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MrBrightside  
#1 Posted : 17 November 2023 14:29:24(UTC)
Rank: Forum user
MrBrightside

Hi All,

I am putting togeather a presentation around near miss reporting and want to relate it back to a famous incident / accident (one people would of heard of) that could have been prevented if the company had responseded to previous reports / near misses or which could have been prevented if near miss reports had been made.

I was thinking the Titanic and that reports of Icebergs were ignored, just thinking of something more recent!

Thank you

Kennedy44397  
#2 Posted : 17 November 2023 14:48:02(UTC)
Rank: New forum user
Kennedy44397

Would this be a relevant example?

'The gas supply company Transco was fined a record £15 million last week after being convicted of serious safety breaches which led to the deaths of a family of four in an explosion. As well as imposing the heavy financial penalty - the previous biggest fine in UK health and safety law had been £2 million'. TUC website  2 September 2005.

https://www.scotsman.com...killer-gas-blast-2479890

Edited by user 17 November 2023 15:21:16(UTC)  | Reason: Providing short summary without opening the link.

A Kurdziel  
#3 Posted : 17 November 2023 15:08:16(UTC)
Rank: Super forum user
A Kurdziel

The only famous one I can think of is the Clapham Rail disaster and only because we did it as one of our case studies for my diploma many, many years ago.  In a nutshell there is this the junction in south London where most of the tracks from all of the south London  trains join up. It was a disaster waiting to happen: there were also sorts of problems with the signalling and there were so many  near misses that they were being treated as routine and of course no action was taken to deal with this as it had been going on for years and nothing bad had happened… One day a driver spotted a signal  change directly from green ("proceed") to red ("danger"). He stopped his train assuming that the signal behind him was now red. No radio in his cab so he had to get out of his cab to call the signal box. While he was making his call another train ploughed into the back his train. His train was now off its track and overhanging another set of tracks and then a third train crashed into the first train which is what killed most of the 35 people.

Kate  
#4 Posted : 17 November 2023 15:34:48(UTC)
Rank: Super forum user
Kate

In a similar vein, you could have the Ladbroke Grove rail crash or the Croydon tram crash. 

Lots of rail investigations come up with a history of SPADs (signals passed at danger).

The Columbia space shuttle disaster is another one that might suit your purpose (probably more apt than the even more famous Challenger one).

firesafety101  
#5 Posted : 17 November 2023 17:28:00(UTC)
Rank: Super forum user
firesafety101

"Ministers ignore warnings before Grenfell." put that into your search box if you want someting every one has heard of.  

MikeKelly  
#6 Posted : 20 November 2023 14:16:17(UTC)
Rank: Super forum user
MikeKelly

Don't forget Piper Alpha.

Mike

peter gotch  
#7 Posted : 20 November 2023 15:25:18(UTC)
Rank: Super forum user
peter gotch

Hi Mr Brightside

Most of the most publicised cases of the type you describe have been in highly regulated sectors, usually in transportation, process safety and particularly more recently healthcare, though from time to time HSE prosecution reports point to previous warnings and near misses being ignored or downplayed.

One of the most extensive narratives is around around BP.

So, you have the HSE report on three incidents at Grangemouth in 2000.

Then if you do some googling you can find the "Telos" report which was commissioned by BP Texas City BEFORE a big band in March 2005.

Then there are the CSB and BP's own report for Texas City.

Then there are reports about BP Deepwater Horizon 2010.

Andrew_C  
#8 Posted : 21 November 2023 07:29:24(UTC)
Rank: New forum user
Andrew_C

Nimrod is the case that we often refer to as there are multiple documented near misses (and actual events).

MrBrightside  
#9 Posted : 21 November 2023 09:42:37(UTC)
Rank: Forum user
MrBrightside

Hi All,

Thank you for the responses so far, I had some of those on my radar and some I had forgot. Its amazing how long ago some of those were and realising that a fair few of the people who will be watching the presentation won't have been born when they happend.

#old

thanks 1 user thanked MrBrightside for this useful post.
peter gotch on 21/11/2023(UTC)
Stiltman  
#10 Posted : 21 November 2023 17:29:40(UTC)
Rank: New forum user
Stiltman

I'd put forward the Buncefield oil depot explosion / fire - look up the official report and be amazed at the circumstances...it could have been so much worse!

A family friend used to work next door at Lucas Aerospace and reckoned they would have had >1000 people inside the blast area had it happened during working hours. He visited the week after and saw loft hatches (interior) blown through roof tiles (exterior) etc. but there were no fatalities, thankfully.

The slack procedures and control systems that were in place beggar belief. And, of course, people had been trying to draw attention to it. On the night it happened the alarm was raised by tanker drivers witnessing a fog of petroleum gases drifting across the site from the overspill. Then it went 'wump'. 

