You could easy reference many aspects of the Longford case to others of
similar result. The more I read the Beaconsfield reports and relevant info, I
am seeing failures and ignoring of information everywhere. This is why I constantly say safety is not going to be controlled by trivial safety programs or phycology. These big incidents (as with many small ones) are caused by corporate greed which forces workers to cut corners and under report real factors.
I think the whole Longford (and A Hopkins book is quite good) incident was
related to complacency bought on by the culture set by top levels and
pressure/budget demands to not interrupt flow to customers (profit driven). Not
doing a HAZOP is nothing short of OHS incompetence in an operation that should
have had one, to ignoring alarms, makes way for my point relative to Isaac
Newton comments below (which I cannot even get into as you will have a 30 page
email).
While the Longford report does mention 2 main causes (but defining operator
error is based on the fact operators were not trained properly, so I feel is
not operator error), I can say there was a multitude of causalities that
contributed (each leaning on each other). These including eleven breaches of
the Occupational Health and Safety Act along with all the social influences
that played a part in ignorance in light of these breaches.
As with most cases related to the proper function of proactive OHS, (that
being it costs a lot of money to be proactively mindful) such OHS topics are
not fully implemented due to this cost. I.e. training workers past what their
obligated basic task is something many companies do not spend money on. You are
shown what to do but not shown how things work to know why things may and can
go wrong.
I.e. Training on such as what would happen if you pump hot liquid through really
cold pipes, what does ice mean on pipes that are normally red hot etc (Longford
accident). Just these two factors may have stopped the incident is people were
trained better...what would this training cost have been compared to the final
outcome? Training is key, funding training is key! What to military pilots do
in-between wars...train, train some more training and train again...(but most
business do not have a set budget like ADF)
Where the ball may fall for the next big one. (I have been working on a
paper what I was calling Foreseeable Trajectories.
Isaac Newton explained that the future of any part of the universe can be
predicted with complete certainty, if its state at any time was known in all
facts. With enough information of the conditions of the objects and of the laws
that govern their motion, all subsequent events can be foreseen. I don’t think
we can be that accurate in safety but I think we can get pretty close.
Now if we look at this in an OHS context, you should be able to see the
commonalty I am referencing. State being the organisation preoccupation with
failure, objects being workers, parts being tasks, and laws being management
systems etc..sorry for the deep thinking, but I do believe you can predict with
a certain amount of accuracy the type of events that may occur in the future
within an organisation using very stringent data collecting (as long as that
data is correct and has full information) and known’s (what we not to be true
for hindsight). Once you know what the certain risks could be, then you ensure
these are mitigated.
Maybe if safety was done by external unbiased consultants and that all
safety people were not owned by the organisation, things may improve as safety
people would not have to lie to keep their jobs. I can tell you right know,
safety records and training needs would not be given a quick glace over as the
business would be greatly constrained to 'doing' what is required to be done to
ensure OHS is best practice as said by these external safety people.
