

A preliminary report by the Australian Transport Safety Bureau has found that somebody in the cockpit entered a takeoff weight 100 tonnes below actual into the performance calculation computer. This meant the aircraft computer applied less thrust than was needed for the plane to take off.

Human error is the most likely cause of the near-miss.

"It should have been picked up during cockpit management checks between one checking the other - it wasn't," he says. "But I would have thought also in the head of one of guys loading it in, they would have thought, 'ah this plane is 100 tonnes too light to be operating from Melbourne to Dubai'."

It is not the first time incorrect loading figures have caused problems. In 2003 a Singapore Airline Boeing 747 had to make an emergency landing at Auckland Airport after the plane's tail also hit the runway on takeoff. Pilot error was also found to be the cause.

Emirates says it has now installed a second computer in the cockpit to double-check the weight's been properly entered.

Wednesday, April 29, 2009

Deadly business - who pays?

Part 12 of a 'Special investigation' from Hazards magazine April 2009.

It continues on from previous parts looking at workplace accidents and ill health; blaming a "hands off approach to safety regulation" and "an absence of oversight." This part examines figures quoted by the British Chambers of commerce for the cost of health and safety legislation and proposes alternative figures for the cost of injury and ill health the society.

According to the report, when the British Chambers of Commerce (BCC) published its ‘2009 Burdens Barometer’ in March 2009, it put the cumulative cost to business of workplace safety regulations covering working time, chemicals, asbestos, explosives, biocides, work at height, vibration and noise, as well as occupational exposure limits and the corporate manslaughter act at over £21.5bn, 28 per cent of the total burden of regulation.

Hazards feels this figure totally ignores the potential benefits of having fewer dead, sick or injured workers which can result in reduced sick leave, retention of trained and productive staff and, potentially, avoidance of safety fines, compensation payouts and spiralling employers’ liability insurance costs. And it ignores entirely the human cost of poorly regulated workplaces.

Hazards has looked for figures showing the cost of accidents. They include

* A May 2006 government regulatory impact assessment put the total cost of non-asbestos occupational cancer deaths each year at between £3bn and £12.3bn.
* A 2008 Health and Safety Executive (HSE) economics briefing put the total cost of each occupational fatality – and there’s hundreds every year - at £1.5 million
* A 2004 HSE report, using 2001/02 figures, put the cost to society of occupational ill-health and injury at between £20bn and £31.8bn.

The main concern of Hazards seems to be summed up by the following statement regarding the cost of accidents to society where "less than a quarter was borne by employers, although they were by and large responsible for the workplace conditions that led to the injury or ill-health."

I do think it is right that publications like Hazards do challenge organisations like the BCC. But I don't see any cause and effect being demonstrated in the article between the way regulations are developed and enforced vs safety performance. And I think bashing employers is likely to be counterproductive.

Andy Brazier

Monday, April 27, 2009

We need the facts to win the ‘war on error’ in hospitals

Article in The National from the United Arab Emirates by Justin Thomas on 26 April 2009

Thomas is assistant professor in the Department of Natural Science and Public Health at Zayed University. He presented at a conference for health care professionals on the topic of "patient safety."

He says "patient safety is an important and complex issue that touches on the psychology of human error, risk management, medical negligence, freedom of information and corporate manslaughter litigation" and gives two examples from the UK:

In one case an elderly woman had been admitted for a fairly routine overnight stay. She choked on some toast. The ward staff did not know the phone number to contact the hospital's team resuscitation team had recently been changed. Also, resuscitation team did not know the number needed to open the new electronic keypad lock on the ward door. Finally, none of the staff on duty that night had been trained in basic life-support techniques. The result was the woman died.

In another case an elderly man received the wrong medication and died. He had been quite healthy, but had the misfortune to be admitted on New Year’s Eve when staff are typically thin on the ground and often made up of temporary staff supplied by agencies.

At least as a result of incidents like the first the NHS has now standardised the emergency number in all hospitals to 222

Thomas poses the question, which hospital would you rather attend. You may feel a 5 per cent rate of medical errors to be "scary stuff." But if the other does not know its error rate you have much more to fear.

According to Thomas you cannot know something is improving if you don’t have reliable quantitative data relating to past and present conditions? "The first step to improving patient safety and knowing we have improved patient safety is the adoption of a common incident classification and reporting system. The mandatory and centralised reporting of all patient safety incidents not only allows us to quantify progress in our “war on error” – but also helps us to identify themes and patterns in the types of errors that are occurring, thus allowing us to propose solutions that can be adopted across the health service, sharing the learning, and preventing future tragedy."

Andy Brazier

Human error leaves Torrens Transit bus commuters stranded

Article on Adelaide Now by Tom Zed 24 April 2009

Bus commuters were left stranded on bus routes because an employee forgot to assign drivers on the company roster. The error was not picked up until the company received a phone call. It was fixed as soon as they found out but over an hour went by without buses.

Apparently there was a "unique set of circumstances" involving the school holidays and an AFL game between Port Power and St Kilda at AAMI stadium happening that evening.

Andy Brazier

Human error likely cause of botched airlift rescue

Article on by Anshel Pfeffe 24 April 2009

A hiker, Ala Aghbariya, wandered into a minefield in Israel near the frontier with Jordan. He set off a mine, was injured and a military rescue helicopter was sent to lift him out. Unfortunately, as the helicopter was climbing he fell to his death.

