Safety Concepts Part 1
In this 'Safety Concepts Part 1' Blog post, The Safety Artisan looks at the meaning of the term "safe". I look at an objective definition of safe - objective because it can be demonstrated to have been met.

This fundamental topic provides the foundation for all other safety topics, and it isn't complex. The basics are simple, but they need to be thoroughly understood and practiced consistently to achieve success.

https://youtu.be/IKAZ3KLsDW8
System Safety Concepts - highlights.

Safety Concepts Part 1: Topics

- A practical (useful) definition of ‘safe’:

- What is risk?

- What is risk reduction?

- What are safety requirements?

- Scope:

- What is the system?

- What is the application (function)?

- What is the (operating) environment?

Safety Concepts Part 1: Transcript

Hi everyone and welcome to the Safety Artisan, where you will find professional, pragmatic, and impartial advice. Whether you want to know how safety is done or how to do it, I hope you’ll find today’s session helpful.

It’s the 21st of September 2019 as I record this. Welcome to the show. So, let’s get started. We’re going to talk today about System Safety concepts. What does it all mean?  We need to ask this question because it’s not obvious, as we will see.

If we look at a dictionary definition of the word ‘safe’, it’s an adjective: to be protected from or not exposed to danger or risk. Not likely to be harmed or lost. There are synonyms – protect, shield, shelter, guard, and keep out of harm’s way. They’re all good words, and I think we all know what we’re talking about. However, as a definition, it’s too imprecise. We can’t objectively say whether we have achieved safety or not.

A Practical Definition of ‘Safe’

What we need is a better definition, a more practical definition. I’ve taken something from an old UK Defence Standard. Forget about which standard, that’s not important. It’s just that we’re using a consistent set of definitions to work through basic safety concepts. And it’s important to do that because different standards, come from different legal systems and they have different philosophies. So, if you start mixing standards and different concepts together, that doesn’t always work.

OK so whatever you do, be consistent. That’s the key point. We’re going to use this set of definitions from the UK Defence Standard because they are consistent.

In this standard, ‘safe’ means: “Risk has been demonstrated to have been reduced to a level that is ALARP, and broadly acceptable or tolerable. And relevant prescriptive safety requirements have been met. For a system, in a given application, in a given Operating Environment.” OK, so let’s unpack that.

System Safety – Risk

So, we start with risk. We need to manage risk. We need to show that risk has been reduced to an acceptable level. As required perhaps by law, regulation, or a standard. Or just good practice in a particular industry. Whatever it is, we need to show that the risk of harm to people has been reduced. Not just any old reduction, we need to show that it’s been reduced to a particular level. Now in this standard, there are two tests for that.

And they’re both objective tests. The first one says as low as reasonably practicable. Basically, it’s asking have all reasonably practicable risk reduction measures have been taken. So that’s one test. And the second test is a bit simpler. It’s basically saying reduce the absolute level of risk to something that is tolerable or acceptable. Now don’t worry too much about precisely what these things mean. The purpose of today is to note that we’ve got an objective test to say that we’ve done enough.

System Safety – Requirements

So that’s dealt with risk. Let’s move on to safety requirements. If a requirement is relevant, then we need to apply it. If it’s prescriptive, if it says you must do this, or you must do that. Then we need to meet it. There are two separate parts to this ‘Safe’ thing: we’ve got to meet requirements; and, we’ve got to manage risk. We can’t use one as an excuse for not doing the other.

So just because we reduce risk until it’s tolerable or acceptable doesn’t mean that we can ignore safety requirements. Or vice versa. So those are the two key things that we’ve got to do. But that’s not actually quite enough to get us there. Because we’ve got to define what we’re doing, with what, and in what context. Well, we’re reducing the risk of a system. And the system might be a physical thing.

Defining the Scope: The System

It might be a vehicle, an airplane, a ship, or a submarine, it might be a car or a truck. Or it might be something a bit more intangible. It might be a computer program that we’re using to make decisions that affect the safety of human beings, maybe a medical diagnosis system. Or we’re processing some scripts or prescriptions for medicine and we’ve got to get it right. We could poison somebody. So, whether it’s a tangible or an intangible system.

We need to define it. And that’s not as easy as it sounds, because if we’re applying system safety, we’re doing it because we have a complex system. It’s not a toaster. It’s something a bit more challenging. Defining the system carefully and precisely is really important and helpful. So, we define what our system is, our thing, or our service. The system. What are we doing with it? What are we applying it to?

