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.

 

[lineclear]

I suggest that Ladbroke Grove fits the OP's requirements.

Michael Hodder's recruitment process missed his conviction. Thames Trains had a poor driver training programme. The instructor who was expected to teach him route knowledge was under the impression that his job was to teach him 'how to drive a turbo'. The bidirectional lines out of Paddington, and ARS' use of them, confused drivers. The signals on SN109's gantry had an unusual reverse-L configuration, and the left hand line's signal was on its own post. SN109 had several previous SPADs. The SPADRAM group that should have thoroughly investigated the SPADs was bogged down by Railtrack's poor culture.

SN109 was obscured by an overbridge for part of its approach, and its red aspect obscured by an OLE insulator for another. At a certain time in the morning at a certain time of the year, the sun illuminated its lower yellow aspect.

Slough IECC equipment produced the same alarm sound for a SPAD as for other occurrences, including a train approaching the workstation area. The signallers' usual action for a SPAD was to wait for the driver to stop and call. Their CSR (radio) training was poor.

On the day, Mr Hodder was driving on cautionary aspects. SN109 became visible through the overbridge. Hodder looked up and saw its lower yellow aspect illuminated by a bright sun, with its red aspect obscured. From then on he drove as if he had a yellow signal, acknowledging the AWS without looking up at the signal again. He applied power, drove the Turbo beyond the signal overlap and into the path of the HST, by which time he realised that something might be wrong.

The signaller had become aware of the SPAD and waited for Hodder to stop and call. Eventually, they may have tried to send a 'stop' message on the CSR, but it didn't send.

Industry rumour is that Hodder was speaking on his mobile phone at the time, but this cannot be substantiated.

 

[Harpo]

SN109 became visible …..Hodder looked up and saw its lower yellow aspect illuminated by a bright sun,

I believe that remains ‘probable’ rather than fact?

 

[Falcon1200]

Should management have agreed to make the informal start/finish times official to avoid the distraction of copying the records?

Good question. Rail shift workers have, certainly in my experience, had no problem adjusting changeover times to suit travel to work, and I have always wondered why the Caledonian Railway was apparently so strict.

(For example, when I started in Glasgow Control in 1984 the Night shift/Early shift changeover was at 0745, not 0600 as per the timesheets!)

 

[35B]

Good question. Rail shift workers have, certainly in my experience, had no problem adjusting changeover times to suit travel to work, and I have always wondered why the Caledonian Railway was apparently so strict.

(For example, when I started in Glasgow Control in 1984 the Night shift/Early shift changeover was at 0745, not 0600 as per the timesheets!)

From memory, at least part of that was that the workers in question lived within walking distance* and were expected to do so, not use the train.

* - an interpretation of "walking distance" that would not meet widespread favour now!

 

[Yew]

On the solution side, I'm a fan of the "Deliberate Action" proposed by David Marquet:


Here is a good quote of it's effectiveness:

“Your guys made the same mistakes – no, your guys tried to make the same number of mistakes – as everyone else. But the mistakes never happened because of deliberate action. Either they were corrected by the operator himself or by a teammate.”‘