HAZOZ –
home
1. Safety & Knowledge Transfer in the Process
Industries
2. Radio National - Oil Pressure
3. Radio National - Toxic Timebombs
4. Four Corners - Too Hot to Handle
5. 7:30 Report - Eburna/Keera Near Miss
6. Making a Success out of Failure
7.The Fallible Engineer
8.The Impact of the Esso Verdicts on Engineering Practice
9. Rail Safety Model
10. Longford and Responding to Plant Upsets
11. Human Error and Blame – the Holmesglen Train
Collision
1. Safety & Knowledge
Transfer in the Process Industries
Are we doing enough to share the learnings of major
incidents?
2. Oil Pressure - Background
Briefing, Radio National, ABC
Profits versus Safety in the Australian Major Hazards Industries.
Programme broadcast on 28/10/01. Examines the reasons behind the recent spate of fires, explosions, spillages and near-misses in the Australian petrochemical industries – are they indicative of a systemic management issue stemming from low profits?
3. Toxic Timebombs -
Background Briefing, Radio National, ABC
Australia’s worst toxic fire - Perth Feb 2001
Programme broadcast on 9/12/01. Examines the parlous state of management of Australia’s toxic chemical waste processing and storage industries.
4. Too Hot to Handle –Four
Corners, ABC TV
Four Corners report into the Perth toxic fire of Feb 2001 (see Toxic Timebombs above). Spectacular footage of the fire.and aftermath. Discusses the outcome of the official inquiry.
5.
Eburna/Keera Near Miss, Yarraville Oil Terminal - 7:30 Report ABC
In Sept, 1999, the tug Keera pulled a fairlead from the deck of a laden tanker, the Eburna, tearing the deck plating and exposing the cargo. The Eburna was laden with petrol and diesel, and was on the Yarra river alongside theYarraville, Melbourne oil terminal. The incident was investigated by the Marine Board of Victoria. The file is a transcript of a 7.30 Report (ABC TV) on 22/02/00.
6. Making a Success Out of Failure
(First published in Engineering Management Journal (UK) Apr 2001.)
Antony Anderson muses on why we don’t learn from our past industrial mistakes. From train crashes to the Concorde tragedy, he says the precedents are always there. Other writers have done the same, but Anderson presents a creative and startling new idea – “It is high time that instead of concealing our failures, disasters and cock-ups we should archive, exhibit and celebrate them.”
He wants nothing less than an exhibition hall devoted to human-induced catastrophes, just as we have for trade shows or travelling art displays. The scope would encompass economic as well as industrial failures. He also wants a library holding the investigation reports of catastrophic failures – a research centre, no less.
His nomination of venue is the Millenium Dome in London – itself something of a disaster (the Dome, not London).
Making a Success out of Failure
7. The Fallible Engineer
(First published in New Scientist, 2 Nov 1991)
Sharon Beder discusses the question of personal criminal liability of engineers involved in failures that threaten the safety of the public. Her starting point is a tragic event of April 1988 that took two lives. A railway embankment at Coledale, NSW, collapsed and crushed a house, killing two persons inside. A geotechnical engineer was prosecuted for manslaughter. Although not convicted, this action caused considerable disturbance among the engineering profession.
Beder discusses the views of prominent members of the Institute of Engineers, Australia, and develops an interesting and useful exploration of the community’s expectations of the profession.
The issue of criminal liabilty of engineers for failures is still a live one today, ten years after Beder’s paper.
8.The
Impact of the Esso verdicts on engineering practice
9.
Rail Safety Model
MODELING AND
ANALYSING OF RAILWAY SECTION
FUNCTIONING WITH RESPECT TO TRAFFIC
RELIABILITY AND SAFETY
by
Nikolay
Georgiev, Department of Technology, organization and management of the
transport, Higher School for Transport Engineering "Todor
Kableshkov", Sofia, Bulgaria, phone: +359 2 717104, e-mail:
[email protected]
10.
Longford and Responding to Plant Upsets (abnormal situations)
The inquiry into the 1998 catastrophic failure at the Longford gas
plant revealed the startling fact that plant personnel knew their duties and
how to perform them during normal production periods and also during a
frightening emergency, but not during the intervening period of plant upsets.
This presents a challenge to the Safety and Engineering professions – to devise
support systems that automatically maximise the likelihood of personnel making
the correct decisions during abnormal situations – even when they do not
understand what is going wrong.
Three issues need to be addressed:-
1. how to recognise that a situation is seriously abnormal, ie, critical
2. proper problem escalation so that the appropriate resources are brought to bear
3. maintaining the appropriate command structure throughout the abnormal situation
The full article is available at the Workplace OHS site:-
From the home page, use the search facility on: “Longford and responding to plant upsets”. Cut the phrase and paste it into the search box. Workplace OHS is mostly a subscribers-only site, but they offer a free trial. Recommended.
11. Human Error and Blame – the Holmesglen Train Collision
Human error will always be with us, and systems of work need to be
designed to accommodate human error.
The above view is commonly expressed among the safety profession. We might even call it a dogma of modern Safety Science. It is certainly difficult to find any argument against the view.
However, the outcome of a recent court case in Melbourne seems to challenge the relevance of this view to employees at the sharp end of industry.
Human Error and Blame – the Holmesglen Train Collision (.html – with pics)
Human Error and Blame – the Holmesglen Train Collision (.doc)