unitHE1

Study Unit HE1 - Disasters (Examples Of)

Copyright Notice: This material was written and published in Wales by Derek J. Smith (Chartered Engineer). It forms part of a multifile e-learning resource, and subject only to acknowledging Derek J. Smith's rights under international copyright law to be identified as author may be freely downloaded and printed off in single complete copies solely for the purposes of private study and/or review. Commercial exploitation rights are reserved. The remote hyperlinks have been selected for the academic appropriacy of their contents; they were free of offensive and litigious content when selected, and will be periodically checked to have remained so. Copyright © 2001, Derek J. Smith (Chartered Engineer).

ALPHA TESTING - MAY 2001 - This version dated 12:54 9th May 2001

This is the first of three related study units on the topic of HUMAN ERROR (AND HOW TO PREVENT IT), an e-learning resource published and supported by Derek J. Smith (Chartered Engineer). The material is a standalone resource, linked to as and when necessary from either the ORGANISATIONAL COMMUNICATION, APPLIED COGNITIVE PSYCHOLOGY, or the INFORMATICS programme. For further information, please e-mail me.

Unit Aims and Outcomes: This study unit introduces a broad spectrum of specific disasters. When you have completed it, you will be able to deploy with enhanced confidence and accuracy the specific skills and vocabulary listed below:

Specific Skills	Vocabulary
1. Narrate instances of property damage, personal injury, or death, resulting from disasters involving transportation systems, and analyse the causes of same, looking for defects in perceptuo-motor, higher cognitive, or communication skills.	AAIB; conceptual design; CVR; FDR; handover error; known defect; mode error; NTSB; safety critical software; situational awareness; SPAD; SPD;
2. Narrate instances of property damage, personal injury, or death, resulting from disasters involving industrial installations, and analyse the causes of same, looking for defects in perceptuo-motor, higher cognitive, or communication skills.	UNDER CONSTRUCTION
3. Narrate instances of property damage, personal injury, or death, resulting from disasters involving crowd control, and analyse the causes of same, looking for defects in perceptuo-motor, higher cognitive, or communication skills.	UNDER CONSTRUCTION
4. Narrate instances of financial loss resulting from corporate mismanagement or fraud, and analyse the causes of same, looking for defects in perceptuo-motor, higher cognitive, or communication skills.	UNDER CONSTRUCTION
5. Narrate instances of financial loss resulting from IT project mismanagement, and analyse the causes of same, looking for defects in perceptuo-motor, higher cognitive, or communication skills.	critical path; Gantt chart; intensive time vs elapsed time; project activities; PERT chart; project deliverables; ready for service (RFS) date; tolerance and float
6. Narrate instances of avoidable defeat or unnecessarily high casualties, resulting from military incompetence, and analyse the causes of same, looking for defects in perceptuo-motor, higher cognitive, or communication skills.	chain of command; cognitive framing; defence in depth; esprit-de-corps; logistics; morale; relevant information and intelligence (RII); scenario fulfilment
7. Narrate instances of personal injury or death resulting from the various types of everyday accidents, and analyse the causes of same, looking for defects in perceptuo-motor, higher cognitive, or communication skills.	UNDER CONSTRUCTION
8. Narrate instances of personal injury or death resulting from the various types of medical error, and analyse the causes of same, looking for defects in perceptuo-motor, higher cognitive, or communication skills.	UNDER CONSTRUCTION

Unit Structure: This unit contains eight short lessons, three operational and five under construction, each contributing to the overall unit outcomes, each with its own hyperlinked support material, and each with its own additional reading and tutorial task(s). Here is the learning sequence:

Unit Preview

Lesson HE1.1: Avoidable Major Disasters - Transportation Systems

Lesson HE1.2: Avoidable Major Disasters - Industrial Installations

Lesson HE1.3: Avoidable Major Disasters - Crowd Control

Lesson HE1.4: Avoidable Major Disasters - Corporate Mismanagement and Fraud

Lesson HE1.5: Avoidable Major Disasters - IT Project Mismanagement

Lesson HE1.6: Avoidable Major Disasters - Military Incompetence

Lesson HE1.7: Everyday Accidents

Lesson HE1.8: Medical Error

So Where To Next?