Edited by user 21 November 2023 17:30:20(UTC)  | Reason: speeling

HSSnail  
#11 Posted : 22 November 2023 08:23:26(UTC)
Rank: Super forum user
HSSnail

Sorry late suggestion. What audience are you presenting to? I know its tempting to go with the big publicity events (I use them in some presentations, especially to mixed groups) but if you can find one that fits your sector I think it has more impact. Can you find any examples in your own company which may actually have more meaning? They may not have had the same publicity or tragic outcomes, but sometimes the loss in down time etc has more meaning to a board.

In terms of impact I often use Aberfran as an example – everyone knew slag heaps slipped when they got wet – but as no specific regulation still built one next to a school – and obviously it resulted in HASAW etc Act 1974.

Holliday42333  
#12 Posted : 22 November 2023 08:33:53(UTC)
Rank: Super forum user
Holliday42333

I agree with HSSnail, in my experience the big incidents resonate with the front part of peoples brain in the moment but then quickly forgotted and the back part of their brain (the bit you want to influence) either writes them off as too big to have to manage or as some kind of sci-fi story that isnt relevant to the individual.

Incidents closer to the work environment tend to interest the back part of the brain far more.

(Yes I know that my description of front and back part of the brain isnt physiologically correct but I find most people understant the concept)

thanks 2 users thanked Holliday42333 for this useful post.
Yossarian on 22/11/2023(UTC), peter gotch on 23/11/2023(UTC)
Connor35037  
#13 Posted : 22 November 2023 16:55:18(UTC)
Rank: Forum user
Connor35037

The Boeing 737 MAX air crashes?

MikeKelly  
#14 Posted : 23 November 2023 14:27:43(UTC)
Rank: Super forum user
MikeKelly

And of course, Seveso--the massive release of dioxins-a case study of what not to do. Although the Production director was shot! 

This gave rise to the directive which bears it's name [and COMAH in the UK]

Regards

Mike

PS I'm not suggesting shooting as a penalty....although....... 

Roundtuit  
#15 Posted : 23 November 2023 14:49:03(UTC)
Rank: Super forum user
Roundtuit

Bhopal

Bosley Mill

Roundtuit  
#16 Posted : 23 November 2023 14:49:03(UTC)
Rank: Super forum user
Roundtuit

Bhopal

Bosley Mill

melrogers  
#17 Posted : 23 November 2023 17:54:29(UTC)
Rank: Forum user
melrogers

There is a case in that has been prosecuted this week following a fatality caused by FLT and not enforcing seat belts. Manufacturing company fined £500k. Good simple case, if near misses had been reported seat belt enforcement could have been improved. 

Kate  
#18 Posted : 23 November 2023 18:54:24(UTC)
Rank: Super forum user
Kate

Except that not wearing a seat belt isn't a near miss.

johnc  
#19 Posted : 23 November 2023 19:05:16(UTC)
Rank: Super forum user
johnc

Originally Posted by: HSSnail Go to Quoted Post
Sorry late suggestion. What audience are you presenting to? I know its tempting to go with the big publicity events (I use them in some presentations, especially to mixed groups) but if you can find one that fits your sector I think it has more impact. Can you find any examples in your own company which may actually have more meaning? They may not have had the same publicity or tragic outcomes, but sometimes the loss in down time etc has more meaning to a board.In terms of impact I often use Aberfran as an example – everyone knew slag heaps slipped when they got wet – but as no specific regulation still built one next to a school – and obviously it resulted in HASAW etc Act 1974.
Agree with this but I find it better to use examples of incidents in the people's workplaces that show by reporting and acting on the relatively minor incidents and changing a process or equipment a serious incident was prevented. An example from my pub company days was new glasswashers were causing.ilcuts to back of fingers. On investigation we quickly realised that the wrist could be cut if the hand was turned over to push baskets (mesh trays) with the potential for an artery to be cut.
thanks 1 user thanked johnc for this useful post.
aud on 14/12/2023(UTC)
A Kurdziel  
#20 Posted : 24 November 2023 09:01:20(UTC)
Rank: Super forum user
A Kurdziel

The problem with “big” accidents like the ones described is that people often do not identify their workplace as somewhere that accidents can happen. I have investigated a number of cases where someone  has suffered an injury(usually minor) where when I follow up, I get,”  That’s always happening! Never reported it because nobody got hurt, did they!”    

thanks 1 user thanked A Kurdziel for this useful post.
chris42 on 24/11/2023(UTC)
MrBrightside  
#21 Posted : 24 November 2023 10:39:21(UTC)
Rank: Forum user
MrBrightside

Thank you all for the sugestions.

