Silver Moor Consulting
  • Home
  • About
  • Consultancy
    • Barrier-based auditing
    • Task design
    • Training & competence
    • Procedures & documents
    • Accident & incident investigation
    • Decision support tools
    • Performance dashboards
    • Risk management >
      • Bowtie risk assessment
    • Operational readiness
    • Safety climate surveys
  • Training
    • Reducing maintenance error
    • Accident investigation training >
      • Accident investigator training
      • Senior accident investigator
      • Root cause analysis
      • On-Train Data Recorder (OTDR) analysis
    • Writing safety critical instructions
    • Bowtie risk methodology
    • Risk assessment
    • Trainer and coaching skills
    • Process mapping
    • Writing better reports
    • Creating a vision
  • Coaching
    • Accident investigator coaching
    • Consultant coaching
    • Manager coaching
  • Contact
  • News
  • Resources
    • Rail images
    • Tram images
    • Bus images
    • Human factors images
    • Event images
    • 1930s road safety advice
    • 1960s railway workshop safety
    • BR Training Manuals
  • Clients
  • Privacy

Norton Fitzwarren rail disasters, November 1890 and 1940

26/11/2018

1 Comment

 
John Baker, our Managing Partner, has researched two railway accidents that happened at the same Somerset village 50 years apart. This research has been in support of Norton Fitzwarren's bid to receive a 'red wheel' heritage plaque from the Transport Trust in recognition of the villagers' efforts to rescue the victims in both crashes. The leader of the project, Mary Hayward, had seen our news article on the 1940 accident and asked if we could help with her research. Of course, we were delighted to help especially since both accidents had a significant 'human factor' element.
​
We have previously written a short article on the 1940 accident, but the accident of the 11th November 1890 was also blamed on 'human error'. In this accident the signaller, George Rice, forgot that he had left a goods train standing on the main line and allowed an approaching fast passenger train into the same section. The passenger train collided with the stationary goods engine, killing 10 passengers and seriously injuring many more.

John's research revealed several new facts about both accidents and also documented more about the victims and those involved. This research has been published on posters that will be displayed in Norton Fitzwarren Village Hall. Copies of the posters for download are included at the end of this article.

As part of the Red Wheel project, John was asked to give a radio interview to the BBC - this is now available on the BBC website.

​On the 17th November, the Transport Trust awarded Norton Fitzwarren with a 'Transport Heritage Site' award. We were delighted to attend to see the culmination of Mary Hayward's work to get the actions of the villagers recognised following these two tragic accidents.

1890 Norton Fitzwarren accident part 1
File Size: 1547 kb
File Type: pdf
Download File

1890 Norton Fitzwarren accident part 2
File Size: 1429 kb
File Type: pdf
Download File

1940 Norton Fitzwarren accident part 1
File Size: 1340 kb
File Type: pdf
Download File

1940 Norton Fitzwarren accident part 2
File Size: 1122 kb
File Type: pdf
Download File

How railway safety has changed
File Size: 1710 kb
File Type: pdf
Download File

Transport Heritage Site award from the Transport Trust
Transport Heritage Site award
Great Western Railway locomotives in the 1890 railway collision at Norton Fitzwarren
Locomotives in the 1890 accident
Great Western Railway coach badly damaged in the 1890 accident at Norton Fitzwarren
Damaged coach in the 1890 accident
Great Western Railway 'King' class locomotive 6028 'King George VI' after being recovered from Norton Fitzwarren in 1940
Locomotive after recovery in 1940
Railway accident site at Norton Fitzwarren in 1940
1940 accident site
Site of the 1940 railway accident at Norton Fitzwarren, taken in November 2018
Site of the 1940 accident
1 Comment

Organisational deficiencies lead to human error in nuclear sector

7/2/2014

0 Comments

 
Nuclear power plant
Research by the International Atomic Energy Authority (IAEA) published in December 2013 showed that 80% of significant events at nuclear power plants can be attributed to human error, while only 20% can be attributed to equipment failure. 
For many years the belief has been that human error is an individual-focused phenomenon or motivational issue. However, it has recently been identified that approximately 70% of these errors are down to weaknesses in organisational processes and cultural values. These organisational deficiencies are often hidden in management processes, structures and values and can create workplace conditions that lead to a human error or reduce the effectiveness of risk control barriers. The full report can be viewed here.

See our pages on how we help organisations manage the conditions that can lead to errors and our accident investigation pages.

0 Comments

Tragic error causes seven deaths on military training exercise

23/1/2014

0 Comments

 
PictureA US Marine firing a 60mm mortar
In March 2013 seven US Marines were killed when a Marine double-loaded a 60mm mortar on a training exercise. Eight other Marines were injured by the explosion.
The investigation concluded that several common 'human factors' led to the accident: 
  • inadequate training and preparation;
  • communication (firing commands);
  • procedures; 
  • supervision, and;
  • task workload. 
See the full news story on the USA Today website.

Fortunately, in industry the outcome of human error is rarely this significant. For details on how we can help identify and manage human factor risks in industry, see our consultancy pages.

0 Comments

    Archives

    November 2020
    November 2019
    June 2019
    April 2019
    March 2019
    November 2018
    June 2018
    May 2018
    December 2017
    September 2017
    March 2017
    February 2017
    January 2017
    November 2016
    September 2016
    July 2016
    June 2016
    May 2016
    April 2016
    March 2016
    February 2016
    November 2015
    October 2015
    May 2015
    March 2015
    February 2015
    January 2015
    November 2014
    October 2014
    September 2014
    June 2014
    March 2014
    February 2014
    January 2014
    December 2013

    Categories

    All
    Accident
    Awards
    Business Skills
    Chartered Management Institute
    Coaching
    Communication
    Construction
    Cranes
    Design
    Distraction
    Events
    Fatigue
    Handover
    Heritage Railways
    Human Error
    Investigation
    Leadership
    Light Rail
    Maintenance Error
    Management
    Medical
    Mentoring
    Metro
    Military
    Mindfulness
    Networking
    Nuclear
    Organisational Failures
    Procedures
    Rail
    Resilience
    Risk
    Rule Compliance
    Social Care
    Strategy
    Supervision
    Task Workload
    Training And Competence
    Tram

    RSS Feed


Silver Moor Business Consulting LLP is registered in England and Wales. Registered Number: OC389666. VAT Registration No. GB 178 0758 72 
Registered Office: Coombe Wood House, Winscombe Hill, Winscombe, North Somerset, BS25 1DH, United Kingdom.

© Silver Moor Business Consulting LLP 2023. All rights reserved.