References

Unit Preview

Here are some definitions of the word "disaster":

"A sudden or great misfortune, mishap, or misadventure" (O.E.D.).

"An event (happening with or without warning) causing or threatening death or injury, damage to property or to the environment, or disruption to the community, which because of the scale of its effects cannot be dealt with by the emergency services and local authorities as part of their day-to-day activities." (Mike O'Brien, MP; Hansard, 22nd November 2000.)

"A sharp and furious eruption [that] splinters the silence for one terrible moment and then goes away." (Erikson, 1976:253.)

There is something very compelling about disasters (providing, of course, they happen at a safe distance). Their images burn themselves into our memories, and our hearts go out to the unfortunate souls on the receiving end. Hence we know the earthquakes, volcanic eruptions, forest fires, hurricanes, famines, and plagues since recordings first began. But we are even more fascinated by that other type of disaster - the ones which need not have happened at all. These disasters also go back to the beginnings of recorded time (remember the Tower of Babel!), but only start to occur with any great frequency with the industrial revolution. This is for the simple reason that with taller buildings, for example, came more collapses, with deeper mines came more Senghennydds, with more chemistry came louder explosions, with more and bigger ships came more and bigger sinkings, with more trains came more derailments, and so on.

So why do they occur? Why do the complex systems which so fascinate us keep letting us down?

Well at the risk of stating the obvious, by far the majority of system failures are down to the humans who have been involved. Only rarely do systems fail due to straightforward component failure; far more likely it was down to the designer for failing to guard against a particular area of risk, or to the builder for allowing a structural flaw to slip through quality checking, or to the operator for not following laid-down procedures, or to the owner(s) for misjudging the true risk of a problem and attempting to live with it for too long, or even to higher authorities for not having implemented better checks and controls. In the remainder of this study unit we present a hundred or so disasters, some large and some small, many famous and others quite obscure; and for ease of reference we have organised them under the following eight headings:

Marine, Rail, and Aerospace Disasters: The first block of case material contains a selection of high profile transportation disasters, usually with considerable loss of life. These are presented and reviewed in Lesson 1. [To go directly to Lesson 1, click here.]

Industrial Installation Disasters: The second block of case material contains a selection of high profile industrial disasters, sometimes with considerable loss of life. These are disasters of or at a given fixed location, for example, in factories, power stations, mines, and the like. These are presented and reviewed in Lesson 2. [To go directly to Lesson 2, click here.]

Crowd Control Disasters: The third block of case material contains a selection of high profile crowd control disasters (ie. stampedes), sometimes with considerable loss of life, and often as the result of fire. These are disasters of or at a given fixed location, for example, in stadia, discos, town squares, and the like. These are presented and reviewed in Lesson 3. [To go directly to Lesson 3, click here.]

Strategic Mismanagement and Fraud: The fourth block of case material relates to disasters in the effective deployment of corporate resources, whether by strategic incompetence or downright dishonesty. These are presented and reviewed in Lesson 4. [To go directly to Lesson 4, click here.]

IT Project Mismanagement Disasters: The fifth block of case material relates to disasters in the effective deployment of corporate IT resources. This includes the scrapping of expensive (and usually publicly funded) computer systems. These are presented and reviewed in Lesson 5. [To go directly to Lesson 5, click here.]

Military Disasters: The sixth block of case material relates to disasters in the effective deployment of military resources. These are presented and reviewed in Lesson 6. [To go directly to Lesson 6, click here.]

Everyday Disasters: The seventh block of case material relates to those minor disasters which those who were not involved prefer to call accidents, and specifically to road traffic accidents, accidents in the home, and industrial injury. These are presented and reviewed in Lesson 7. [To go directly to Lesson 7, click here.]