The reason to include something big or well known was to simply re-enforce the importance that Near Miss reporting can have if acted or not acted upon. The session will include local and industry examples, its just something to get people thinking.

I want to use less written words on the presentation and more Videos, pictures, testimonials etc I apprecaite that most people will think "well this won't happen to me/us" the moment they leave the room and forget about it, but I want to hopefully get some talking points.

I normally use myself as an example of why people do stupid things when doing beavioual safety (when I was younger and working in Construction / Warehousing but this was the 90's). 

We have managed to get a Near Miss system in place, however not quite at the point where it becomes second nature to think to report something (that comes with time). This is part of a continious re-enforcement to give people a little nudge.

thanks 2 users thanked MrBrightside for this useful post.
A Kurdziel on 24/11/2023(UTC), HSSnail on 29/11/2023(UTC)
flysafe  
#22 Posted : 24 November 2023 12:49:35(UTC)
Rank: Forum user
flysafe

Originally Posted by: melrogers Go to Quoted Post

There is a case in that has been prosecuted this week following a fatality caused by FLT and not enforcing seat belts. Manufacturing company fined £500k. Good simple case, if near misses had been reported seat belt enforcement could have been improved. 

I would be interested in knowing more about this one but i cant see it in the news

melrogers  
#23 Posted : 28 November 2023 15:57:37(UTC)
Rank: Forum user
melrogers

Originally Posted by: flysafe Go to Quoted Post
Originally Posted by: melrogers Go to Quoted Post

There is a case in that has been prosecuted this week following a fatality caused by FLT and not enforcing seat belts. Manufacturing company fined £500k. Good simple case, if near misses had been reported seat belt enforcement could have been improved. 

I would be interested in knowing more about this one but i cant see it in the news

This is the story: https://press.hse.gov.uk/2023/11/08/manufacturing-company-fined-half-a-million-pounds-after-forklift-truck-death/

thanks 1 user thanked melrogers for this useful post.
flysafe on 29/11/2023(UTC)
BTaylor6  
#24 Posted : 29 November 2023 09:56:32(UTC)
Rank: New forum user
BTaylor6

Originally Posted by: MrBrightside Go to Quoted Post

Hi All,

I am putting togeather a presentation around near miss reporting and want to relate it back to a famous incident / accident (one people would of heard of) that could have been prevented if the company had responseded to previous reports / near misses or which could have been prevented if near miss reports had been made.

I was thinking the Titanic and that reports of Icebergs were ignored, just thinking of something more recent!

Thank you

Torres  
#25 Posted : 07 December 2023 13:51:49(UTC)
Rank: Forum user
Torres

Hey There, Not sure what kind of business you are at.. the below might be of interest, there are also videos out about the incident, another video from that group is called "it wont happen to me" below info taken from wikidpedia! I showed that video here and it really caught peoples attention!!

In November 1990, Woodward – at that time employed by Coca-Cola Schweppes – was involved in a factory incident during which he inadvertently handled chemicals in a dangerous manner, as a result of his and other's failure to comply with full safety procedures, combined with poor training by their employer.The resulting explosion cost him his sight.

A subsequent investigation revealed that there had been at least two previous near misses that were not investigated properly and had been put down to operator clumsiness. A memo suggesting that the process be changed for safety reasons was still sitting on the relevant manager's desk waiting for action when this accident occurred. The reaction was traced to stabilisers in the two chemicals, that had acted as catalysts in the resulting exothermic reaction.

The company was fined, as well as taking a loss estimated at £2.6 million. The company changed their approach to safety, and following the incident, Ken became an advocate of safety standards and practices. In 2006, Kenneth Woodward was awarded the O.B.E in the Queen's Birthday Honours for services to Health and Safety.

DH1962  
#26 Posted : 11 December 2023 10:17:03(UTC)
Rank: Forum user
DH1962

It helps if what you use is close to the industry/service your audience works in. I used  the Barrow in Furness prosecution for legionella quite a lot when presenting to people in local government or with building management roles, and also Buncefield for something with dramatic images.

 ​​​​​​​HSE - Legionnaires' disease - Barrow incident

 If you mention the Titanic, even in passing, here’s a good quote:

When anyone asks me how I can best describe my experience in nearly forty years at sea, I merely say, uneventful. I have never been in any accident... or any sort worth speaking about. I never saw a wreck and never have been wrecked nor was I ever in any predicament that threatened to end in disaster of any sort.

– E. J. Smith, 1907, Captain, RMS Titanic

 Although that’s maybe more apposite to planning for emergencies.

thanks 1 user thanked DH1962 for this useful post.
aud on 14/12/2023(UTC)
Blackburn31728  
#27 Posted : 13 December 2023 09:53:50(UTC)
Rank: Forum user
Blackburn31728

Look for the Charlie video its brill

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