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BBC Disaster Series

Sample Support Material For more information contact:

Level 3 75 King St

Sydney NSW 2000 Australia

A.B.N. 91 002 025 050

tel. 61 2 9279 4499 fax. 61 2 9279 4488 Email. [email protected] Web. www.futuremedia.com.au

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Fatal Error: PowerPoint Presentation

FATAL ERROR CHOOSING THE WRONG ENGINE

THE P-E-P FACTOR…

Not just learning from the past… but applying the lessons-learnt…

All images and BBC logo © BBC Worldwide 2010


WHAT DOES P-E-P STAND FOR?

• Pre-event • Event • Post-event

We can consider these as representing: ‘before (past)’, ‘during (present)’ & ‘after (future)’.

You will workshop each of these after we watch the video

TODAY’S 2-HOUR P-E-P TALK IS BASED ON THE DISASTER:

Kegworth Air Disaster January 8, 1989



TODAY’S PRESENTATION & THE WORKBOOK – 2-HOUR SESSION

• Introduction – 15 minutes • The Video – 30 minutes • P-E-P exercises – 35 minutes • Assessment & marking – 20 minutes • Applying the lessons & Summary – 20 minutes

WHAT ARE WE EXPECTED TO LEARN? Participants should learn the need for: a) consultative planning & communication in Workplace

Health & Safety matters; b) application, maintenance, review & update of Workplace

Health & Safety management systems; c) clear definition & delegation of Workplace Health & Safety

responsibilities;

CONTINUED NEXT SLIDE…



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WHAT ARE WE EXPECTED TO LEARN? ( CONT.)

P-E-P EXERCISES – 25 mins

d) unambiguous training offi staffiffi (at all levels) on how to ffiulffiil their Workplace Health & Saffiety responsibilities;

e) contingency planning ffior Workplace Health & Saffiety ffiailures (ie ffiire, ffiirst-aid, security, evacuation, clean-up, incident investigation);

ffi) the right to speak-up - and be heard – re. Workplace Health & Saffiety matters.

Now you have watched the video, consider what you have witnessed, & consider what sort(s) offi thing would you place into one offi the three categories?

• Pre-event? • Event? • Post-event?



HINDSIGHT…

• In a ffiully-ffiunctional saffiety system, ‘could have done.’, ‘should have done.’ & ‘might have done the right thing’ are not good enough. It is only ‘did the right thing’ that suffiffiices.

• What ‘right things’ would you put in place?

ASSESSMENT & MARKING - 35mins

True/false questionnaire... • Write your name on the sheet in the space provided • Read through the assessment sheet.

• Place a cross in the ‘true’ or ‘ffialse’ box that best suits your answer • You may reffier to your notes • No talking nor copying, please!

T F

CONTINUED NEXT SLIDE.



OUR WORKPLACE – 15 mins

• Handout 6 – Applying the Lessons Learned outlines the outcomes arising ffirom enquiry into the disaster.

• Consider how these ‘lessons’ might apply to our

workplace?

SUMMARY – 5 mins (text removed)

CONTINUED NEXT SLIDE.



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SPIRAL TO DISASTER PIPER ALPHA

TRAINING PACKAGE

FACILITATOR’S GUIDE

All images and BBC logo

© BBC Worldwide 2010

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FACILITATOR’S GUIDE

CONTENTS

• Contents of the CD • Introduction • Using the package

• Preparing Work Books & Handouts • Running the Ms Power Point Show • Getting a response • Summary

• Facilitator’s checklist

FACILITATOR’S CHECKLIST

THIS BRIEF CHECKLIST IS TO JOG YOUR MEMORY ON SOME THINGS TO CONSIDER WHEN

PREPARING AND PRESENTING TRAINING SESSIONS, ETC.

KEY CONSIDERATIONS CHECK

1. Receive brief outlining delivery of some training/ education/ information/ etc. to others;

2. (text removed)

3. Acquire area appropriate in safety/ environment/ size/ energy supply/ etc. for presentation of above training/etc.;

4. Record names of Participants;

5. Time-keep as appropriate;

6. Scroll through a MS Power Point slideshow (or equivalent), elaborate on key points from slides;

7. (text removed)

8. If required, play a DVD/CD at appropriate time;

9. (text removed)

10. If required, break whole class into relatively similar sized groups at appropriate intervals;

11. (text removed)

12. Encourage group interaction and discussion;

13. (text removed)

14. Thank and farewell the participant/s;

15. (text removed)

AS MUCH AS POSSIBLE, GET INTO THE ROOM/HALL AND TEST YOUR PRESENTATION ON SITE.

(text removed)

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FACILITATOR’S SLIDE GUIDE

SLIDE INSTRUCTION TIME


MAJOR MALFUNCTIONCHALLENGER SPACE SHUTTLE

TRAINING PACKAGE

1


THE P-E-P FACTOR…

Not just learning from the past… but applyingthe lessons-learnt…

5 This slide is an ‘in-passing slide.

Let the Participants know that though we can learn a lot from the mistakes of history, we should actively use that knowledge to prevent a recurrence…

10 MIN

All images and BBC logo© BBC Worldwide 2010

• Pre-event• Event• Post-event

WHAT DOES P-E-P STAND FOR?

We can consider these as representing: ‘before (past)’, ‘during (present)’ & ‘after (future)’.

You will workshop each of these after we watch the video

7 Slowly browse from here to slide 9. Allow the class to ponder the question presented.

Time permitting, allow brief discussion re the causes of the disaster.

(Remind Participants this is a 2 hour presentation, & some folk may have limited time, so you have to minimise personal discussion, but you are ‘available to chat after the show’.)


OUR WORKPLACE – 15 mins

• Handout 6 – Applying the Lessons Learned outlines the outcomes arising from enquiry into the disaster.