Medical Errors: The eighth block of case material relates to minor disasters within the healthcare industry, and specifically to misdiagnosis and/or mistreatment. These are presented and reviewed in Lesson 8. [To go directly to Lesson 8, click here.]

Then, because most disasters are ultimately the result of human fallibility, they are automatically the subject of forensic psychological enquiry. In Unit HE2, we therefore review the main psychological explanations of human error, looking at such issues as .....

why designers keep having good ideas long after it is too late to incorporate them into their design (and what can be done about it)

why warnings are ignored (and what can be done about it)

why warnings that warnings are being ignored are even more assiduously ignored (and what can be done about it)

why warnings are withheld for fear of giving offence (and what can be done about it)

why warning-givers are frequently punished for disloyalty, thus discouraging future warning-givers (and what can be done about it)

why the obvious is not always that obvious (and what can be done about it)

why formally established procedures frequently degenerate into local bad habits (and what can be done about it)

why red lights sometimes fail to make it across the gap between the retina and the brain (and what can be done about it)

Lesson HE1.1: Avoidable Major Disasters - Transportation Systems

Recommended Reading: "The Titanic Disaster Hearings: The Official Transcripts of the 1912 Senate Investigation" Kuntz, T. (Ed.) (1998)

To see an abstract, or to order this book, click here.

[Kuntz jacket]

Here are some reminders of the sort of thing which can go wrong with transportation systems:

A cautionary tale - the perils of penny pinching: The following fragment of dialogue is taken from the 1912 Titanic transcripts mentioned above:

Senator Smith: "Are you given glasses [ie. binoculars]?" Frederick Fleet (Titanic lookout): "We had none[.] We asked for them in Southampton, and they said there was none for us."

A cautionary tale - not all things are obvious to all people: There follows Recommendation #6 from the official Board of Trade Enquiry (Lord Mersey's Report) into the loss of the Titanic in 1912 (it having been perfectly legal prior to 1912 for a ship to carry far more people than could be evacuated in an emergency). [To see the full list of Board of Trade Recommendations, click here.]

"[It is recommended that] the provision of the lifeboat and raft accommodation on board such ships should be based on the number of persons intended to be carried in the ship ....."

To see the detailed case material, click as shown below:

Maritime Disasters

Rail Disasters

Aviation Disasters

You should briefly familiarise yourself with the layout and content of this material, and then work your way through the exercises below. These will highlight selected key aspects of the case material, and prepare you for the theoretical analysis in Unit HE2.

LESSON RATIONALE: This particular body of case material contains repeated examples of what can go wrong with the design, construction, or operation of modern transportation systems. These lessons of history are therefore a rich research resource for the designers, builders, and operators of tomorrow's systems when carrying out their risk analyses, quality checks, and audits.

