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.
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?
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.
Human error is a central concept in ergonomics and human factors. But what is 'human error'? Is it helping us to improve safety? The language we use may be preventing us from learning or improving. In this article, I discuss a better way of thinking about human error.
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.