It's different in the aircraft industry. You might imagine that the legal ramifications of near misses or crashes are such that knowledge relating to them is suppressed: not the case at all. The aeronautical magazines are quick to report all sorts of incidents, often revealing details such as maintenance crews using the wrong bolts, or blind spots on small aircraft. The consequence is that the air industry has a constantly evolving safety culture, where everyone shares and learns from one other. One could argue that this is understandable, given the consequences of failure, but it is odd that it isn't translated into other dangerous industries.
Reading the Cullen report on the Paddington train crash, one is struck by the inevitability of the accident. A signal that had been passed at red/danger eight times in the past six years was passed again by a recently qualified driver who "had not been instructed directly" about signals that might be missed. The signal box was automatically alerted but the signalmen had "a dangerously complacent attitude to 'signals passed at danger'" – SPAD in rail terminology. They treated SPADs as a "driver issue" and had "no adequate training" in what to do in the 33 seconds that elapsed between the SPAD and the crash. The inquiry refers to another SPAD the year before as a "dress rehearsal" for the crash and with hindsight we can see this accident as an "inevitable surprise", to use the title of Peter Schwartz's survival guide to the 21st century. Here, in a sense, we have an accident waiting impatiently to happen and a culture of denial rather than anticipation.
However, before you get the idea that this culture was unique to Railtrack, take a look at NASA. The inquiry into the recent Columbia disaster illustrates the same culture of denial, but goes into a level of detail that is unprecedented in the UK. It comments that "complex systems fail in complex ways", and that "NASA's organisational culture had as much to do with this accident as the foam did" and concludes that "NASA has not demonstrated the characteristics of a learning organisation". It reveals that it knew the day after the launch that there had been a "major foam strike" on the wing and that this had happened on a smaller scale a number of times previously. Attempts to call up defence satellites to image the damage were overridden by senior management and calculations as to the extent of the damage were optimistically interpreted.
I received a very strong letter from Railtrack boss John Armitt and two visits from the British Transport Police
One issue, closer to our industry, was raised by the Institute of Civil Engineers in June, and has to do with the security of energy supply. Although the ICE talked in terms of power cuts in 20 years after the disruption in the supply of the raw materials we use to make our electricity, the truth was just around the corner. The power cuts in the USA, Canada and the UK revealed the vulnerability of developed nations. The systems we have are prone to collapse, open to sabotage and have little distributed robustness. Years of nationalised generation have created a monster, but it may be that a benign inevitable surprise will come to our rescue. The scale of power production is dropping from the megawatt power station to local level – right down to systems built into houses. We are moving from centrally controlled grids to an energy internet – your boiler will act as a power plant while delivering hot water with twice the efficiency.
Returning to trains and questions of possible sabotage, last year I was asked to chair a meeting at the ICE on the Potters Bar accident. Although the accident was subject to a police investigation, there was some talk about short-term lessons the profession could learn. I later learned a sobering lesson about the difference between trains and planes. It came in the form of a very strong letter from John Armitt, Railtrack's chief executive, who didn't think any discussion should take place while an investigation was in progress, followed by two visits from the British Transport Police, complete with evidence bag, who wanted to know who was at the meeting and what they said.
Mark Whitby is the founder of engineer Whitbybird.