EXERCISES (AND STANDARD STUDY TIMES): Depending on how thoroughly you have been exploring the hyperlinks provided, it has probably taken you less than 30 minutes to read the foregoing text, and now you have to do some real work. Complete the following exercises, taking careful note of the expected study times:
HE1.1.0	Browse the Internet, starting with the keywords <air sea rail disaster>, but probing ever more deeply and widely as other potential keywords take your eye. Look to build up a small e-folio of useful general commentary, recent research, and up-and-coming new theories (advertisements for forthcoming conferences are very useful in this respect). Study this information carefully, and you will suddenly find yourself as good at, if not better than, the experts in your organisation. Specialist reference archives are particularly valuable so note their location carefully. The Times and other news archives should be particularly fruitful in this respect. [No formal time limit.]
HE1.1.1	In which of the air disasters listed was the pilot too polite to remind Air Traffic Control that he was running out of fuel. How many died? [2 minutes, once familiar with the list.]
HE1.1.2	In which of the air disasters listed were junior members of the flight crews unwilling to correct mistakes by their seniors? [2 minutes, once familiar with the list.]
HE1.1.3	List all the rail disasters where SPD was a factor. [5 minutes, once familiar with the list.]
HE1.1.4	List all the disasters (any category) which resulted in major new procedures being implemented. [5 minutes, once familiar with the list.]
HE1.1.5	List all the disasters (any category) which resulted from fundamental design errors. [5 minutes, once familiar with the list.]
HE1.1.6	List all the disasters (any category) which resulted from prior warnings being ignored or overruled. [5 minutes, once familiar with the list.]
HE1.1.7	List all the disasters (any category) which resulted from communication breakdown between humans. [5 minutes, once familiar with the list.]
HE1.1.8	List all the disasters (any category) which resulted from communication breakdown between human and computer. [5 minutes, once familiar with the list.]
Submitting Exercises for Assessment and Feedback (Fee-Paying Clients Only): Simply e-mail your answer(s) for full tutorial feedback. State each conclusion clearly, and briefly explain how you arrived at it. You may do this one exercise at a time, or all at once. Additional questions may then be asked, and additional tasks given as required. [Submit an Exercise] Please cooperate with this student-tutor exchange, because it will eventually form the basis of your individual student progress record. Do not proceed to Lesson HE1.2 until all the tutorial tasks are completed and signed off.

Lesson HE1.2: Avoidable Major Disasters - Industrial Installations

Recommended Reading: "New Perspectives: Chernobyl and Other Nuclear Accidents" Condon, J. (1998)

To see an abstract, or to order this book, click here.

[Chernobyl thumbnail]

UNDER CONSTRUCTION

EXERCISES (AND STANDARD STUDY TIMES): Depending on how thoroughly you have been exploring the hyperlinks provided, it has probably taken you less than 30 minutes to read the foregoing text, and now you have to do some real work. Complete the following exercises, taking careful note of the expected study times:
HE1.2.0	Browse the Internet, starting with the keywords <industrial mining disaster>, but probing ever more deeply and widely as other potential keywords take your eye. Look to build up a small e-folio of useful general commentary, recent research, and up-and-coming new theories (advertisements for forthcoming conferences are very useful in this respect). Study this information carefully, and you will suddenly find yourself as good at, if not better than, the experts in your organisation. Specialist reference archives are particularly valuable so note their location carefully. The Health and Safety Executive archives should prove particularly fruitful in this respect. [No formal time limit.]
Submitting Exercises for Assessment and Feedback (Fee-Paying Clients Only): Simply e-mail your answer(s) for full tutorial feedback. State each conclusion clearly, and briefly explain how you arrived at it. You may do this one exercise at a time, or all at once. Additional questions may then be asked, and additional tasks given as required. [Submit an Exercise] Please cooperate with this student-tutor exchange, because it will eventually form the basis of your individual student progress record. Do not proceed to Lesson HE1.3 until all the tutorial tasks are completed and signed off.

Lesson HE1.3: Avoidable Major Disasters - Crowd Control

Recommended Reading: "The Day of the Hillsborough Disaster" Taylor, R., Ward, A., and Newburn, T. (Eds.) (1995)

To see an abstract, or to order this book, click here.

[no thumbnail available]

Here are some reminders of the sort of thing which can periodically go wrong at crowded events:

61 teenagers died in a Halloween disco fire on 29th October 1998 in Gothenburg, Sweden. The fire was started deliberately in an emergency stairwell following an argument over the cost of admission.

49 party-goers died in a disco fire on 20th October 2000 in Mexico City, Mexico. Evacuation was hampered by there being only a single available exit, and by the first to the door being stopped and asked to settle their bills first!

309 party-goers died in a disco fire on 25th December 2000 in Luoyang, China. The privately run dance hall was operating illegally and emergency exits were blocked.

