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View Full Version : A warning from another mode of transport


PAXboy
1st Nov 2011, 21:55
I have thought carefully before posting here but this is my 'home' forum and this is a fine example of a problem that is sometimes mentioned in these forums. Namely: Pressure on staff to do more for less. More work in less time that can lead to corners being cut.

Now, I am well aware that the airline world is highly regulated and so on and so forth BUT human nature will usually prevail. It is our old enemy 'the normalisation of deviance'. That is, when people have deviated from the rules for a long time and nothing has gone wrong, so it is thought that nothing will go wrong.



One example is the Space Shuttle Challenger in January 1986.
One example is the Kings Cross tube station fire in November 1987.

Both events were warned about by engineers and both events still occurred. As I recall, those warnings were given well in advance for the Tube and immediately before in the Shuttle case.

Here is an event where an email exists warning mgnt a YEAR before the crash, with injury and death to passengers.

... the inquest was told how Mr Lewis sent an email to his bosses one year before the crash, in which he described the inspection system as a "shambles". Mr Lewis said in his email: "It's time for the hierarchy to stop ducking the issue and sort this shambles out once and for all... ensuring the infrastructure is now safe and fit for purpose is now virtually impossible.

The inquest jury also heard how Mr Lewis and his team were "under staffed" and "under pressure" and their work was "not entirely compliant".

Colleague Paul Wills, an assistant track section manager for Network Rail, told the inquest staff had to put up with "bully-boy" management.

He said workers had been harassed while carrying out inspections of the track in Cumbria and a backlog of maintenance work had piled-up due to lack of time.


There is more: BBC News - Grayrigg inquest: Engineer 'forgot' to inspect track (http://www.bbc.co.uk/news/uk-england-cumbria-15544690)

radeng
2nd Nov 2011, 12:28
Accident at Grayrigg on 23rd February 2007 :: The Railways Archive (http://www.railwaysarchive.co.uk/eventsummary.php?eventID=6279)

full accident reports showing a management shambles.

PAXboy
3rd Nov 2011, 02:29
Thanks for the further info radeng. It does have all the hall marks:


Mgmt had been warned that staff were stretched
Corners were cut
Report states that three aspects all had to be present for the derailment to occur = Swiss Cheese
The unfortunate man who did not make the inspection due to pressure has to live with this
Will the mgmt who ran the outfit get charged?

As I say, this is a text book example and should be taught to all mgmt in all lines of business - even those where cut corners are not likely to lead to death of their customers.

PAXboy
4th Nov 2011, 17:37
The family of the woman who died, have said:

The family of a grandmother killed in the Grayrigg train crash blamed Network Rail today for her death. They said they held the firm responsible for the death of Margaret Masson after a jury at her inquest found a set of badly-maintained points caused the 2007 train derailment in Cumbria.

Her son George Masson described as a "scapegoat" the overworked engineer who admitted forgetting to check the points, but who had warned Network Rail bosses months before the crash about safety concerns.

Network Rail, which is responsible for track maintenance, was also facing calls for a public inquiry into its handling of the rail network and possible criminal charges.
Network Rail 'to blame for Cumbria rail crash death' - Home News - UK - The Independent (http://www.independent.co.uk/news/uk/home-news/network-rail-to-blame-for-cumbria-rail-crash-death-6257191.html)

Then they nail the big points:
"The one that tried to make changes lost his job, his pension, he was not listened to from above," Mr Masson said. "Before I knew anything about this I wanted to take his head off his shoulders. "Now I totally respect him. He's got my utmost respect for what he tried to do.


"It's been swept under the carpet. They have not learned from Potter's Bar. "He's the only one who has shown any remorse or integrity."

Ah yes, they did not learn from Potters Bar crash (2002) which was also people cutting corners on maintenance.

We are fortunate that the airline world is run by superhumans who never cut corners in pursuit of profit ...

OFSO
14th Nov 2011, 17:40
I think the phrase one is looking for is

FAMILIARITY BREEDS CONTEMPT

Never far from my own mind as I snuggle down in my seat on the TGV to Paris every month and prepare to charge off at 300kph. One just hopes one is not on the train where this aphorism applies.....