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CROSS Safety Report

Learning from historic failures

Report ID: 154 Published: 1 January 2010 Region: CROSS-UK

This report is over 2 years old

Please be aware that it might contain information that is no longer up to date. We keep all reports available for historic reference and as learning aids.

Overview

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

Full Report

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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.

First incident

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.

Second incident

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

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