To see the detailed case material LINK NOT YET AVAILABLE. You should briefly familiarise yourself with its layout and content, and then work your way through the exercises below. These will highlight selected key aspects of the case material, and prepare you for the theoretical analysis in Unit HE2. We have included several cases of fire disaster under this heading, because of the need to design hotels and discos and the like for rapid evacuation, and to operate them to the highest procedural standards.

LESSON RATIONALE: This particular body of case material contains repeated examples of what can go wrong with the design, construction, or operation of crowd control and safety systems. These lessons of history are therefore a rich research resource for the designers, builders, and operators of tomorrow's systems when carrying out their risk analyses, quality checks, and audits.

EXERCISES (AND STANDARD STUDY TIMES): Depending on how thoroughly you have been exploring the hyperlinks provided, it has probably taken you less than 30 minutes to read the foregoing text, and now you have to do some real work. Complete the following exercises, taking careful note of the expected study times:
HE1.3.0	Browse the Internet, starting with the keywords <disco fire>, but probing ever more deeply and widely as other potential keywords take your eye. Look to build up a small e-folio of useful general commentary, recent research, and up-and-coming new theories (advertisements for forthcoming conferences are very useful in this respect). Study this information carefully, and you will suddenly find yourself as good at, if not better than, the experts in your organisation. Specialist reference archives are particularly valuable so note their location carefully. The National Fire Protection Association archives should prove particularly fruitful in this respect. [No formal time limit.]
Submitting Exercises for Assessment and Feedback (Fee-Paying Clients Only): Simply e-mail your answer(s) for full tutorial feedback. State each conclusion clearly, and briefly explain how you arrived at it. You may do this one exercise at a time, or all at once. Additional questions may then be asked, and additional tasks given as required. [Submit an Exercise] Please cooperate with this student-tutor exchange, because it will eventually form the basis of your individual student progress record. Do not proceed to Lesson HE1.4 until all the tutorial tasks are completed and signed off.

Lesson HE1.4: Avoidable Major Disasters - Strategic Mismanagement and Fraud

Recommended Reading: "All That Glitters: The Fall of Barings" Gapper, J. and Denton, N. (1997)

To see an abstract, or to order this book, click here.

[Barings thumbnail]

UNDER CONSTRUCTION

EXERCISES (AND STANDARD STUDY TIMES): Depending on how thoroughly you have been exploring the hyperlinks provided, it has probably taken you less than 30 minutes to read the foregoing text, and now you have to do some real work. Complete the following exercises, taking careful note of the expected study times:
HE1.4.0	Browse the Internet, starting with the keywords <strategic decision disaster>, but probing ever more deeply and widely as other potential keywords take your eye. Look to build up a small e-folio of useful general commentary, recent research, and up-and-coming new theories (advertisements for forthcoming conferences are very useful in this respect). Study this information carefully, and you will suddenly find yourself as good at, if not better than, the experts in your organisation. Specialist reference archives are particularly valuable so note their location carefully. The Department of Trade and Industry, National Audit Office, Welsh Assembly, and Hansard electronic archives should be particularly fruitful in this respect. [No formal time limit.]
Submitting Exercises for Assessment and Feedback (Fee-Paying Clients Only): Simply e-mail your answer(s) for full tutorial feedback. State each conclusion clearly, and briefly explain how you arrived at it. You may do this one exercise at a time, or all at once. Additional questions may then be asked, and additional tasks given as required. [Submit an Exercise] Please cooperate with this student-tutor exchange, because it will eventually form the basis of your individual student progress record. Do not proceed to Lesson HE1.5 until all the tutorial tasks are completed and signed off.

Lesson HE1.5: Avoidable Major Disasters - IT Project Mismanagement

Recommended Reading: "PRINCE 2: An Outline" Central Computer and Telecommunications Agency (1997)

To see an abstract, or to order this book, click here.

