Disasters: Prevention, Preparation and Post-mortem

The study of disasters reveals a consistent mixture of bad design, poor safety procedures and human error. Human error arises from factors such as fatigue, boredom, lapses of attention and occasional inexplicable inaccuracy in reading the instruments.

An analysis of 251 accidents in the chemical industry by a Lloyd surveyor showed that all the human failure accounted for about a third, poor design and inadequate basic maintenance played a significant role. Operational, as opposed to operator, failure accounted for nearly half. It is useful to bear these findings in mind in considering safety policies.

Numerous statues have as their central aim the promotion of greater safety. One of the most significant in terms of numbers potentially affected is the Health and Safety at Work Act 1974, but many others deal with the areas of wide concerns including The Environmental Protection Act, The Civil Innovation Act 1982, The Merchant Shipping Act 1988, and The Offshore Safety Act 1992.

Road traffic legislation is largely motivated by safety worries, building regulations also have a safety angle, as does The Consumer Protection Act, 1987. The Food Safety Act 1990 reflects the growing anxieties about hazards in the food chain.

Many recent disaster enquiry reports have revealed weaknesses in management strategies in relation to health and safety at work. In their study of work of the Health and Safety Inspectorate, Hutter Lloyd- Bostock refer to the “power of accidents” both to assist in the effective enforcement of safety laws and sometimes to interfere with it.

In terms of safety prevention, more maybe gained from patient observation of data about minor incidents than from a particular major accident. Inspectors gain their information from extensive accident reporting which is required under the legislation. Any accident occurring or in connection with the work and resulting in three or more days incapacity and any injuries requiring 24 hours in hospital as reportable to the Heath and Safety Commission.

An important aspect of safety work is the communication of risk and hazard findings. In the professional and exports sphere communication of the wider implications of accident investigations is done through National Industrial Groups which are part of Factory Inspectorate. Each National Industrial Group has a specific industry to watch, for example, chemical or steel. Investigation of accidents can draw attention to areas of risk and therefore may lead to prevention, but investigation is time-consuming and may distract inspectors from preventive visits. The resources available for either of these types of preventive works are limited with 638 Factory Inspectors for 4, 00,000 workplaces, 171 Agriculture Inspectors 3,00,000 workspaces and 52 Railway Inspectors for entire railway network.

The work of Heath and Safety Commission has attracted far more attention as an area of in-depth regulatory behavior than that of other agencies which also engage in preventive work, such as the fire service. Somewhat surprisingly, it is only in the last 20 years that fire preventive has been placed on statutory footing.

Mitigation

The term nearly involves the process of calculating costs against the benefits. So far the discussion has been concerned with imposition of regulatory schemes which require those engaged in some business activities or those who employ others in their enterprises to observe particular standard. Level of inspection, and the amount of revenue devoted to these regulatory schemes are reflections to the acceptability of the various risks. Should people whose homes are in high risk areas for land slip or for flooding, be required, encouraged or given financial incentives to move elsewhere? Should farmers have to consider the wider impact of their land use systems such as long term soil erosion? As well as being public policy questions, in order for people to make decisions about such matters they need to feel confident about the risk predictions that are available to them.

Communication of information about this hazard and risk to the public may play a key role in the prevention and mitigation of disasters. The more that is known about “choice in the face of adversity” the better. Engineering-based approaches to mitigation emphasis protection, defense, constraint and control.

A universal example is that of the bush-fires which threatened the outskirts of Sydney in the early weeks of 1994. New South Wales authorities had embarked on a fire management strategy in the 1970s, which involved burning selected forest areas in the cooler months. Protests about polluting effects led to the abandonment of the plan. At the same time, builders continued to construct houses close to forest areas. The Mississippi flooding in 1993 also demonstrated the difficulties of separating human from natural cause and of getting the right balance in safety measures. Efforts to control local flooding were thought to have exacerbated the damage caused when the river eventually did flood.

Four distinct behavior patterns have been noted amongst people who live in hazardous place:

• Passive acceptance of risk , “it doesn’t matter what I do”
• Taking action to reduce further losses, “I must be ready”
• Drastic change in land use considered, “I will not let it happen”  
• Risk denial, “it will never happen again”

Planning for Disaster

Disaster relief and disaster preparedness are closely connected with the wealth and living conditions. Disasters occur through interaction between natural forces and socio-technical systems. Statistics of the largest natural disaster of the past years shows that high-cost damage occurs in highly developed countries, while in less developed countries people lose lives and financial and economic consequences are most severe. The after effect to local and national economies following disaster is not inconsiderable. Rapid population growth, unlimited urbanization, shrinking natural resources and newly emerging technologies are together to form a powerful explosive brew. The International Decade for Natural Disaster Reduction (IDNDR) is a call to all governments and the international community to work together to reduce these disaster effects particularly in developing areas.

