1. Kegworth Plane Crash 1989
Passengers & crew thought captain saw left & right differently – no-one thought to challenge
Knowledge based error – level of training for new plane brought into question; using trial & error to find what instruments did
In emergency fell back on well learnt behaviour, not suitable for new design, e.g. one of instruments could have shown problem not considered as on old plane was unreliable
Rule based error – pilot applied set of rules to finding problem engine and appeared to work
Distracted by questions from ground control
Perception of risk – did not consider all options as plane could fly on 1 engine – loss of 1 engine not thought serious
Pilots not attuned to new design – nothing to draw attention to draw eyes to small display showing danger

2. Herald of Free Enterprise ferry capsize 1987
Crew working 24hr shifts; assistant bosun asleep after normal duties – closing bow doors peripheral duty
“Own job” culture – bosun saw doors open but not his job to close
Crew used to workplace and did not perceive risk
Wrong priorities - speed of turnaround more important than safety. Money not spent on safety features, e.g. bow door indicators on bridge
Routine violation – sailing with bow doors open became routine though against rules. Appeared to be , or was, condoned by management

3. Piper Alpha oil platform explosion 1988
Knowledge based errors – personnel not trained in policy & procedures; decisions taken from poor knowledge base
Misperception – production priority over safety
Routine violations – breaking rules of PTW became common – reinforced by management condoning overtly or covertly (turning blind eye)
Organisation’s negative H&S culture – managers did not have authority to make safety decisions that could lose revenue
Previous problems not remedied
No one person to take control in emergency
Personnel followed what training they had & went up to living accommodation (and died)
Those saved had not followed training & had gone downwards to sea

4. Ladbroke Grove train crash 1999
Negative H&S culture of organisation influences individual
Knowledge based error – driver did not have required knowledge/experience to adjust behaviour on approaching signals – not aware it was “black spot”
Working at rules level as had not had time to develop skill/knowledge of job
Complexity of signals at junction – could have concentrated on route and not signal

5. Glenridding Beck schoolboy drowned 2002
Serious errors of judgement by party leader
Some shortcomings in checking procedures
Some shortcomings in LEA arrangements for educational visits
Misunderstandings between LEA & school as to certain responsibilities
Heads can delegate H&S functions – need to clearly define responsibilities & establish lines of accountability
Good practice to review H&S procedures in light of reported incidents
All schools should have someone acting as focal point for H&S with clearly defined responsibilities & been provided with effective training & resources
Monitoring important to ensure compliance & needs to cover activities and H&S management systems as well as sites – check compliance with risk assessments / safe operating procedures, Should be seen as supportive
Good practice for school governing bodies to receive evidence from monitoring by school & LEA showing both what has been done & what could be better – aim continuous improvement
H&S considerations should feature in performance monitoring, staff appraisal / development
Favourable OFSTED reports on school trips not confirmation of safe practice and no substitute for thorough risk assessment

6. Milford Haven explosion & fire 1994
Control valve being shut when control system indicated open
Inadequate maintenance of plant & instrumentation – inadequate control systems and faulty actuator/valve, sensors
Modification of plant carried out without assessment of potential consequences
Control panel graphics did not provide necessary process overviews
Excessive number of alarms in emergency reduced effectiveness
Poor plan layout; human factors / ergonomic issues in control room
Wrong priorities – keeping plant running when should have been shut down
Inadequate emergency operating procedures / training

7. Chernobyl reactor explosion 1986
Gross violations of operating rules & regulations during test
Knowingly ignored regulations to speed test completion
Lack of knowledge of nuclear reactor physics & engineering, experience & training
Key systems switched off
Developers of reactor plant considered combination of events impossible & did not allow for creating of emergency protection system capable of preventing events leading to disaster, e.g. intentional disabling of emergency protection system plus violation of operating procedures
Primary cause – extremely improbable combination of rule infringement plus operational routine allowed by staff