HARDING MEMORIAL LECTURE | BTS
● It requires cooperation and a shared focus amongst all parties towards a resolution.
● Information must be shared without fear that it may be used against the originator.
If instigated there are still grey areas. Subjective decisions might need to be made concerning what should have been within a person’s experience and training. An investigation of some sort is inevitable, but
how that is undertaken can result in very different experiences, numbers of people involved, and costs. Investigations require a unique approach, and it is therefore difficult to generalize, but the process will require neutral scrutineers acceptable to all sides. A range of skills within the scrutineers will still be required, including, for example, technical, legal and contractual, but resolution should be achieved with less aggravation, fewer diverting accusations and defences, quicker and at a lower cost. Our industry is considered to have made progress
and the worst of the adversarial confrontations are diminishing, but not disappearing. It is moving towards a more open culture that actually encourages reporting, investigation and dissemination of findings. However, it probably still has a way to go. If an incident results in sides being taken, and lawyers and technical experts engaged for each party, then it still haven’t achieved a Just Culture process.
FATALITIES ON PROJECTS As noted, fatalities in their own right do not appear as incidents within general lists of tunnel failures. A fatality may be a result of an incident, for example a flood or a collapse, but they are not measured as a failure for other causes, such as man-machine interface. They do, however, deserve consideration even if not measured in the conventional data pool. The projects listed in figure 4 present the published
most dangerous projects in terms of the total number of fatalities, but the numbers should be viewed with caution. There is some inconsistency in the numbers when checked against different sources. Also, some of the data is estimated, in particular the ‘rounded’ numbers towards the top of figure 4. These projects often used labor that was considered unimportant at the time and records were not kept with any accuracy. It is also likely that there are other reasons that will affect the accuracy of the tabulated data or result in projects not appearing in the figure at all, such as political repression and expediency, and a lack of tracking of workers health in the longer term. The highest number of fatalities for a tunnel project
was on the Hawks Nest Tunnel (USA). The total number shown is an estimate because the fatalities were largely as a result of silicosis, which didn’t manifest itself until many years after the project was completed and the tracking and recording of workers was incomplete. The projects towards the top of the figure are relatively old, while the tunneling projects towards the bottom
of the figure were constructed between the late 1970s and 2000, and tunneling is therefore over-represented within the construction industry during this period. The tunneling fatalities were primarily a result of man- machine interface, use of explosives, flooding or falls of ground. Of these, only the flooding and falling ground events appear as incidents in the earlier data considered on tunnel failures. Tunneling, like other areas of construction, has seen
a vast reduction in the number of fatalities, particularly since the Channel Tunnel. Table 1 summarizes the fatality rates in UK construction covering 10-year periods for the last 40 years, including members of the public who have died as a result of construction activities. Non-fatal injuries have also decreased significantly,
with 103,100 between 2002 and 2011, down to 47,514 between 2012 and 2021. Improvements aside, the numbers are obviously still too high, and the industry needs to change and treat and record injury and fatalities as a failure.
CONCLUSION Why failures happen are less likely to be due to the physical world conspiring against us and are more likely to be due to our own actions or inactions. Making mistakes is just part of being human and we need an approach and a process that recognizes that learning from failure is a necessary ingredient for all of our future successes. To enable that to happen we require a culture that
promotes open discussion and dissemination of results without fear rather than one that promotes stances of protection of self-interest and the considered necessity of confidentiality agreements. The existing ‘Just Culture’ used in other industries might be a good starting point to improve learning opportunities in the industry and prevent the next generation from making the same mistakes that we did.
Burma-Siam Railway (102,000) Suez Canal (120,000)
US transcontinental Railroad (1,500) White Sea-Baltic Sea Canal (25,000) Panama Canal (30,600)
Karakoram Highway (1,000)
Hawks Nest Tunnel (1,000) Erie Canal (1,000)
Fort Peck Dam (250) Aswan Dam (500)
Los Angeles Aqueduct (43) Willow Island Power Plant (51) World Trade Centre (60) Grand Coulee Dam (80) Hoover Dam (213)
New York City Third Water Tunnel (24) Brooklyn Bridge (27)
Oakland Bay Bridge (24)
St Gotthard Road Tunnel (19) Seikan Tunnel (16) Channel Tunnel (12)
Golden Gate Bridge (11)
Below, figure 4:
Published most dangerous projects by number of fatalities
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