When I studied for my PhD in the 90’s I looked at the published reports of 6 major accidents that had occurred at the time. One thing that still strikes me to this day is that in every case the inquiry had uncovered information about previous near misses that were very similar to the accident, with the implication being that if lessons had been learnt from the near misses the major accident could have been avoided. In particular:
* Piper Alpha (1998 - 167 fatalities) - previous incident reports highlighting potential problems with shift handover, permits-to-work, fire fighting capability and evacuation of platforms;
* Allied Colloids Fire (1992 - major environmental impacts) - Need for segregation of chemicals involved well known for many years. A similar incident had been experienced on the site.
* Hickson & Welch (1992 - 5 fatalities) - Explosive properties of chemicals involved well known for many years. A similar incident had been experienced at another of the company’s sites.
* Clapham Junction (1988 - 35 fatalities) - Similar incidents had highlighted problems with design, testing and training within the company’s signalling department.
* Herald of Free Enterprise (1987 - 193 fatalities) - Tannoy calls to send crew to their stations for departure missed on many occasions. Previous incidents where the company’s ships had left port with their bow doors open.
However, I am not sure that the IOSH/Cardiff paper really says anything very relevant to these types of failures (or Macondo). I believe the underlying causes were largely related to lack of risk management competence with regard to major hazards. I find the paper to be focussed (biased) on employee/management communication.
The IOSH/Cardiff paper seems to be based on the principle that:
* Behavioural safety = Bad
* Outsourcing = Bad
* Workforce engagement = Good
* More regulation = Good
I am sure plenty of people will agree with these sentiments, but I have not seen anything in the paper that confirms that they make any difference in the Container Terminal industry. Also, I note that whilst weakness are identified in the way safety and health and managed, there is nothing to say whether performance is actually better or worse than any other industry.
Unfortunately, the paper does not address (in my opinion) the really important/interesting issues around a truly global industry, with multi-national companies, working within wildly different cultures, with different levels human skill and technology. It is easy to suggest that a ‘zero harm’ strategy has its limitations, but I note that an alternative is not proposed. Lots of global mega-companies in other industries have similar high level strategies, which suggests to me that at the corporate level anything more complex has proven difficult to put into practice.