Question - what is the "swiss cheesiest" accident report?

[Strathclyder]

Barring Chernobyl, Piper Alpha was the one that sprang to mind most readily when I saw the thread (and before I saw the preference for non-fatal accidents in the opening post).

The windscreen bolts one with the flight from Birmingham (can't remember the aircraft type) is a good example as well, I've been on courses that used it

I honestly can't remember which air accident it was

British Airways Flight 5390 which occured on 10th June 1990, the aircraft model involved was a BAC One-Eleven and it was flying from Birmingham to Málaga. One of the most remarkable events in aviation history imho.

 

[edwin_m]

Abermule is a good example of a chain of human errors, any one of which would have prevented the accident if it hadn't happened. The OP has clarified their field is healthcare, where there are relatively few engineered safegards so one with a strong human factors content is probably better. It also saves including detailed explanation of what the engineering should be doing and why in a particular case it didn't. However Abermule had multiple fatalities.

 

[Harpo]

To my mind, ‘swiss cheesiest’ is an incident with a lot of contributory factors where taking away any one of the factors might have avoided the incident.

The Dagenham East collision on 30 Jan 1958 might have been avoided by removal of any one of the factors of-

-Fog
-Driver shortage
-Poor route knowledge of junior staff
-Driver on the right, signals on the left due to steam loco running bunker first
-High/difficult to see stop (red) signal was missed
-Lack of warning system on stop (red) signals*
-Subsequent clear stop signal (green) in rear of the preceeding train**

I’ve tried to make that non-technical as it’s always stuck out to me as a lot of holes lining up.


* Early form of AWS only on distant signals so stop signal passed without warning and next distant gave ‘clear’ as it was associated with the -
** Closed intermediate box

 

[Tracked]

Quintinshill?

Various human error, starting with the informal late start, but also including the guards and drivers of the trains stopped there not following regulations. Plus, both expresses being late

 

[Brightonboy]

Quintinshill?

Various human error, starting with the informal late start, but also including the guards and drivers of the trains stopped there not following regulations. Plus, both expresses being late

Quintinshill had, of course, many fatalities but does offer a useful example of paperwork not being done correctly.

 

[edwin_m]

Quintinshill had, of course, many fatalities but does offer a useful example of paperwork not being done correctly.

In fact doing the paperwork contributed to the accident by distracting the signallers.

 

[35B]

In fact doing the paperwork contributed to the accident by distracting the signallers.

Only because they had to falsify it to conceal what was actually happening at shift change

 

[edwin_m]

Only because they had to falsify it to conceal what was actually happening at shift change

But it's an interesting discussion point. Should management have agreed to make the informal start/finish times official to avoid the distraction of copying the records?

 

[35B]

But it's an interesting discussion point. Should management have agreed to make the informal start/finish times official to avoid the distraction of copying the records?

I'm not sure - the words "had to" are doing a lot of heavy lifting, when what was actually involved was criminal.