Rosenthal suggests some words of warning:

Firstly, that crisis reality is not as homogeneous as it sometimes suppose; crises give rise to multiple, sometimes divergent perceptions and definition of the situations. Various interested groups such as political authorities, administrative, operational agencies and private organizations pursue completive and conflicting interests.

Secondly, the tendency for clear-cut stories of success and failure following disasters should be avoided. A crisis for some may be an opportunity for others; the management of disasters is often more complex than appears and can be counter-productive. High degrees of uncertainty and time pressure are elements which need to be recognized in each and every attempt to “manage” crisis. Local rather than centralized decision- making may be appropriate and coordination may prove to be time wasting, with bureaucratic politics still operating at the time of crisis

In United Kingdom the term “Civil Defence” refers to preparing the civilian population to withstand external hostile attack, a task which has traditionally been carried out at local authority level. Much emergency planning for other contingencies such as environmental or technological disasters have emerged from this base. Emergency planning also springs from the local bases of police, fire and ambulance emergency services.

The Civil Defence Act 1948 imposes duty on all local authorities to perform such functions as may be prescribed by the designated Minister. The regulations provide little in the way of obligation to keep plans up-to-date or under regular revision.

As a result of both understandable apathy and resource prioritization, by the 1970’s, when Nuclear weapons became a politically volatile issue, many authorities had all but abandoned any pretense at civil defence planning.

Manchester City Council’s declaration that it was a Nuclear Free Zone in 1980 was followed eventually by 170 other councils. These authorities refused to consider contingency planning for nuclear threat and the Government was forced to cancel it’s “Operation Hardrock” civil defence exercise in 1982, because over a third of authorities refused to participate. The Government was provoked into introducing regulations aimed at forcing authorities to take on Civil Defence again. These imposed a duty on county councils to draw up, keep under review and revise their civil defence plans.

Public Investigation Of Disaster

Inquiries

Major disasters are almost inevitably followed by some form of inquiry. Inquiries following disasters serve a number of purposes. As well as providing a forum to those directly affected, whether bereaved or survivors, can transact their grief and anger or other emotions in a controlled and public manner, they can also furnish an opportunity to exert pressure for policy changes. For example, the resources of Nuclear Installations Inspectorate were increased after Chernobyl, as were those of London Transport after the Kings Cross fire

The Sheen Inquiry into the Herald capsize led directly to establishment of the Department of Transport’s Marine Accident Investigation Branch.

Although there is a tendency to refer to all inquiries following disasters generically as “Public Inquiries”, inquiries can be set up under a number of different statutory bases, although confusingly most of those concerned with disaster aftermath are not “statutory inquiries” within the term of Tribunal and Inquiries  Act. For example The Regulation of Railways Act 1871 or The Civil Aviation Act 1982, exceptionally, established under the 1921 Tribunals of Inquiry Act. These tribunals have power of High Court.

Inquests

One thing disasters in England and Wales have in common is that each death will have been the subject of Inquest. Sudden deaths can be dealt with post-mortem without an inquest, unless death was violent or unnatural. The coroner has a discretion to hold inquest in other cases in order to allay suspicion. Inquests have been pivotal in the move towards corporate manslaughter charges.

In order to bring verdict of unlawful killing, a jury needs to be convinced on the criminal standards of proof that the deaths were caused unlawfully. Before 1980 jury could add a “rider” to their verdict, but was later abolished on recommendation of Brodrick Committee.

The Coroners Act 1988 does not set down a list possible verdicts for the jury. Section 11(3)(a) merely provides that they shall “give their verdict and certify it by an inquisition”; and subsection (5)(b) provides that “an inquisition….shall set out so far as such  particulars have been proved-

• Who the deceased was and
• How, when, and where the deceased came by his death   

The Scottish System: Fatal Accident Inquiries

Death in Scotland is dealt with differently. Under the Sudden Deaths and Fatal Accidents Inquiry Act 1976, a Fatal Accident Inquiry is compulsory only in two circumstances; following a death in employment and following a death in legal custody. This act also abolished the use of juries. The procurator fiscal can also apply to the sheriff to hold an FAI where:

“It appears to be expedient in the public interest…that an inquiry under the act should be held into the circumstances of the death on the grounds that it was sudden, suspicious and unexplained, or has occurred in circumstances such as to give rise to serious public concerns”

The underlying paradox in talking about emergency planning arises from the fundamental nature of disaster- that it can never be predicted, it is out of run of things, a force beyond control. The one thing we know for sure is that the disasters will happen. The dichotomy between preparedness and fatalism pulls perpetually.

By: Navin Kumar Jaggi & Vikram Gupta