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Fri 20 Jan 2012
TRAGEDY PLAYED OUT AS FARCE
The images of the Costa Concordia Cruise Liner on its side have been broadcast around the world. The funnel of the ship almost touches the land and the rocks which ripped a hole in the hull of the huge ship stand as mute evidence of disastrous failings of navigation. As of today 11 people are known to have lost their lives, but 21 people are still missing. It is clear that the actions of the Captain will receive huge media attention as investigations begin, and this is where tragedy becomes farce. The reason he hit the rocks was that he took the vessel close to the island to salute a retired colleague – Captain Palombo. As far as I know BA does not approve pilots of its aircraft to fly by their friends’ houses to give them a wave. Nor do airline pilots ignore navigation equipment, but Captain Schettino was navigating by sight, due to ‘his knowledge of the area’. He said afterwards; ‘I don’t know why it happened.’ This must rate as one of the most inadequate reflections on a fatal incident. Now...

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The Chiefton after recovery
Thu 25 Aug 2011
LOSS OF THE TUG CHIEFTON
Living close to the Thames as it sweeps around the Isle of Dogs, I am so used to seeing tugs plying up and down river, that I had never properly considered the dangers inherent in what they do. All that changed on the 12th of August when, less than a hundred yards from where I sat, on a calm sunlit morning, the tug Chiefton capsized in thirty seconds, and a man was lost. Clearly something had gone catastrophically wrong, and we will need to wait until the results of the investigation before commenting specifically on the circumstances of this case, but it prompted me to see if it was a unique occurrence. Sadly I discovered that there have been numerous recently documented cases. · July 2002 the North Arm Venture sank in British Columbia whilst towing, and the frightening speed of its capsize can be seen on Youtube. All crew were saved. · December 2007 the Flying Phantom sank in the Clyde, with the loss of three men. ·...

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Two anchors
Mon 16 May 2011
MULTIPLE REDUNDANCY?
An important aspect of safe, uninterrupted operation, is multiple redundancy. Hospitals have two or three backup generators in case the mains supply fails, modern Airbus aircraft have three separate ‘fly by wire’ systems, any one of which can control the aircraft, and critical computer systems may have several servers on different continents to protect against breakdown. Unfortunately we have seen several instances, some very recently, in which multiple redundancy was bypassed, through error or natural disaster, causing the entire system to fail. In his excellent book ‘The Blame Machine (Why human error causes accidents)’, RB Whittingham explains how a single maintenance error caused all four engines of a BAe 146 of the Royal Flight to lose their oil at the worst time – during flight. By luck and pilot skill the aircraft made an emergency landing on the one engine which, despite losing oil at a terrifying rate, was still working. A few more minutes and the pilots would have been flying a glider. One of the reasons the Royal Flight uses BAe 146 aircraft is the reliability of the four engines. Any one of those engines will, as in this case, allow...

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The Swiss Cheese model from the Bly Report
Mon 4 Oct 2010
DEEPWATER HORIZON AND SAFETY LEADERSHIP
If there is a single legacy from the deaths of the 11 men who perished on the Deepwater Horizon rig, on the 20th April, I hope it is that business leaders will never again be content to make the sort of claim that BP CEO Tony Hayward made 20 times during his congressional testimony, ‘I wasn't familiar with any of the decisions or any of the documents surrounding this well prior or during the drilling of the well.’ In this article I am going to focus on two things. Firstly the Bly report published by BP on September 8th. Secondly the leadership response at the time. So let’s take a look at the BP investigation into the causes of the disaster, or ‘accident’ as the report repeatedly calls it. What did Tony Hayward do to protect his people, his assets and his business? You will recognise the image attached to this blog as the Swiss Cheese model, and this one is taken from page 32 of the Bly report. Here we have 8 lines of defence. The report makes it clear that BP had subcontracted...

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Sun 5 Sep 2010
SITUATIONAL AWARENESS
I was saddened this weekend to read the news that two light aircraft had collided at an air race in the Isle of Wight[1]. Miraculously one pilot managed to land safely but tragically the other aircraft crashed, killing the two people on board. Thankfully a mid air collision is mercifully rare, because two aircraft should never be in the same airspace at the same time, but when it does occur it is often because of the loss of something which is well known in aviation, but less familiar elsewhere. It is known as situational awareness (SA)[2]. Imagine you are driving through an unfamiliar town and you have no sat-nav. You do have a UK roadmap which is open on the seat next to you. You have been told to follow the signs to the city centre. Suddenly you are diverted at roadworks. At the next t-junction there are no diversion signs, so you guess left. The weather takes a turn for the worse and a thick fog descends. You hear a pinging noise and look down to see that your fuel gauge is on empty. The fog is so bad that you can’t see road...

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