Defining the Scope: The Application

What are we using it for? Now, just to illustrate that no standard is perfect. Whoever wrote that defense standard didn’t bother to define the application. Which is kind of a major stuff-up to be honest, because that’s really important. So, let’s go back to an ordinary dictionary definition just to get an idea of what it means. By the way, I checked through the standard that I was referring to, and it does not explain it in this standard.

What it means by the application. Otherwise, I would use that by preference. But if we go back to the dictionary, we see application: the act of putting something into operation. OK, so, we’re putting something to use. We’re implementing, employing it, or deploying it maybe we’re utilizing it, applying it, executing it, enacting it. We’re carrying it out, putting it into operation, or putting it into practice. All useful words that help us to understand.

I think we know what we’re talking about. So, we’ve got a thing or a service. Well, what are we using it for? Quite obviously, you know a car is probably going to be quite safe on the road. Put it in water and it probably isn’t safe at all. So, it’s important to use things for their proper application, to the use to which they were designed. And then, kind of harking back to what I just said, the correct operating environment.

Defining the Scope: The Operating Environment

For this system, and the application to which we will put it to. So, we’ve got a thing that we want to use for something. What’s the operating environment in which it will be safe? What is it qualified or certified for? What’s the performance envelope that it’s been designed for? Typically, things work pretty well within the operating environment, within the envelope for which they were designed. Take them outside of that envelope and they perform not so well.

Maybe not at all. You take an airplane too high and the air is too thin, and it becomes uncontrollable. You take it too low and it smashes into the ground. Neither outcome is particularly good for the occupants of the airplane. Or whoever happens to be underneath it when it hits the ground. All of those three things:  what is the system? What are we doing with it? and where are we doing it? All those things have to be defined. Otherwise, we can’t really say that risk has been dealt with, or that safety requirements have been met.

System Safety: why Bother?

So, we’ve spent several slides just talking about what safe means, which might seem a bit over the top. But I promise you it is not, because having a solid understanding of what we’re trying to do is important in safety. Because safety is intangible. So, we need to understand what it is we’re aiming for. As some Greek bloke said, thousands of years ago: “If you don’t know to which port, you are bound, then no wind is favorable.”

It’s almost impossible to have a satisfactory Safety Program if you don’t know what you’re trying to achieve. Whereas, if you do have a precise understanding of what you’re trying to achieve, you’ve got a reasonably good chance of success. And that’s what it’s all about.

Copyright

Well, I’ve quoted you some information from a UK government website. And I’ve done so in accordance with the terms of its Creative Commons license. More information about the terms of that can be found on this page.

End: Safety Concepts Part 1

If you want more, if you want to unpack all the Major Definitions, all the system safety concepts that we're talking about, then there's the second part of this video, which you can see here.

I hope you enjoy it. Well, that's it for the short video, for now. Please go and have a look at the longer video to get the full picture. OK, everyone, it's been a pleasure talking to you and I hope you found that useful. I'll see you again soon. Goodbye.

Back to the Start Here Page.

Meet the Author

Learn safety engineering with me, an industry professional with 25 years of experience. I have:

•Worked on aircraft, ships, submarines, ATMS, trains, and software;

•Tiny programs to some of the biggest (Eurofighter, Future Submarine);

•In the UK and Australia, on US and European programs;

•Taught safety to hundreds of people in the classroom, and thousands online;

•Presented on safety topics at several international conferences.
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Simon Di Nucci https://www.safetyartisan.com/2019/09/22/safety-concepts-part-1/

How to Get the Most from The Safety Artisan #3
This is 'How to Get the Most from The Safety Artisan #3'.

Last time #2, I posted about the two major focus areas for The Safety Artisan's teaching. These are System Safety and Australian Work Health and Safety or WHS.

In my first post, I talked about the fundamental lessons under the start here topic. Even if you are experienced in safety, you may find that things are done very differently in another industry or country - I did. 

Now for Something Completely Different

Hi everyone, and welcome to The Safety Artisan. I'm your host, Simon. In this post, I want to talk about how you can connect with me, The Safety Artisan, and get more out of the website.

There are three ways you can do this.

Get Free and Low-cost Courses on Udemy

I have lots of free and paid and low-cost courses on Udemy. In these, I provide video lessons and lots of supporting content, for example, my PHIA Guide.

Subscribe to The Safety Artisan Mailing List and get your Free Gift!

Follow on YouTube or Social Media

Second, you can follow the safety Artisan on YouTube or on social media. If you sign up on my YouTube Channel and tick for notifications, you will be reminded every time I issue a new video lesson.

I'm also on Twitter, Instagram, Facebook, Google My Business, Tumblr, Pinterest, and Vkontakte. Phew! 