[PRINCE jacket]

Here is a reminder of the sort of thing which can go wrong with large computer systems, typically those funded by taxpayers and shareholders:

A cautionary tale - it was your money: The Home Office's CASEWORK system, designed to speed up the processing of asylum applications, has recently been scrapped at a cost of £80 million, and immigration service officers are resorting to fallback procedures to deal with the casework backlog (Daily Mail, 16th February 2001).

To see the detailed case material, click here. You should briefly familiarise yourself with its layout and content, and then work your way through the exercises below. These will highlight selected key aspects of the case material, and prepare you for the theoretical analysis in Unit HE2.

LESSON RATIONALE: This particular body of case material contains repeated examples of what can go wrong with the design, construction, or operation of large corporate IT systems. These lessons of history are therefore a rich research resource for the designers, builders, and operators of tomorrow's systems when carrying out their risk analyses, quality checks, and audits.

EXERCISES (AND STANDARD STUDY TIMES): Depending on how thoroughly you have been exploring the hyperlinks provided, it has probably taken you less than 30 minutes to read the foregoing text, and now you have to do some real work. Complete the following exercises, taking careful note of the expected study times:
HE1.5.0	Browse the Internet, starting with the keywords <computing disaster>, but probing ever more deeply and widely as other potential keywords take your eye. Look to build up a small e-folio of useful general commentary, recent research, and up-and-coming new theories (advertisements for forthcoming conferences are very useful in this respect). Study this information carefully, and you will suddenly find yourself as good at, if not better than, the experts in your organisation. Specialist reference archives are particularly valuable so note their location carefully. The Computer Weekly electronic archives should be particularly fruitful in this respect. [No formal time limit.]
HE1.5.1	List all the IT disasters where project management deficiencies were a contributory factor. [5 minutes, once familiar with the list.]
HE1.5.2	List all the IT disasters where underestimation was a contributory factor. [5 minutes, once familiar with the list.]
HE1.5.3	[Informatics programme students only] List all the IT disasters which could have been avoided by better application of BS7799. [5 minutes, once familiar with the list.]
Submitting Exercises for Assessment and Feedback (Fee-Paying Clients Only): Simply e-mail your answer(s) for full tutorial feedback. State each conclusion clearly, and briefly explain how you arrived at it. You may do this one exercise at a time, or all at once. Additional questions may then be asked, and additional tasks given as required. [Submit an Exercise] Please cooperate with this student-tutor exchange, because it will eventually form the basis of your individual student progress record. Do not proceed to Lesson HE1.6 until all the tutorial tasks are completed and signed off.

Lesson HE1.6: Avoidable Major Disasters - Military Incompetence

Recommended Reading: "On the Psychology of Military Incompetence" Dixon, N. (1994)

To see an abstract, or to order this book, click here.

[Dixon jacket]

LESSON RATIONALE: This particular body of case material contains repeated examples of what can go wrong with the design, construction, or operation of military command and control systems. These lessons of history are therefore a rich research resource for the designers, builders, and operators of tomorrow's systems when carrying out their risk analyses, quality checks, and audits.

EXERCISES (AND STANDARD STUDY TIMES): Depending on how thoroughly you have been exploring the hyperlinks provided, it has probably taken you less than 30 minutes to read the foregoing text, and now you have to do some real work. Complete the following exercises, taking careful note of the expected study times:
HE1.6.0	Browse the Internet, starting with the keywords <military incompetence>, but probing ever more deeply and widely as other potential keywords take your eye. Look to build up a small e-folio of useful general commentary, recent research, and up-and-coming new theories (advertisements for forthcoming conferences are very useful in this respect). Study this information carefully, and you will suddenly find yourself as good at, if not better than, the experts in your organisation. Specialist reference archives are particularly valuable so note their location carefully. Various nations have their respective Institutes of Strategic Study on the Internet, whose archives may be worth a look. [No formal time limit.]
Submitting Exercises for Assessment and Feedback (Fee-Paying Clients Only): Simply e-mail your answer(s) for full tutorial feedback. State each conclusion clearly, and briefly explain how you arrived at it. You may do this one exercise at a time, or all at once. Additional questions may then be asked, and additional tasks given as required. [Submit an Exercise] Please cooperate with this student-tutor exchange, because it will eventually form the basis of your individual student progress record. Do not proceed to Lesson HE1.7 until all the tutorial tasks are completed and signed off.