An internal air force committee found that there was no technical error or malfunction in the equipment used or with the helicopter's operational systems. Rather, it is believed that the rescue crew's misjudgment during the operation was the cause of the accident.

It is a bit difficult to understand the misjudgment in this case. Does it mean a physical judgment, meaning an attachment was not made properly, or that a decision was made not make the attachment?

Human Error Contributed to Freeway Complex Fire

Article in KTLA news on 25 April 2009

Human error, in addition to adverse weather conditions and poor brush clearing, resulted a Freeway Complex Fire, that burned thousands of homes through six cities and four counties. Costs are estimated at $150 million, although no one was seriously injured.

A report issued by Orange County Fire Authority revealed that actions taken by four Corona firefighters trapped in flames at the beginning of the fire last November may have delayed the response to the firestorm.

Other firefighters ordered to report to Yorba Linda to stand guard defied orders and went to save the Corona crew, which may have allowed the fire to spread faster into Orange County.

Radio confusion delayed a request for air tankers. One fire chief asked for them whilst another did not. This meant they were not ordered for over an hour.

Different fire departments were using different radio frequencies and so could not communicate directly.

Andy Brazier

Human error caused fatal accident: officials

Article in the China Post 26 April 2009

Two tourists from China killed in Taipei, Taiwan when an overloaded crane fell and crushed the tour bus taking them to the world's tallest building.

The small crane was operating a mid-sized boom on the 31st floor of a planned MRT transit hub when the boom broke off and fell to the street below.

The crane was hauling a weight of four tons at the time of the accident, above its 3.2-ton capacity. Also, the operators also failed to take into consideration the wind factor.

Labor officials from the city determined it was a case of human error and denied the city government might have failed to oversee the construction site saying many fines had been issued for various violations and saying they had "done all that needed to be done."

Six crane operators have been released on bail after hours of interrogation. Two representatives from two construction companies involved in the construction project were also questioned, but they were later freed without bail.

Andy Brazier

Tuesday, April 21, 2009

Human error is a business risk you are willing to assume

I use Google Alerts to point me to interesting articles for this blog. I was a bit confused when articles kept popping up with the sentence "Human error is a business risk you are willing to assume" referenced, but where the articles did not seem to be very relevant.

Going to one of the articles I noticed that it was part of the "Legal disclaimer and risk disclosure." Basically it is saying use information taken from the website at your own risk.

Andy Brazier

Doing less with more

Article in Hoist magazine by Jim Galante 3 April 2009. Suggests there are "double dividends of integrating lean thinking and ergonomics."

Managers today face more challenges than ever before. They are being told to cut costs whilst maintaining or even increasing production rates; and maintaining quality. Staffing levels are being reduced, and so there is the need to "do more with less."

There are further issues when you consider "the American workforce is aging and many of the next generation of workers are looking more toward white collar jobs."

Many think good applied ergonomics can help. Whereas in the past it seen as “a nice thing to do” because it made the worker’s job easier and making them happier, the benefits of improved quality and productivity; and reduced possibility of injuries are being recognised. "Ergonomics today has become an essential and fundamental part of a well run business."

According to Galante, ergonomics can play a significant role in achieving the goals of lean thinking. "Improving productivity by reducing or even eliminating waste is a core lean value. Good ergonomics eliminates excessive body motions and limits the number of repetitions in most work tasks. Good ergonomics will reduce mistakes and will improve quality - more lean values."

Galante references the Ergonomic Guidelines for Manual Material Handling, published by the EASE Council. This considers four applications in which lean thinking and ergonomic principles are related and essential to creating effective, sustainable programmes. They are:

1 Removing waste - Removing wasted, unnecessary motion can have a significant positive impact on systems and processes as well as decrease lead times and inventory, increase quality and substantially increase productivity.

2 Flexible processes - Understanding the whole organisational system requires all business processes to be flexible. This will significantly aid a company’s ability to respond to changes which are occurring in the marketplace. This can be flexibility in set-up/change-over, the type of assist device, inventory controls or linkages (transporting or storing materials).

3 The negative impacts of fatigue - Ergonomic assist devices can dramatically reduce or even eliminate the forces required to perform a task as well as reduce the associated reaching, bending or stretching. They will reduce fatigue and stress that would be experienced by the worker. These symptoms are often a precursor to a lost time injury.

4 The needs of the office and the service sector - By focusing on strategic placement of parts, products, tools and equipment and reviewing the layout of the work area, human stress and ergonomic related injuries can be reduced. The white paper discusses these changes and presents practical solutions and improvements.

The bottom line

In today’s demanding work environment companies need to take every advantage and a good ergonomics programme compliments a good lean initiative. The two together with all their tools, techniques, and philosophies will prove to be vital contributors to success both in the short- and long-term.

About the author

James J. Galante is the chairman of the EASE Council. Ergonomic Assist Systems and Equipment (EASE) is the resource for trends, information, practices, equipment, and organisations that focus on ergonomics and improving the working interface between people and the materials they must move and use to reduce injury, increase productivity while providing a significant return on investment. Visit the EASE website for these many resources at

Mobile phone as a source of ignition

I have been aware of several stories over the years about mobile (cell) phones starting fires at petrol stations. However, I have never seen any real evidence of them being true.

The website, which looks at rumours and urbane legends has studied it, and concludes there is no evidence to support any of the stories.

A useful reference for the next time the story is circulated.

Andy Brazier