On LinkedIn, you can see my full resume/CV and find my most popular articles.

Just Get in Touch

Third, you can directly get in touch with me by commenting on a post - ask a question! There is no such thing as a 'dumb' question, only dumb accidents.

You can also ask general questions by filling in the form on the Connect Page. (This is better than sending me a Direct Message on social media, as I get a lot of spam.)

There are a lot of different topics that I could cover. It is surprisingly difficult to find out what people really like to hear about. So, if there's something that you want to learn about then just ask. I will bump the topic up on my 'to do' list.

That's All, folks!

Well, that's it from me, I hope you enjoy The Safety Artisan website and get as much as you can out of it. See you soon!

How to Get the Most from #3: What subjects do you want?

Leave a comment.
#Askmeanything #coursesafetyengineering #engineersafety #FollowMe #howto #ineedsafety #knowledgeofsafety #learnsafety #needforsafety #safetyblog #safetydo #safetyengineer #safetyengineerskills #safetyengineertraining #safetyengineeringcourse #safetyprinciples #SocialMedia #softwaresafety #Subscribeforemails #theneedforsafety #YouTube
Simon Di Nucci https://www.safetyartisan.com/2021/09/08/how-to-get-the-most-from-the-safety-artisan-3of3/

Preliminary Hazard Identification & Analysis Guide: Free
Get the Preliminary Hazard Identification & Analysis Guide for free! It's a 50-page .pdf download, collated from reliable sources.

- Contents;

- Introduction;

- Aim; and

- Get it here for free.

Contents:

- Introduction ..................................1

- Aim ................................................1

- Description ....................................2

- Method ..........................................3

- Guidance .......................................4

- Inspect the Workplace ..................7

- How to find hazards .....................8

- Review available information ......8

- Consult Your Workers .................10

- When to Consult with Workers ...10

- Hazard Checklists ........................12

- Functional Safety Analysis ..........16

- FMEA/FMECA ............................21

- SWIFT .........................................28

- HAZOP ........................................42

The Safety Artisan's PHIA Guide

Preliminary Hazard Identification & Analysis Guide - Introduction

Hazard Identification has been defined as: “The process of identifying and listing the hazards and accidents associated with a system.”

Hazard Analysis has been defined as: “The process of describing in detail the hazards and accidents associated with a system and defining accident sequences.”

Preliminary Hazard Identification and Analysis (PHIA) is intended to help you determine the scope of the safety activities and requirements. It identifies the main hazards likely to arise from the capability and functionality being provided. It is carried out as early as possible in the project life cycle, providing an important early input to setting Safety requirements and refining the Project Safety Plan.

PHIA seeks to answer, at an early stage of the project, the question: “What Hazards and Accidents might affect this system and how could they happen?”

Aim

The aim of the PHIA is to identify, as early as possible, the main Hazards and Accidents that may arise during the life of the system. It provides input to:

- Scoping the subsequent Safety activities required in any Safety Plan. A successful PHIA will help to gauge the proportionate effort that is likely to be required to produce an effective Safety Case, proportionate to risks.

- Selecting or eliminating options for subsequent assessment.

- Setting the initial Safety requirements and criteria.

- Subsequent Hazard Analyses.

- Initiate Hazard Log.

Did You Know?

You can also get the Guide with the PHIA Courses on Udemy.

Preliminary Hazard Identification & Analysis Guide: Free
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Simon Di Nucci https://www.safetyartisan.com/2024/06/10/preliminary-hazard-identification-analysis-guide-free/

How to Get the Most fromThe Safety Artisan #2
Hi everyone, and welcome to The Safety Artisan. I'm Simon, your host. This is 'How to Get the Most from The Safety Artisan #2'.

In my previous post (#1) I talk about the Start Here topic page. There you will find lessons that deal with fundamental issues - most of them are free.

This time I'm talking about two other topic areas, which are the main focus of The Safety Artisan - so far. 

System Safety

The first topic is system safety. I spend a lot of time talking about system safety because it's used in so many different industries. You can apply its principles to just about anything.

And because it takes a systematic approach to safety you can scale it up or down. It is used on the biggest, multinational, multi-billion dollar projects you can imagine. You can also tailor it so that it can be used sensibly on much smaller projects. You can get good results for a lot less money and time.

So I present a whole suite of sessions on system safety, in particular how to do system safety analysis according to a US Military Standard 882E. Whether you're working on US military systems or not doesn't matter. The principles, practices, and procedures in the standard will equip you to tackle almost any standard.

But you've got to understand your standard, and what it was designed to achieve. Then you can make it work for you.