Lesson HE1.7: Everyday Accidents

Here are some reminders of the sort of thing which can happen to any of us at any time:

A cautionary tale - in the wrong place at the wrong time: Between 1980 and 1999, 27 US and Canadian children aged between 2 and 14 years died from suffocation, having become trapped in discarded chest freezers, even though all products manufactured after 1970 have catches which can be opened from the inside. Most of the 9 million chest freezers manufactured prior to 1970 had latches which snapped shut on closure, and could only be opened from the outside, a design which with the benefit of hindsight was an unnecessary risk. Similarly, between 1972 and 1997, there were 31 separate fatalities on US roller coaster rides [for details, click here].

A cautionary tale - in the wrong place at the wrong time: At the Australian Grand Prix on 4th March 2001, a race marshall was hit in the chest by a roadwheel which had sheered off Jacques Villeneuve's BAR race car, following a 175 mph collision with the crash barriers. This followed the death of an Italian marshall at Monza in September 2000.

"A five-year-old British boy has been in a coma for almost two weeks after a skiing accident in which his neck was trapped by a safety bar on a chair lift in the French Alps. [The boy] was flown to hospital by helicopter after he arrived at the top of a slope with the bar fastened across his neck, trapping his throat against the chair rail. His shocked parents were told by witnesses that the three adults who had shared the ski lift with their son simply handed [him] to the lift attendant at the top, saying he had had a blackout. They then skied off." (The Sunday Times, 28th April 1996.)

"[The girl] lost control at speed on a corner on the 160 meter run after the wooden toboggan hit a tree before flipping over. She smashed her head against a rock hidden beneath the snow and was knocked unconscious. Later surgeons declared her clinically dead. [] No one appears to have been wearing helmets. [The organiser] said last night: 'We are all devastated. I had trained safety advisers give all of the people on the toboggan run full instructions before they set off. You can't do any more than that.'" (The Daily Mail, 21st February 2001.)

The relative contribution of drink driving, seat belts, speeding, road design, vehicle design, and road safety education has recently been summarised on the Health Evidence Bulletin Wales website [for details, click here].

There is no separate file of case material under this heading, so you should briefly familiarise yourself with the resources shown above, and then work your way through the exercises. These will highlight selected key aspects of the case material, and prepare you for the theoretical analysis in Unit HE2.

LESSON RATIONALE: This particular body of case material contains repeated examples of what can go wrong with the design, construction, or operation of road traffic and other everyday systems. These lessons of history are therefore a rich research resource for the designers, builders, and operators of tomorrow's systems when carrying out their risk analyses, quality checks, and audits.

EXERCISES (AND STANDARD STUDY TIMES): Depending on how thoroughly you have been exploring the hyperlinks provided, it has probably taken you less than 30 minutes to read the foregoing text, and now you have to do some real work. Complete the following exercises, taking careful note of the expected study times:
HE1.7.0	Browse the Internet, starting with the keywords <accident prevention> and <road safety>, but probing ever more deeply and widely as other potential keywords take your eye. Look to build up a small e-folio of useful general commentary, recent research, and up-and-coming new theories (advertisements for forthcoming conferences are very useful in this respect). Study this information carefully, and you will suddenly find yourself as good at, if not better than, the experts in your organisation. Specialist reference archives are particularly valuable so note their location carefully. The Department of the Environment, Transport, and the Regions (DETR) and Royal Society for the Prevention of Accidents (RoSPA) electronic archives should be particularly fruitful in this respect. [No formal time limit.]
Submitting Exercises for Assessment and Feedback (Fee-Paying Clients Only): Simply e-mail your answer(s) for full tutorial feedback. State each conclusion clearly, and briefly explain how you arrived at it. You may do this one exercise at a time, or all at once. Additional questions may then be asked, and additional tasks given as required. [Submit an Exercise] Please cooperate with this student-tutor exchange, because it will eventually form the basis of your individual student progress record. Do not proceed to Lesson HE1.7 until all the tutorial tasks are completed and signed off.

