Preventing Corporate Accidents Dedication The author dedicates this book to 28 colleagues who died as a result of the explosion at the Nypro Chemical Plant at Flixborough, Lincolnshire, UK on 1st June 1974 and to all those injured, bereaved or in any way affected by the tragedy at the time and since. The book is written in the hope that it will contribute in a small way to the prevention of such accidents in the future. Preventing Corporate Accidents An Ethical Approach R.B. Whittingham AMSTERDAM•BOSTON•HEIDELBERG•LONDON•NEWYORK•OXFORD PARIS•SANDIEGO•SANFRANCISCO•SINGAPORE•SYDNEY•TOKYO Butterworth-HeinemannisanimprintofElsevier Butterworth-HeinemannisanimprintofElsevier LinacreHouse,JordanHill,OxfordOX28DP,UK 30CorporateDrive,Suite400,Burlington,MA01803,USA Firstedition2008 Copyright(cid:2)2008,R.B.Whittingham.PublishedbyElsevierLtd.Allrightsreserved TherightofR.B.Whittinghamtobeidentifiedastheauthorsofthisworkhasbeen assertedinaccordancewiththeCopyright,DesignsandPatentsAct1988 Nopartofthispublicationmaybereproduced,storedinaretrievalsystem ortransmittedinanyformorbyanymeanselectronic,mechanical,photocopying, recordingorotherwisewithoutthepriorwrittenpermissionofthepublisher PermissionsmaybesoughtdirectlyfromElsevier’sScience&TechnologyRights DepartmentinOxford,UK:phone(+44)(0)1865843830;fax(+44)(0)1865853333; email:permissions@elsevier.com.Alternativelyyoucansubmityourrequestonlineby visitingtheElsevierwebsiteathttp://elsevier.com/locate/permissions,andselecting ObtainingpermissiontouseElseviermaterial Notice Noresponsibilityisassumedbythepublisherforanyinjuryand/ordamagetopersons orpropertyasamatterofproductsliability,negligenceorotherwise,orfromanyuse oroperationofanymethods,products,instructionsorideascontainedinthematerial herein.Becauseofrapidadvancesinthemedicalsciences,inparticular,independent verificationofdiagnosesanddrugdosagesshouldbemade BritishLibraryCataloguinginPublicationData AcataloguerecordforthisbookisavailablefromtheBritishLibrary LibraryofCongressCataloging-in-PublicationData AcatalogrecordforthisbookisavailabefromtheLibraryofCongress ISBN:978-0-7506-8062-2 ForinformationonallButterworth-Heinemannpublications visitourwebsiteatbooks.elsevier.com PrintedandboundinU.K. 08 09 10 10 9 8 7 6 5 4 3 2 1 Working together to grow libraries in developing countries www.elsevier.com | www.bookaid.org | www.sabre.org Contents Preface ix Part I Companies at risk 1 Introduction to Part I 3 1 Management error 7 Introduction 7 Human error 9 The corporate environment 14 An ethical approach 16 Afternote 17 References 18 2 The corporate entity 19 Introduction 19 Corporate origins 20 Corporate characteristics 22 Corporate accountability 28 Corporate manslaughter 33 Critique of legislation 45 Conclusion 48 References 49 3 Corporate ethics 50 Introduction 50 Ethics 51 Ethics and the law 53 Individual ethics 58 Corporate ethical behaviour 61 The influence of human actors 64 Managerial and professional ethics 68 Conclusion 72 References 75 Part II Strategies to prevent corporate accidents 77 Introduction to Part II 79 vi Contents 4 Safety culture 83 Introduction 83 Culture 84 Organizational culture 89 Safety culture 98 Changing the safety culture 107 Case studies 111 References 114 5 Understand the risk 116 Introduction 116 What is risk? 117 Expressions of risk 120 Risk assessment 128 Risk perception 137 Case studies 141 References 142 6 Safety regulation 144 Introduction 144 Historical background 145 Safety regulation in the UK 147 Risk acceptance criteria 154 The ALARP principle 158 Reducing the regulatory burden 164 Case studies 170 References 173 7 Safety management 176 Introduction 176 Regulatory and standard setting approaches to safety management 178 Auditing approaches to safety management 185 Behaviour-based approach to safety management 190 Analytical approaches to safety management 197 A systems approach to managing safety 198 Case studies 206 References 208 8 The learning organization 209 Introduction 209 Organizational learning 210 Learning from accidents 215 Building a just culture 230 Information disclosure 234 Case studies in failures of organizational learning 243 References 246 Contents vii 9 Corporate social responsibility 248 Introduction 248 Corporate ethical policy 250 Corporate citizenship 255 Corporate structure models 256 Corporate social responsibility 266 Case studies 273 References 274 10 Conclusions 276 Summary 276 Part I: Companies at risk 277 Part II: Strategies to prevent corporate accidents 281 Case studies 285 A better way forward? 