Episode 36 – Texas City

This episode features the BP Texas City Refinery explosion of 2005. Unlike most accidents featured on the show, it is a story
of management fully aware of danger as a situation tumbled towards disaster. Knowing you have a problem may be an important part of fixing it – but only part.

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Episode 35 – Independence and Nimrod XV230

What is independence? Why does it matter for safety? Why can’t we have perfect independence, and why wouldn’t we want it even if we could have it? Are there times independence is an actively bad thing? And what happens when independence is vital, but just isn’t in place … ?

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Episode 34 – Operator or Automation?

This episode is about a clash of principles I call the “Question of Final Authority”.
The question is: In a given situation, should automation be designed to prevent system states which the designers judge to be dangerous, or should the interface provide facility for the operator to execute any control at any time?”

The dilemma regarding whether to provide hard interlocks or allow overrides can be found in many industries:
For road transport: should speed limits be automatically enforced, or should drivers have the ultimate control?
For military engines: should thermal limits be allowed to be temporarily exceeded through the use of “battle shorts” in emergency or combat situations?
For aircraft: should “alpha” or “flight envelope” protection be strictly enforced, or permitted to be exceeded at the judgement of the pilot?
For railways: should signal interlockings be overridden (or signals permitted to be disobeyed) in order to move trains out of dangerous situations?
For smart infusion pumps, which provide limits on medication doses: should these limits be soft, where they can be overridden by doctors or hard, where they can never be overridden?

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Episode 33 – We Don’t Kill Enough People

This episode discusses measurement of safety and the Imperial Sugar disaster.
Measurement is the foundation of both research and business improvement. If we can’t compare
two companies, or our own company at two points in time, how can we know whether our
safety management is working? How can we know if our safety management is even likely to work?

For major accident hazards, there simply aren’t enough data points to measure the effect of individual
safety improvements. We can work backward in time to create more data, but that then makes that same data less
reliable.

Once we’ve twisted your brain enough with the various methods of safety measurement, we’ll relax by talking about
a series of deadly explosions at a sugar factory.

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Episode 32 – Safety Management is not Enough

In the 1970s and 1980s there was a series of accidents which triggered a really intensive examination of organisational safety. Both the idea and reality of management failure weren’t new in safety research; what was special about each of these accidents is that they all occurred in industries that had strong safety regulation in place. Previously you could just observe that the accident happened because of a lack of safety management. Suddenly that wasn’t enough. There was plenty of safety management going on, it just wasn’t working. More sophisticated explanations were needed.

This episode mentions the new Graduate Certificate in Safety Leadership at Griffith University. If you’re in Australia, check it out. If you do apply, be sure to mention that you heard about it on the podcast (I don’t get recruitment fees or anything like that, it’s just good to know).

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Episode 31- Unsafe Safety

This episode is about attempts to make things safer that actually make things worse. The episode focusses on the work of two specific authors, Edward Tenner (Why Things Bite Back: Technology and the Revenge of Unintended Consequences) and Lisanne Bainbridge (The Ironies of Automation). There are examples throughout the episode, but the main case studies are China Air 006 and the New Orleans Hurricane Protection System.

Episode transcript is available here.

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Episode 30 – Not the Titanic

We’re up to 30 episodes of DisasterCast, and we still haven’t talked about the Titanic. Why start now?
This episode talks around the Titanic. We talk about icebergs, lifeboats, shipwrecks and radios, but not the sinking of the unsinkable.

The next episode will be about dangerous safety features – ways that people can or have been hurt by systems specially designed to keep them safe. If you have any suggests, post a comment to this episode, or use the feedback link above.

Transcript is now available.

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Episode 29 – Ethics and DC-10s

Safety engineering and management is full of compromises. We compromise between short term and long term risk. We compromise between absolute assurance and practicability. We compromise between blame and understanding. The one thing we can’t compromise is our professional code of conduct. Or can we? Should our actions be bound by a strict set of rules, or by their intended and expected outcomes? Is an action good because its what we would want if we were in someone elses shoes, or because it makes us into the sort of person we want to be?

And just how did McDonnell Douglas manage to stage two near-perfect dress rehearsals before a DC-10 crashed into the French woodlands?

Episode transcript is now available.

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Episode 28 – Level Crossings

This episode is all about level crossing safety. Level crossings are a simple situation, repeated throughout the world, that illustrate a number of important safety concepts. Through accidents such as Hixon, Lockington, Kerang, Langenweddingen and Fox River Grove we can learn lessons about human factors, dependability trade-offs, safety management interfaces and risk prioritisation.

Episode 28 transcript is now available.

The Introduction to System Safety course in Canberra, 7-11 April 2014. Let me know via the feedback link above if you’re coming along.

References

  1. The study of train drivers and heavy vehicle drivers mentioned in the episode
  2. The Hixon accident report [pdf]
  3. The Lockington accident report [pdf]
  4. The Kerang rail safety investigation report [pdf]
  5. The Fox River Grove Highway/RailRoad Accident Report [pdf]
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Episode 27 – Security and Safety

In this episode we talk about Stuxnet, and the relationship between safety and security more generally.
Stuxnet demonstrated that a determined cyber attacker could influence the operation of potentially hazardous industrial machinery.
Just how representative is Stuxnet? It required elite teams from at least one, possibly two countries, and achieved only minor damage.
Are we in danger of non-state actors causing industrial accidents using their home PCs? Maybe we should ask the 14 year old who derailed
trams using a rewired TV remote control …

Transcript is available here.

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