Disasters Flashcards
When was Kegworth air disaster?
8th Jan 1989 @ 2025 hrs
Outline of Kegworth air disaster
BMI Boeing 737 400 left Heathrow Fan blade in No 1 engine detached Shuddering, smoke and fumes Crew shut down No 2 engine Shuddering stopped Diverted to East Midlands airport On approach, vibration & fire in No 1 engine when power increased Struck M1 embankment 47 deaths
Causes of Kegworth air disaster
Crew shut down wrong engine
Events outside crew training & experience
Reacted prematurely to initial engine problem
Crew did not interpret instruments properly
Passengers and cabin staff saw flames but did not tell flight crew
Human error in Kegworth air disaster
No-one challenged flight crew when wrong engine shut down
Level of training on new aircraft was poor - trial and error to understand instruments
Initial action to shut down No 2 engine seemed to work
New design instrument panel meant pilots not attuned to indication of danger
When was Herald of Free Enterprise
6th March 1987
Outline of Herald of Free Enterprise disaster
Sailed from Zeebrugge for Dover
Inner and outer bow doors left open
Chief Officer responsible for bow doors had to be on bridge 15 mins before sailing
Assistant Bosun with duty to close doors had fallen asleep
Bosun saw doors open but did not act
Captain assumed bow doors closed unless told otherwise
Pressure to sail early
Ballasted bow down to access Zeebrugge loading ramp
Request for indicator ref bow door position ignored
Emergency lighting did not work when vessel heeled over
many lifejackets locked away to prevent vandalism
Crew worked 24 hrs on, 48 hrs off
188 deaths
Human error in Herald of Free Enterprise disaster
Number of officers reduced by one third as more time to relax on longer crossing
Fatigued crew
Individual crewmen stuck strictly to their own job
Wrong priorities - pressure to leave early
Routine violation leaving with bow doors open
Date of Piper Alpha disaster
6th July 1988
Outline of Piper Alpha disaster
Explosions on North Sea oil production platform
Pump had been shut down using PTW to remove a safety pressure valve
Blind flange put in its place
Suspended PTW at end of working day, but not put on display in control room
Working pump failed
Night shift started pump that was fitted with blind flange
Not airtight
Gas exploded, cut main power supply
167 deaths
Causes of Piper Alpha disaster
Containment wall not blast resistant, only fire resistant
Two other oil rigs feeding into Piper Alpha not shut down for one hour after disaster
Gas pipelines ended in the area where the oil fire started
Men waited in accommodation block but explosion meant helicopters could not land
Routes to lifeboats were blocked
Most people stayed put until overcome by some and fumes
Valve lock off procedure not in PTW
No inspection of work on suspended pump (common practice)
Human error in Piper Alpha disaster
Often multiple jobs on one PTW Inaccurate description of work on PTW PTWs often not displayed Poorly trained staff ref procedures Perception that production more important than safety Routine violations ref PTW system Negative H&S culture Problems known but not fixed No single person in charge of emergency response
Date of Ladbroke Grove disaster
5th Oct 1999 @ 0811 hrs
Outline of Ladbroke Grove disaster
Great Western express train inbound to Paddington collided with outbound Thames Train
Thames Train driver went through red light
31 people dead
Fire
Newly qualified Thames Train driver
No training ref Ladbroke Grove blackspot or issue of signals passed at danger (SPADs)
Human error in Ladbroke Grove disaster
New driver did not have required knowledge
Could not see red light
Issue known about but not resolved
Complex junction - driver may have been concentrating on where he was going
Failure to implement automatic train protections (braking) system
Poor safety culture and attitude towards training
Date of Three Mile Island disaster
28th March 1979
