On 30 June 2005 the 17.40 train from Stratford on Avon narrowly escaped a disaster through the driver’s attention to the track ahead: the tunnel had collapsed. Had the train arrived a few minutes earlier, disaster would have resulted.
We know this event as the Gerrards Cross tunnel collapse and, some years on, the industry still does not know the cause, other than through informal grapevines. Similar situations exist for other equally important collapses and events in the UK, for example the collapse of the five storey steel frame in Ilford in 2012, or the substantial reinforcement cage in 2011 which ‘lozenged’ during fixing, killing four workers.
Further afield, in Canada, a comprehensive report on the collapse of the de la Concorde highway bridge was available some 12 months after the event. Similar exemplary examples are found from Holland, United States and elsewhere.
How is it that such crucial data, relating to the root, or contributory causes of serious incidents, are not obtainable in the UK? We depend upon the forensic analysis of these events to learn, change and hence improve. It is not just the exceptional from which we need to benefit (the Buncefield fire resulted in new understandings regarding gas cloud behaviours); the commonplace construction failure, or one resulting from a series of minor shortcomings, still plays a vital part in the learning jigsaw. These are the only positives one can take from what is otherwise a negative occurrence; sometimes fatally so and always so in financial terms.
The perceived barriers to communication are well known. Parties involved in civil actions are often barred from speaking out through confidentiality clauses. Release of information relating to incidents which may result in a criminal case are considered sub judice. It may be years before the latter is concluded.
However there are ways of dealing with these obstacles. Other countries have investigative processes, with legal backing, which allow them to circumvent these constraints. It may surprise some to know that the UK also has a statutory means of investigating and making special reports on incidents, an option falling to Health & Safety Executive (HSE) under the auspices of the Health and Safety at Work Act; but it is rarely used; a recent specific proposal to investigate how the situation could be generally improved was vetoed by the HSE itself.
In a safety-critical but self-protective industry, there needs to be a better way.
- John Carpenter is a risk management consultant