Re: [SystemSafety] Alton Towers was HF [No Classification]

From: Barnes, Robert A (NNPPI) < >
Date: Fri, 22 Apr 2016 15:44:57 +0000

This message has been marked as No Classification by Barnes, Robert A (NNPPI)

It might fulfil the definition of a 'normal accident' and the failure may have arisen out of an interaction between a number of factors that aren't technical; however, the limitations of the control system (no absolute determination of train position) will not have helped.

Does the UK Health and Safety Executive still publish investigation reports? This is one that I would be interested in getting a look at.


-----Original Message-----

Sent: 22 April 2016 13:13
To: Peter Bernard Ladkin; The System Safety List; Harald Schaub; Karsten Loer; Werner Krämer Subject: Re: [SystemSafety] Alton Towers was HF

I don't agree with the findings as reported. According to the UK Health & Safety Executive's own definition:

"A human error is an action or decision which was not intended. A violation is a deliberate deviation from a rule or procedure."

Disabling the safety system override was an intended violation. Intent is an important distinction in Human Factors analyses.

Best Regards

Dr. Carl Sandom, Director, iSys Integrity Limited, +44 (0) 7967 672560 _________________________________________________________

-----Original Message-----

From: Peter Bernard Ladkin [mailto:ladkin_at_xxxxxx Sent: 22 April 2016 12:04
Subject: Alton Towers was HF

For those who don't know, an amusement park in England, Alton Towers, suffered an accident on its new Smiler ride on 2 June 2015 Some people were seriously injured.

The UK HSE has prosecuted the owner and court proceedings have just started. The owner has pleaded guilty. The technical engineering was all OK. The human engineering not so. Summary: it was HF.

A question for those of you in IEC SC65A WG 17 on HF and functional safety: does your current proposal require measures which, had they been followed, would have avoided this accident?

PBL Prof. Peter Bernard Ladkin, Faculty of Technology, University of Bielefeld, 33594 Bielefeld, Germany Je suis Charlie Tel+msg +49 (0)521 880 7319

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systemsafety_at_xxxxxx Received on Fri Apr 22 2016 - 17:45:18 CEST

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