Lesson HE1.8: Medical Error

Here are some reminders of the sort of thing which can happen to any of us in even the most trivial encounters with our respective healthcare systems:

"A London hospital trust is reviewing its computer systems after a programming error led to cancer patients being given the wrong doses of chemotherapy []. The hospital traced the mistake to an instruction in a computer program which had been typed in lower case instead of capital letters." (Computer Weekly, 14th May 1998.)

"An 18 year old cancer patient is expected to die [and subsequently did] after doctors mistakenly injected a drug [vincristine] into his spine. [] The Department of Health is aware of 13 similar cases since 1985, of which 11 were fatal ....." The Times, 24th January 2001.

"The latest victim of a hospital injection blunder died yesterday as an enquiry began into the tragedy. The unnamed patient had spent three days in intensive care after an 'experienced consultant' injected a local anaesthetic [bupivicaine] into a vein instead of the spine." The Mail on Sunday, 11th February 2001.

"A little girl died in hospital because she was poisoned with 'laughing gas' when she should have been given oxygen, it emerged last night. The death of [the three year old] was the third fatal blunder by NHS staff to be revealed in recent weeks, raising disturbing questions over the safety of patients in Britain's overstretched NHS," The Daily Mail, 15th February 2001.

"..... despite [the 13 month old boy] showing classic signs of meningitis, medics told his family 'not to fuss' and treated the child with Calpol, the infant pain relief medicine. Hospital staff, who were apparently enjoying their Christmas buffet, then ignored [the boy] as his condition worsened, leaving his increasingly worried family to care for him, is it claimed" (Daily Mail, 21st February 2001).

LESSON RATIONALE: This particular body of case material contains repeated examples of what can go wrong with the design, construction, or operation of healthcare systems. These individually minor lessons of history are therefore a rich research resource for the designers, builders, and operators of tomorrow's healthcare systems when carrying out their risk analyses, quality checks, and audits.

EXERCISES (AND STANDARD STUDY TIMES): Depending on how thoroughly you have been exploring the hyperlinks provided, it has probably taken you less than 30 minutes to read the foregoing text, and now you have to do some real work. Complete the following exercises, taking careful note of the expected study times:
HE1.8.0	Browse the Internet, starting with the keywords <medical error>, but probing ever more deeply and widely as other potential keywords take your eye. Look to build up a small e-folio of useful general commentary, recent research, and up-and-coming new theories (advertisements for forthcoming conferences are very useful in this respect). Study this information carefully, and you will suddenly find yourself as good at, if not better than, the experts in your organisation. Specialist reference archives are particularly valuable so note their location carefully. The British Medical Association, Department of Health, and NHS electronic archives should be particularly fruitful in this respect. [No formal time limit.]
Submitting Exercises for Assessment and Feedback (Fee-Paying Clients Only): Simply e-mail your answer(s) for full tutorial feedback. State each conclusion clearly, and briefly explain how you arrived at it. You may do this one exercise at a time, or all at once. Additional questions may then be asked, and additional tasks given as required. [Submit an Exercise] Please cooperate with this student-tutor exchange, because it will eventually form the basis of your individual student progress record. Do not proceed until all the tutorial tasks are completed and signed off.

So Where To Next?

If you have got to this point by mistake, click to return as appropriate:

Otherwise, congratulations!! You have reached the end of the DISASTERS (EXAMPLES OF) study unit, and will probably want to get to grips with the accompanying theory. Click to proceed as appropriate, and good luck!

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References

REFERENCES ARE GIVEN AT THE END OF UNIT HE2