Australian Work Health and Safety

The second topic that I cover in detail is Australian Work Health and Safety (WHS). I've done a series on WHS because I find that is often misunderstood.

Unusually for health and safety legislation, WHS covers not just workplace health and safety, but the duties of designers, manufacturers, importers, installers, and users of plant, substances, and structures. In fact, anyone who is involved through its lifecycle.

Coming to Australia?

WHS also contains and concepts like 'So Far As Is Reasonably Practicable or SFAIRP/SFARP. These are often misunderstood and misapplied. This is a shame because the public guidance that is out there is excellent.

For example, I introduce Codes of Practice, especially the ones that tell you how to manage risk and Consult, Cooperate, and Coordinate on WHS matters. From my personal experience, I explain how to use this guidance and how to get results.

Even if you don't work in Australia, you'll find that many principles used in WHS law are found in other western nations. For example, I compared safety laws in the UK and Australia, based on my experience of working in both countries.

How to Get the Most from The Safety Artisan #3: Coming Soon...

Next time, I talk about how you can connect and interact with The Safety Artisan to get better learning results for you!
#CodesofPractice #coursesafetyengineering #engineersafety #ineedsafety #knowledgeofsafety #learnsafety #needforsafety #riskmanagement #safetyblog #safetydo #safetyengineer #safetyengineerskills #safetyengineertraining #safetyengineeringcourse #safetyprinciples #softwaresafety #systemsafety #SystemsEngineering #theneedforsafety #WHSCodeofPractice #WorkHealthandSafety
Simon Di Nucci https://www.safetyartisan.com/2021/09/01/how-to-get-the-most-from-the-safety-artisan-2of3/

How to Get the Most from The Safety Artisan #1
In this post, 'How to Get the Most from The Safety Artisan #1' I will show you some of the free resources you can access...

Welcome

Hi everyone, and welcome to The Safety Artisan, my name is Simon and I'm a professional system safety engineer with more than 25 years of experience in various industries.

Simon Di Nucci, FIE(Aust), MSc, CPEng NER

In the next three posts, I'm going to tell you how to get the most from The Safety Artisan website. I'm going to start with the basics. 

Start Here

As the name suggests, start here is a good place for newcomers to start looking at blog posts and lesson videos. Most of them are Free!

Now, before you skip this bit because you've done some work in safety before, let me share two things with you.

Concepts

I have worked on many projects where we didn't have a clear and unambiguous idea of what 'safe' means. I'm not joking!

That's right, we were spending lots of money trying to make something safe, but we didn't really know what that meant. Surprisingly, the bigger and more expensive the project, the more difficult it is to get a clear picture of the basics. This might sound daft but on a big project, you have to work hard to stay focused on the fundamental principles of what you're trying to achieve.

If from the very beginning, you can understand clearly what safe means in your particular domain is, and how are you are going to manage risk, then you can arrive at a successful end game. But it's not easy.

Second, Differences Across Countries and Industries

Another point to note is that many industries do things differently. You may have worked in rail, or in a chemical plant, or with ships, submarines, or planes and you know how safety works in your industry. But it's still good to learn from others - and their mistakes.

'Learn from others' Mistakes' said Bismark.

I have worked in all of these industries - and more - and I can tell you that the way things are done in different domains varies greatly. So when you're going for an interview, or when you're starting a new job, you might get some surprises...

The law on safety (and environmental protection) also varies from country to country. I've worked on projects in the UK, Australia, Europe, and the USA, and there are significant differences in practice. In particular, I emigrated from the UK to Australia, and I've compared practices in the two countries.

Coming Next...

Next week I will tell you about the more advanced topics that I cover. In the Third Post, I will talk about how you can connect with The Safety Artisan and get the online learning that YOU want.
#coursesafetyengineering #engineersafety #howtoriskassessment #howtoriskassessmentanalysis #ineedsafety #knowledgeofsafety #learnriskassessment #riskassessmenttechnique #riskassessmenttraining #riskassessmenttutorial #riskassessmentvideo #safetyblog #safetydo #safetyengineer #safetyengineerskills #safetyengineertraining #safetyengineeringcourse #safetyprinciples #softwaresafety #theneedforsafety
Simon Di Nucci https://www.safetyartisan.com/2021/08/25/how-to-get-the-most-from-the-safety-artisan-1of3/

Lessons Learned from a Fatal Accident

Lessons Learned: in this 30-minute video, we learn lessons from an accident in 2016 that killed four people on the Thunder River Rapids Ride in Queensland. The coroner's report was issued this year, and we go through the summary of that report. In it we find failings in WHS Duties, Due Diligence, risk management, and failures to eliminate or minimize risks So Far As is Reasonably Practicable (SFARP). We do not 'name and shame', rather we focus on where we can find guidance to do better.



https://youtu.be/QaSoFld7W0g

In 2016, four people died on the Thunder River Rapids Ride.