287 References 288 Appendix 1 Case studies in corporate manslaughter 289 Introduction 289 A1.1 The capsize of the Herald of Free Enterprise 290 A1.2 The Southall rail accident 298 References 307 Disclaimer 307 Appendix 2 Case studies in corporate accidents 308 Introduction 308 A2.1 The loss of the space shuttle Columbia 309 A2.2 The Davis-Besse nuclear power plant incident 314 A2.3 The fire and explosion at the Conoco-Phillips Humber oil refinery 318 A2.4 Children’s heart surgery at the Bristol Royal Infirmary, 1984--1995 323 A2.5 The Tokai-Mura criticality accident 330 A2.6 The disposal of the Brent Spar oil storage facility 338 A2.7 The Tylenol incident, Chicago, Illinois, USA, 1982 342 References 344 Appendix 3 Safety management tables 346 Reference 351 Index 353 (cid:84)(cid:104)(cid:105)(cid:115)(cid:32)(cid:112)(cid:97)(cid:103)(cid:101)(cid:32)(cid:105)(cid:110)(cid:116)(cid:101)(cid:110)(cid:116)(cid:105)(cid:111)(cid:110)(cid:97)(cid:108)(cid:108)(cid:121)(cid:32)(cid:108)(cid:101)(cid:102)(cid:116)(cid:32)(cid:98)(cid:108)(cid:97)(cid:110)(cid:107) Preface The idea of writing a book about corporate accidents followed completion of my previous book, which addressed the complex subject of ‘human error’ and its role in accident causation. The importance of the subject was underlined by the fact that according to the UK Health and Safety Regulator around 80 per cent of acci- dents are caused by human error. But when my last book was completed there still seemed to be unfinished business. I was particularly concerned with the part played by the corporate environment in causing (or preventing) accidents, an aspect which was outside the scope of my previous book. I therefore decided to investigate the subject of corporate responsibility for health, safety and environ- ment and in particular the failures of corporate systems which have led in the past to serious accidents often involving many fatalities. The objective is to draw atten- tion to the elements of these higher level systems which are essential to accident prevention in the hope that companies may be able to recognize and correct any deficiencies or improve their existing systems. It turned out that the subject matter is more related to legal, sociological and organizational studies than to engineer- ing, psychology and ergonomics, the disciplines most relevant to my last book and with which most human factors practitioners are familiar. In the first part of the book I have dealt with subjects such as the nature of the corporation and how the legal concept of ‘corporate personhood’ is acted out by various stakeholders in order to fulfil the necessary responsibilities for accident prevention. The book also enters the difficult and sometimes controversial area of corporate ethics and later in the book it is shown how this is an important aspect of preventing corporate accidents. In the second part of the book I have selected six corporate systems which, I believe, when properly addressed, comprise important strategies to pre- vent corporate accidents. In the process I have tried to identify what I believe are the most important elements of these systems regarding accident prevention. The choice of these corporate systems is supported by a number of detailed historical accident case studies described in appendices. If this book can go some way towards assisting companies and their directors, senior managers and safety experts to reduce the chance of a serious corporate accident then it will have ful- filled its purpose.
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