On 23 March 2005, a massive explosion and fires killed 15 people and injured another 180 at the BP Texas City Refinery, Texas. This disaster led to many investigation reports. It has been said that BP failed to learn from numerous warning signs that could have prevented the disaster. Many years later, I question how much wider industry has learnt - and provide a reflection toolkit based on 12 quotes from the investigations.
There are nine key principles that organisations can apply to capture the human contribution to adverse events. These principles will help you to apply human factors in the investigation process. They also demonstrate how organisations learn (and fail to learn) from adverse events.
Following a medication error that led to the death of a patient, the nurse who administered the medication was sacked. Following an investigation by the Department of Health, no action was taken against the nurse or the hospital. However, following an anonymous complaint, another investigation found deficiencies in hospital systems and also led to the nurse being charged with criminal homicide. No disciplinary action was taken against the hospital, but the nurse was found guilty of criminally negligent homicide. This article examines the series of events and comments on the impact of this case on the health profession and patient safety.
A focus on individual behaviours is not the most effective approach to address workplace health and safety, unless all other necessary measures have been taken. Addressing behaviours should not be used to compensate for poorly-designed work or workplaces. This article outlines the importance of the Hierarchy of Controls to determine the most effective measures to address workplace health and safety, and considers the position of individual behaviours within this hierarchy.
Trevor Kletz was a safety hero. Over a career spanning nearly 70 years, his thoughts on human factors, human error and accident investigation helped to move the industry from a focus on individual behaviour to organisational and system failures. His proposal that we should shift from blame to learning is the basis of current safety thinking.