Lessons Learned: Key Points



We examine multiple failings in:



- WHS Duties;



- WHS Due Diligence;



- Risk management; and



- Eliminating or minimizing risks So Far As is Reasonably Practicable (SFARP).



Transcript: Lessons Learned from a Theme Park Tragedy



Introduction



Hello, everyone, and welcome to the Safety Artisan: purveyors of fine safety engineering training videos and other resources. I'm Simon and I'm your host and today we're going to be doing something slightly different. So, there are no PowerPoint slides. Instead, I'm going to be reading from a coroner's report from a well-known accident here in Australia and we're going to be learning some lessons in the context of WHS workplace health and safety law.



Disclaimer



Now, I'd just like to reassure you before we start that I won't be mentioning the names of the deceased. I won't be sharing any images of them. And I'm not even going to mention the firm that owned the theme park because this is not about bashing people when they're down. It's about us as a community learning lessons when things go wrong to fix the problem, not the blame. So that's what I'd like to emphasize here.



The Coroner's Report



So, I'm just going to I'm just turning to the summary of the coroner's report. The coroner was examining the deaths of four people back in 2016 on what was called the Thunder River Rapids Ride. Or TRRR or TR3 for short because it's a bit of a mouthful. This was a water ride, as the name implies, and what went wrong was the water level dropped. Rafts, these circular rafts that went down the rapids, went down the chute, got stuck. Another raft came up behind the stuck raft and went into it. One of the rafts tipped over. These rafts seat six people in a circular configuration. You may have seen them. They're in - different versions of this ride are in lots of theme parks.



But out of the six, unfortunately, the only two escaped before people were killed, tragically. So that's the background. That happened in October 2016, I think it was. The coroner's report came out a few months ago, and I've been wanting to talk about it for some time because it illustrates very well several issues where WHS can help us do the right thing.



WHS Duties



So, first of all, I'm looking at the first paragraph in the summary, the coroner starts off; the design and construction of the TRRR at the conveyor and unload area posed a significant risk to the health and safety of patrons. Notice that the coroner says the design and construction. Most people think that WHS only applies to workplaces and people managing workplaces, but it does a lot more than that. Sections 22 through 26 of the Act talk about the duties of designers, manufacturers, importers, suppliers, and then people who commissioned, install, et cetera.



So, WHS supplies duties on a wide range of businesses and undertakings, and designers and constructors are key. There are two of them. Now, it's worth noting that there was no importer here. The theme park, although the TRRR ride was similar to a ride available commercially elsewhere, for some reason, they chose to design and build their version in Queensland. Don't know why. Anyway, that doesn't matter now. So, there was no importer, but otherwise, even if you didn't design and construct the thing, if you imported it, the same duties still apply to you.



No Effective Risk Assessment



So, the coroner then goes on to talk about risks and hazards and says each of these obvious hazards posed a risk to the safety of patrons on the ride and would have been easily identifiable to a competent person had one ever been commissioned to conduct a risk and hazard assessment of the ride. So, what the coroner is saying there is, “No effective risk assessment has been done”. Now, that is contrary to the risk management code of practice under WHS and also, of course, that the definition of SFARP, so far as reasonably practicable, basically is a risk assessment or risk management process. So, if you've not done effective risk management, you can't say that you've eliminated or minimized risks SFARP, which is another legal requirement. So, a double whammy there.



Then moving on. “Had noticed been taken of lessons learned from the preceding incidents, which were all of a very similar nature …” and then he goes on. That's the back end of a sentence where he says, you didn't do this, you had incidents on the ride, which are very similar in the past, and you didn't learn from them. And again, concerning reducing risks SFARP, Section 18 in the WHS Act, which talks about the definition of reasonably practicable, which is the core of SFARP, talks about what ought to have been known at the time.



So, when you're doing a risk assessment or maybe you're reassessing risk after a modification - and this ride was heavily modified several times or after an incident - you need to take account of the available information. And the owners of TRRR the operators didn't do that. So, another big failing.



The coroner goes on to note that records available concerning the modifications to the ride are scant and ad hoc. And again, there's a section in the WHS risk management code of practice about keeping records. It's not that onerous. I mean, the COP is pretty simple but they didn't meet the requirement of the code of practice. So, bad news again.



