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Viewpoint - Martin Brown

We must learn safety lessons, as the partial collapse of the GE19 bridge shows that safety cannot be ignored.

I trained as an engineer and have been in safety for nearly 30 years. I have seen work-related death and experienced awards for success – both extremes define why we care so much about our work.

When things are going well safety is important, but it can be characterised as negative bureaucracy, hindering progress. When things go wrong, safety is at the centre of all we do – incidents lead to an incredulous benefit of hindsight and soul searching for those "obvious" errors.

Often it is the consequence of the event that defines the focus. In reality luck plays a part. Move someone a few inches and that falling spanner misses them and the event is sidelined as a joke, a close shave, rather than the death it could have been. Remember the word "hazard" is derived from the Arabic word for dice, "al zahr". We know the near miss is as crucial, but have to work to act accordingly.

Key to management is data. We must collect even what might read badly.

The data we have has to inform action. Many of us will have followed the brilliant GB cycling team in Beijing, and admired the brilliant preparation. It is that attention to detail that has helped define its triumph.

The Apollo space programme was the same. Its engineers' approach to "what if" analysing, to considering in detail, high consequence but low frequency events from the inception, meant they could consistently recover situations, such as Apollo 13.

Last week NCE reported on the incident involving the new GE19, bridge over the main line out of Liverpool Street Station, part of the new East London Line. The company I work for is Transport for London (TFL) – the client.

Before the GE19 incident, this project was seen to be going well. After the incident people felt different, yet the fundamentals had not altered. What had happened is we had missed a unique set of circumstances.

Final positioning of the bridge required a horizontal "plan jack" of about 38mm, with movement aided by polytetrafluoroethylene covered plates. The plates were wrongly inserted, (between the base of the bridge and the top of a set of tapered plates). Temperature contraction initiated a small movement, dislodging some of the packing, allowing the bridge to fall 200mm onto the final bearings.

TFL's investigation raised many questions, and some key lessons have emerged: we must never forget temporary works are as important to get right as the final design; we must constantly question the fundamentals; and we must ensure that people are clear in their roles.

Those of us who sit behind desks, owe it to those on the tools to analyse the potential for error to eliminate and mitigate and explain the controls very clearly so all remain safe. The aim of the good (safe) engineering taught in universities must be made real on site. We don't want to be lucky, we want to be consistently brilliant. There is no substitute for analysis of the fundamentals – each and every time.

 Martin Brown is director health, safety and environment for Transport for London's rail division.

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