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

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.

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

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.

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

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.

The Boeing 737 MAX air crashes?

Bhopal

Bosley Mill

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. 

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.

Originally Posted by: flysafe

Originally Posted by: 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. 

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/

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.

Look for the Charlie video its brill