Due Diligence



And then finally, I’ve got to the bottom of page one. So, the coroner then notes the maintenance tasks undertaken on the ride whilst done so regularly and diligently by the staff, seemed to have been based upon historical checklists which were rarely reviewed despite the age of the device or changes to the applicable Australian standards. Now, this is interesting. So, this is contravening a different section of the WHS Act.



Section 27, talks about the duties of officers and effectively that sort of company directors, and senior managers. Officers are supposed to exercise due diligence. In the act, due diligence is fairly simple- It's six bullet points, but one of them is that the officers have to sort of keep up to date on what's going on in their operation. They have to provide up-to-date and effective safety information for their staff. They're also supposed to keep up with what's going on in safety regulations that apply to their operation. So, I reckon in that one statement from the coroner then there's probably three breaches of due diligence there to start with.



Risk Controls Lacking



We've reached the bottom of page one- Let's carry on. The coroner then goes on to talk about risk controls that were or were not present and says, “in accordance with the hierarchy of controls, plant and engineering measures should have been considered as solutions to identified hazards”. So in WHS regulations and it’s repeated in the risk code of practice, there's a thing called the hierarchy of controls. It says that some types of risk controls are more effective than others and therefore they come at the top of the list, whereas others are less effective and should be considered last.



So, top of the list is, “Can you eliminate the hazard?” If not, can you substitute the hazardous thing for something else that's less hazardous- or with something else that is less hazardous, I should say? Can you put in engineering solutions or controls to control hazards? And then finally, at the bottom of my list are admin procedures for people to follow and then personal protective equipment for workers, for example. We'll talk about this more later, but the top end of the hierarchy had just not been considered or not effectively anyway.



A Predictable Risk



So, the coroner then goes on to say, “rafts coming together on the ride was a well-known risk, highlighted by the incident in 2001 and again in 2004”. Now actually it says 2004, I think that might be a typo. Elsewhere, it says 2014, but certainly, two significant incidents were similar to the accident that killed four people. And it was acknowledged that various corrective measures could be undertaken to, quote, “adequately control the risk of raft collision”.



However, a number of these suggestions were not implemented on the ride. Now, given that they've demonstrated the ability to kill multiple people on the ride with a raft collision, it's going to be a very, very difficult thing to justify not implementing controls. So, given the seriousness of the potential risk, to say that a control is feasible is practicable, but then to say “We're not going to do it. It's not reasonable”. That's going to be very, very difficult to argue and I would suggest it's almost a certainty that not all reasonably practicable controls were implemented, which means the risk is not SFARP, which is a legal requirement.



Further on, we come back to document management, which was poor with no formal risk register in place. So, no evidence of a proper risk assessment. Members of the department did not conduct any holistic risk assessments of rides with the general view that another department was responsible. So, the fact that risk assessment wasn't done - that's a failure. The fact that senior management didn't knock heads together and say “This has to be done. Make it happen”- That's also another failing. That’s a failing of due diligence, I suspect. So, we've got a couple more problems there.



High-Risk Plant



Then, later on, the coroner talks about necessary engineering oversight of high-risk plant not being done. Now, under WHS act definitions, amusement rides are counted as high-risk plant, presumably because of the number of serious accidents that have happened with them over the years. The managers of the TRRR didn't meet their obligations concerning high-risk plants. So, some things that are optional for common stuff are mandatory for high-risk plants, and those obligations were not met it seems.



And then in just the next paragraph, we reinforce this due diligence issue. Only a scant amount of knowledge was held by those in management positions, including the general manager of engineering, as to the design modifications and past notable incidents on the ride. One of the requirements of due diligence is that senior management must know their operations, and know the hazards and risks associated with the operations. So for the engineering manager to be ignorant about modifications and risks associated with the ride, I think is a clear failure of due diligence.



Still talking about engineering, the coroner notes “it is significant that the general manager had no knowledge of past incidents involving rafts coming together on the ride”. Again, due diligence. If things have happened those need to be investigated and learned from and then you need to apply fresh controls if that's required. And again, this is a requirement. So, this shows a lack of due diligence. It's also a requirement in the risk management code of practice to look at things when new knowledge is gained. So, a couple more failures there.



No Water-Level Detection, Alarm Or Emergency Stop



Now, it said that the operators of the ride were well aware that when one pump failed, and there were two, the ride was no longer able to operate with the water level dropping dramatically, stranding the rafts on the steel support railings. And of course, that's how the accident happened. Regardless, there was no formal means by which to monitor the water level of the ride and no audible alarm to advise one of the pumps had ceased to operate. So, a water level monitor? Well, we're talking potentially about a float, which is a pretty simple thing. There's one in every cistern, in every toilet in Australia. Maybe the one for the ride would have to be a bit more sophisticated than that- A bit industrial grade but the same principle.



