CROSS Safety Report
Learning from historic failures
This report is over 2 years old
This report is not to discuss or preempt the findings of the investigation but to draw attention to historical failures where ground conditions have been highlighted in subsequent Health and Safety Executive (HSE) reports on the incidents.
Key Learning Outcomes
For all built environment professionals:
It is important to raise and maintain an awareness of historical failures with your team and the wider design team
Raising awareness is the first step in the process of bringing about improvements to industry guidance and practices
Find out more about the Full Report
The Full Report below has been submitted to CROSS and describes the reporter’s experience. The text has been edited for clarity and to ensure anonymity and confidentiality by removing any identifiable details. If you would like to know more about our secure reporting process or submit a report yourself, please visit the reporting to CROSS-UK page.
This report is not to discuss or preempt the findings of the investigation but to draw attention to historical failures where ground conditions have been highlighted in subsequent HSE reports on the incidents.
The was the collapse of the NATAM tunnelling on the Heathrow Express project in the central area of Heathrow Airport. In the subsequent investigation by the HSE and their review of NATAM collapses world-wide attention was drawn, from the evidence, that a more detailed ground investigation, along the proposed line of tunnelling, was required when undertaking this kind of work.
The second incident was the Abbystead Underground Pumping Station in 1984 where a methane explosion killed 16 visiting members of the public. The subsequent investigation examined the design and construction process and operation of the pumping station. In the chain of events, it was identified that reliance was placed on geological survey data that was at least 100 years old and that previous mining operations and other geological information was not made available.
Much is being said about learning from past failures but little notice is being taken, possibly because of the factors identified, by Professor Hatamura in Japan, and described as the ‘forest of failures'. There appears to be a need for a ‘social conscience’ in the design and construction phases of a project to maintain an awareness of historical failures and raise these, where appropriate, with the client and designer at the early design of a project. This is, the writer believes, a role for the CDM Co-ordinator.
Expert Panel Comments
Find out more about the Expert Panels
Expert Panels comment on the reports we receive. They use their experience to help you understand what can be learned from the reports. If you would like to know more, please visit the CROSS-UK Expert Panels page.
There are no Expert Panel comments on this report. The Expert Panels are only asked to comment on selected reports. These are normally reports where there is an opportunity for them to help you understand what can be learned from the report.
Submit a report
Your report will make a difference. It will help to create positive change and improve safety.
Our secure and confidential safety reporting system gives professionals the opportunity to share their experiences to help others.
No feedback has yet been published for this page.