Page - 1520 - in Book of Full Papers - Symposium Hydro Engineering

Kings Cross Fire Transport Sector 1987 A fire at this underground station in London killed 31 people. A discarded cigarette probably set fire to grease and rubbish underneath one of the escalators. Organisational changes had resulted in poor escalator cleaning. The investigation pointed to poor fire training and a culture that viewed fires as inevitable. Space Shuttle Challenger Aerospace 1986 An explosion shortly after lift-off killed all seven astronauts on board An O-Ring seal on one of the solid rocket boosters split after take-off releasing a jet of ignited fuel. Inadequate response to internal warnings about the faulty seal design. Decision to go for launch in very cold conditions. Decision making result of conflicting scheduling/safety goals, mindset and effects of fatigue. Total IT failure for British Airways 2017 All flights grounded knock-on costs from stranded passengers and planes “in the wrong place”. According to BA, caused by an employee who disconnected a power supply which created a surge when re-connected. Employee was “not authorized to do what he did” Virgin Galactic crash 2014 Co-pilot unlocked braking system too early The National Transportation Safety Board determined the cause of the breakup of SpaceShipTwo was Scaled Composite’s failure to consider and protect against human error and the co- pilot’s premature unlocking of the spaceship’s feather system as a result of time pressure and vibration and loads that he had not recently experienced. 1520