And no alarm to advise the operators that this pump had failed, even though it was known that this would have a serious effect on the operation of the ride. So, there are multiple problems here. I suspect you'll be able to find regulations that require these things. Certainly, if you looked at the code of practice on plant design because this counts as industrial plants, it's a high-risk plant, so you would expect very high standards of engineering controls on high-risk plants and these were missing. More on that later.



In a similar vein, the coroner says “a basic automated detection system for the water level would have been inexpensive and may have prevented the incident from occurring”. So basically, the coroner is saying this control mechanism would have been cheap so it's certainly reasonably practicable. If you've got a cheap control that will prevent a serious injury or a death, then how on earth are you going to argue that it's not reasonable to implement it? The onus is on us to implement all reasonably practical controls.



And then similarly, the lack of a single emergency stop on the ride, which was capable of initiating a complete shutdown of all the mechanisms, was also inadequate. And that's another requirement from the code of practice on plant design, which refers back to WHS regulations. So, another breach there.



Human Factors



We then move on to a section where it talks about operators, operators’ accounts of the incident, and other human factors. I'm probably going to ask my friend Peter Bender, who is a Human Factors specialist, to come and do a session on this and look at this in some more detail, because there are rich pickings in this section and I'm just going to skim the surface here because we haven't got time to do more.



The coroner says “it's clear that these 38 signals and checks to be undertaken by the ride operators was excessive, particularly given that the failure to carry out any one could potentially be a factor which would contribute to a serious incident”. So clearly, 38 signals and checks were distributed between two ride operators, because there was no one operator in control of the whole ride- that's a human factors nightmare for a start- but clearly, the work designed for the ride was poor. There is good guidance available from Safe Work Australia on good work design so there's no excuse for this kind of lapse.



And then the coroner goes on to say, reinforcing this point that the ride couldn't be safely controlled by a human operator. The lack of engineering controls on a ride of this nature is unjustifiable. Again, reinforces the point that risk was not SFARP because not all reasonably practicable controls had been implemented. Particularly controls at the higher end of the hierarchy of controls. So, a serious failing there.  



(Now, I've got something that I'm going to skip, actually, but - It's a heck of a comment, but it's not relevant to WHS.)



Training And Competence



We're moving on to training and competence. Those responsible for managing the ride whilst following the process and procedure in place - and I'm glad to see you from a human practice point of view that the coroner is not just trying to blame the last person who touched it. He's making a point of saying the operators did all the right stuff. Nevertheless, they were largely not qualified to perform the work for which they were charged.



The process and procedures that they were following seemed to have been created by unknown persons. Because of the poor record-keeping, presumably who it is safe to assume lacked the necessary expertise. And I think the coroner is making a reasonable assumption there, given the multiple failings that we've seen in risk management, in due diligence, in record-keeping, in the knowledge of key people, et cetera, et cetera. It seems that the practice at the park was simply to accept what had always been done in terms of policy and procedure.



And despite changes to safety standards and practices happening over time, because this is an old ride, only limited and largely reactionary consideration was ever given to making changes, including training, provided to staff. So, reactionary -bad word. We're supposed to predict risk and prevent harm from happening. So, multiple failures in due diligence here and on staff training, providing adequate staff training, providing adequate procedures, et cetera.



The coroner goes on to say, “regardless of the training provided at the park, it would never have been sufficient to overcome the poor design of the ride. The lack of automation and engineering controls”. So, again, the hierarchy of controls was not applied, and relatively cheap, engineering controls were not used, placing an undue burden on the operator. Sadly, this is all too common in many applications. This is one of the reasons they are not naming the ride operators or trying to shame them because I've seen this happen in so many different places. It wouldn't be fair to single these people out.



‘Incident-Free’ Operations?



Now we have a curious, a curious little statement in paragraph 1040. The coroner says “submissions are made that there was a 30-year history of incident-free operation of the ride”. So, what it looks like is that the ride operators, and management, trying to tell the coroner that they never had an incident on the ride in 30 years, which sounds pretty impressive, doesn't it, at face value?



But of course, the coroner already knew or discovered later on that there had been incidents on the ride. Two previous incidents were very similar to the fatal accident. Now, on the surface, this looks bad, doesn't it? It looks like the ride management was trying to mislead the coroner. I don't think that's the case because I've seen many organizations do poor incident reporting, poor incident recording, and poor learning from experience from incidents. It doesn't surprise me that the senior management was not aware of incidents on their ride. Unfortunately, it's partly human nature.



