Description:
Written Assignment:
Word limit: 1500 words
Choose an incident, accident or event (but not the Cave Creek incident) that has had significant disastrous outcome. Analyse and comment on the events that led to the potentially disastrous incident.
Consider:
• What happened to make the event significant and disastrous
• Analyse the details of what led to the disastrous outcome (i.e. what and why things went wrong) in terms of active failures and latent conditions. Think about the Failure Pathway while you analyse this.
• Discuss any codes of practice (written guidelines by an official association) and legislation that may have been present at the time of the event and how the presence or absence of these may have influenced the disastrous outcome.
• Examine what may have been different if the current Risk Management Standard (ISO31000) and other current codes of practice had been available at the time of the event.
More explanation:
Part of the assignment instructions read: Discuss any codes of practice (written guidelines by an official association) and legislation that may have been present at the time of the event and how the presence or absence of these may have influenced the disastrous outcome.
• Examine what may have been different if the current Risk Management Standard (ISO31000) and other current codes of practice had been available at the time of the event.
• The idea here is that you demonstrate awareness of the current standards and explore if any of those, or other, codes of practice (written guidelines by an official association) were present or not
• Would things have been different if there was such a thing as the ISO31000 at the time of the event?
• What codes of practice were present at the time?
• It is not so much about huge detail or being certain of how things might have been different. It is about showing that you are able to think about how the codes of practice, officially or unofficially, might or might not have applied to the event.
• Additionally you will want to mention what legislation or codes of practice were present at the time (and perhaps compare these to the current codes or practice or at least what impact they had on the event).
• For example for Ballantynes Fire you might wish to mention the Fire Boards Fire Escape By Law or the Fire Brigade Act (1926).
• For Erebus the list is far more extensive and includes things such as: Civil Aviation Authority; Air Safety Regulations; Air NZ Policies; McMurdo Base Air Traffic Control protocols and policies; Civil Aviation Regulations (1953);
• For the Wahine it may include things such as International Convention on the Safety of Life at Sea (1948); New Zealand Shipping and Seamen’s Act (1952); Marine Department, Government of New Zealand; Lloyd’s Register of Shipping
• Present your assignment at the appropriate academic standard.
Recommended readings for this include:
Systems Safety in the wake of the Cave Creek Disaster by Phillip Capper John Reason’s article on Active Failures and Latent Conditions
Some examples of incidents you might like to explore in New Zealand:
• Mt Erebus (1979)
• Tangiwai Rail (1953)
• Army cadet at Ruapehu (1990)
• Gold mine collapse in Wahi (2001)
• Wahine (1968
• Ballantyne’s fire in Christchurch (1947)
• Pike River (2010)
• Air NZ Ansett 703 crash near Palmerston North (1995)
• Mangatepopo Stream / Elim School Tragedy (2008)
• Seacliff Hospital (1942)
• Piper Navajo Aircraft crash at Christchurch Airport (2003)
Or any other major incidents or disasters that you would like to explore further.