• Consider how these ‘lessons’ might apply to our workplace?

35 Pass around H/O 6.

(text removed)

1 HR 40 MIN

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H/O 1: INTRODUCTION to SEVERN TUNNEL PRESENTATION

WELCOME!

Welcome to today’s presentation of the video ‘Crash in the Dark’, which discusses the collision of two trains in the Severn Tunnel in the UK in 1991.

As with other videos in this series, the aim is to use real-life system failure to raise awareness of the potential of similar occurrences in our own workplace: “Can we prevent us heading down the same path to failure?”

(text removed) Whatever the safe system we develop, make sure it is not only practical, but is practically applied!

BACKGROUND BRIEFING

Facility: Severn Tunnel – a tunnel built for rail traffic running between England and Wales

Date of disaster: 7 December, 1991

Event: (text removed)

Though the crash occurred at the Welsh end of the tunnel, emergency crews were informed it had occurred at the English end. (text removed)

KEY SLIDES FROM THE PRESENTATION: (text and images removed)

KEY PHOTOS AND ILLUSTRATIONS (text and images removed)

────────────────────────────────────────────────────────────────────────

H/O 2: P-E-P EXERCISE

(ALLOCATED TIME TO PREPARE REPORT: 15 MINUTES)

This presentation is not necessarily going to make an investigator of you. However, it is handy to know various processes are used by investigation teams to discover ‘what went wrong and what can we do to prevent that happening again’. (text removed)

We are calling these ‘Pre-event’; ‘Event’ and ‘Post-event’: ‘P-E-P’, and this presentation: a ‘P-E-P talk’.

The aim is to encourage you to consider any occurrence, and think about the things that might have led up to it, what happened during the occurrence, and then to consider the after-effects. (text removed)

Some questions to consider

Apart from the standard ‘How and Why and Where and When and Who and What’ questions at each stage, some specific questions to ask at the various phases of the P-E-P exercise might include:

Pre-event (text removed)

Event (text removed)

Post-event (text removed)

Why go to all this trouble?

An example of a ‘shallow’ review of a damaging occurrence vs. a ‘deeper’ study, comes from an Australian safety specialist,..

(text removed)

How many factors might YOU find?

This particular video, “The Wrong Stuff” is a composite of a number of aircraft damaging occurrences and potentially damaging occurrences. There are a number of factors to consider…(text removed)

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H/O 3: P-E-P OUTCOMES

In considering the following commentaries, it is important to know the application of so-called ‘safety case’ risk management techniques – if adhered to – are meant to eliminate or extensively minimise the negative outcomes associated with the various issues arising from the air crash outlined in the video “The Unflyable Plane”.

(text removed)

Note that in each P-E-P section below, the ‘bullet points’ are our notes and the numbered statements are from the conclusions disclosed in the official report into the crash… (text removed)

Pre-EVENT ISSUES

• Potential for failure of 3 hydraulic systems • (text removed)

EVENT ISSUES

• Good luck had it that a back-up, (text removed) • The Captain... (text removed) • Though it may not have made much difference, it was not until later that…(text removed) • The choice of…(text removed)

Post-EVENT ISSUES

• Emergency crews were able to (text removed) • (text removed) • Well-disciplined ground staff…(text removed) • Emergency triage (text removed)

*****

FINALLY, IN ITS REPORT, THE NTSB MADE THE FOLLOWING STATEMENT RE THE ‘PROBABLE CAUSE’ OF THE EVENT SEQUENCE: (text removed)

────────────────────────────────────────────────────────────────────────

H/O 4: CUT PRICE TRAGEDY ASSESSMENT (ALLOCATED TIME TO COMPLETE THIS ASSESSMENT: 10 MINUTES)

Participant’s Name: Date:

Facilitator’s Name:

The following statements are either TRUE or FALSE.

Place a cross x in the box you think is correct.

NUMBER STATEMENT TRUE FALSE

01 (text removed)

02 “Oxygen is not a hazardous substance.”

03 (text removed)

04 ““No clear guidelines existed regarding the disposal of the oxygen generators.”

06 “Indicators existed to demonstrate significant failures in fulfilling legislative demands.” (text removed)

MARK

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H/O 5: ASSESSMENT ANSWERS

(and COMMENTARY)

NUMBER STATEMENT TRUE FALSE

01 “Material Safety Data Sheets (MSDS) only need to be available for…” (text removed)

X

MSDS are to be referred to at …(text removed)

02 “Calculation of risk associated with day-to-day operations…(text removed)

X

In simple terms, general day-to-day business risk calculation is … (text removed)

“Those who fail to plan, plan to fail.”

03 “Engineering controls are not useful in an emergency…”

X

In this emergency, the system of shutting down air-ducts, reconfiguring the pitch of fan blades, etc. can be engineered to alert personnel…(text removed)

In this emergency, a critical engineering failing (that was foreseeable) was …(text removed)

────────────────────────────────────────────────────────────────────────

H/O 6: APPLYING THE LESSONS LEARNED…

(ALLOCATED TIME TO PREPARE REPORT: 10 MINUTES)

The following are the major recommendations after the various findings arising from studies into the 1981 Hyatt Regency Kansas City disaster.

Consider whether your work area has any similar issues, & whether we could improve (or have already improved).

1 Early in the investigation into the incident, it was found the building codes were not followed in either design. (text removed)

2 Though a senior engineer carried-out calculations… (text removed)

3 The Commission found there was… (text removed)

To summarise, most systems come down to these six core points:

1. (text removed) 2. (text removed) 3. (text removed) 4. (text removed) 5. (text removed) 6. (text removed)

MY MARK?

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BBC Disaster Series - Health & Safety Training DVDs Videos … Disaster Series Support Material... · BBC Disaster Series Sample Support Material For more information contact: Level