Nobody likes to dwell on their failures or think about nasty things happening, and nobody likes to go to the boss saying we need to shut down a moneymaking ride. Don't forget, this was a very popular ride. We need to shut down a moneymaking ride to spend more money on modifications to make it safer. And then management turns around and says, “Well, nobody's been hurt. So, what's the problem?” And again, I've seen this attitude again and again, even on people operating much more sophisticated and much more dangerous equipment than this. So, whilst this does look bad- the optics are not good, as they like to say. I don't think there's a conspiracy going on here. I think it's just stupid mistakes because it's so common. Moving on.



Standards



Now the coroner goes on to talk about standards not being followed, particularly when standards get updated over time. Bearing in mind this ride was 30 years old. The coroner states “it is essential that any difference in these standards are recognized and steps taken to ensure any shortfalls with a device manufactured internationally is managed”. Now, this is a little bit of an aside, because as I've mentioned before, the TRRR was actually designed and manufactured in Australia. Albeit not to any standards that we would recognize these days. But most rides were not and this highlights the duties of importers. So, if you import something from abroad, you need to make sure that it complies with Australian requirements. That's a requirement, that's a duty under WHS law. We'll come back to this in just a moment.

#coursesafetyengineering #duediligence #engineersafety #fatalaccident #ineedsafety #knowledgeofsafety #learnsafety #lessonslearned #needforsafety #riskmanagement #safetyblog #safetydo #safetyengineer #safetyengineerskills #safetyengineertraining #safetyengineeringcourse #safetyprinciples #SFARP #softwaresafety #theneedforsafety #themeparkaccident #thunderriverrapidsride #WHS

Simon Di Nucci https://www.safetyartisan.com/2023/12/06/lessons-learned-from-a-fatal-accident/

Understanding System Safety Engineering: A Quick Guide

Understanding System Safety Engineering: A Quick Guide, takes you through some key points of this complex subject.



Introduction



System safety engineering plays a crucial role in ensuring the safety of complex systems. In this post, we will explore the fundamental concepts of system safety engineering and its importance in the realm of systems engineering.



System Safety Engineering Explained



System safety engineering, as the name implies, focuses on engineering safety within a systems-engineering context. It involves deliberately integrating safety measures into the framework of complex systems.



Read on, or watch this short video for some pointers:



https://youtu.be/hse2M_ZeDzQ

What is System Safety Engineering?



Key Points of System Safety Engineering



1. Consider the Whole System



In system safety engineering, a holistic approach is essential. It's not just about hardware and technical aspects; it includes software, operating environments, functions, user interactions, and data. This comprehensive view aligns with systems theory, ensuring a thorough safety assessment.



2. A Systematic Process



System safety engineering follows a systematic process. Starting with high-level requirements, it meticulously analyzes potential risks, safety obligations, and components. The V model illustrates this structured approach, emphasizing the importance of verification and validation at every stage.



The Systems Engineering 'V' Model



3. Emphasis on Requirements



Unlike simple commodities like toasters, complex systems require rigorous requirement analysis. System engineers meticulously decompose the system, defining boundaries, interactions, and functionalities. These requirements undergo rigorous validation, minimizing surprises and ensuring safety from the start.



Bowtie showing the Foundations of System Safety



4. Think Safety from the Start



A significant aspect of system safety engineering is the early integration of safety considerations. By addressing safety concerns right from the beginning, potential issues are identified and resolved cost-effectively. This proactive approach enhances the overall safety of the system.



Which way should we go?



Summary



In summary, system safety engineering is characterized by its systematic approach to understanding the entire system, following a structured process, and integrating concepts from systems engineering and systems theory. By focusing on comprehensive requirements and thinking about safety from the start, system safety engineering ensures the safety and reliability of complex systems.



Meet the Author



If you found this helpful, there's more depth in this article, and you can also see System Safety FAQ. There's a low-price introductory course on the System Safety Process - on Udemy (please use this link, otherwise Udemy takes two-thirds of the revenue).

#ComplexSystems #ComplexSystemsSafety #CostEffectiveSafety #EarlyIntegration #EngineeringSafety #HolisticApproach #ProactiveSafety #RequirementsAnalysis #safetyengineering #SafetyValidation #SystemReliability #systemsafety #systemsafetyanalysis #SystematicProcess #SystemsEngineering #VModel

Simon Di Nucci https://www.safetyartisan.com/2023/10/25/understanding-system-safety-engineering-a-quick-guide/