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.
Five years ago, I launched this website with a series of articles about the Nimrod XV230 disaster. Today, on the 15th anniversary of this tragedy, I'd like to reflect on the key recommendations. From the subtitle of the independent Review - "A failure of leadership, culture and priorities" - it's obvious that there may be lessons for us all. The question is, have we learned these lessons?
This article was prompted by the 2019 television drama series 'Chernobyl', and focuses on human error, safety culture and designing for safety. It provides some discussion points to engage with your key stakeholders and to facilitate safety moments.
The UK NHS (National Health Service), like healthcare in other countries, is a complex system. It is one of the largest employers in the world - some NHS Trusts employ around 20,000 staff and have a turnover of more than £1 billion. The NHS is not a single organisation - there are many parts that make up the NHS. However, these components do not operate as separate entities, they are interconnected and work together as a system. This creates challenges for those that lead these organisations. A recent report on leadership by The King's Fund: "Leadership in today's NHS: Delivering the impossible" questions whether senior leadership roles in the NHS are still "do-able".
I was heavily influenced by a HSE publication 'Organising for Safety', led by Dr Donald Broadbent. This post provides a key conclusion from this report and considers its relevance over 20 years later.
Violations of procedures are a significant cause of many workplace accidents. This post introduces this type of human failures and includes a Briefing Note with strategies to prevent violations.
Nimrod XV230 was due to a catalogue of organisational failures and the lessons are relevant to any high-hazard or complex organisation. In this article I provide ten questions to help stimulate discussion and reflection on leadership, culture and priorities.