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Mark's blog: lessons from history

NCE's Historic Disasters Challenge is a timely reminder that we live on our past and learn from our mistakes.

Mark Whitby is chairman of Ramboll Whitbybird

Remembering these is essential. Unfortunately, the understanding of the underlying causes of many disasters is frustrated by the legal process, which can mean that the evidence is buried for years. But there have been some refreshing insights given recently. Good examples are the US reports on the Columbia Shuttle disaster (http://caib.nasa.gov) and Hurricane Katrina (https://ipet.wes.army.mil/).

These reports, whilst looking at the physical causes of the disasters, also focus on the systemic management culture.

In the case of the Shuttle report, which was published six months after the disaster, the view of the Commission was that the management were as responsible for the disaster as was the failure of the foam. For engineers, they are riveting reads.

Closer to home, the Cullen Report on the Paddington Train Crash, which took a number of years to come out after the event, is equally interesting, particularly when one discovers that the Transport Police failed to secure vital black-box evidence in the Slough signal box. In particular, it highlighted the need for scenario training that could, in the case of the signal operators, have prevented the disaster. The train travelled for approximately 500m having missed the signal, before the signalmen allegedly alerted the driver to the potential disaster. They also had the option of switching the points. One wonders what the conversation was they were having at the time.

What each of the reports demonstrates is that there is seldom a single cause leading to an accident, and that often there is, behind the scenes, a systemic weakness in the chain of command. Two recent legal cases have interesting repercussions. First, the case against Scotland Yard for the shooting of Jean Charles de Menezes at Stockwell Tube Station, which was brought by the Health and Safety Executive. This prosecution is highly relevant and suggests that, whilst individual officers were not responsible, the corporate body failed in its duty of care.

The other case is closer to home, as far as engineers are concerned, and involves the current inquest into the death of Iveta Iravanian, who was crossing four lanes of one-way traffic in Victoria when, apparently, the green man switched to red, leaving her only four seconds to complete the journey before the traffic lights themselves went green. She was struck by a National Express Coach in the last lane and died shortly afterwards. That the pedestrian lights only had four seconds before the traffic lights went to green is contrary to the 14-second recommendation but is not against any law. However, it is possible evidence of a lack of care awarded to pedestrians by the traffic engineers concerned. The time interval has subsequently been extended.

Regardless of the particular outcome of the inquest I would argue, just as in the case of the prosecution against Scotland Yard, that there is a case to be brought by the HSE against TfL. No doubt, no individual engineer wittingly made the situation unsafe, but regardless, it would appear that TfL failed to maintain a holistic view of the overall safety required of the traffic system.

We might wonder what purpose such prosecutions may have. In the case of Scotland Yard's conviction there is much for all the police to learn from. The prosecution of TfL would reveal similar lessons for all engineers. However whilst I suspect that in the case of the police on or two lives might be saved in a year, lessons learned for engineers could save 20.

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