Railway

Safety
Engineering
MODULE 2 : HOW HARM OCCURS
Learning Objectives

At the end of the activity the student will be able to

learn below topics:

• How does harm occur?

• Mechanism of Failure

• Outcomes of Failure
How does harm
occur?
 Gert construes harm as any
of the following:

1. Death
2. Pain
3. Disability
4. Mortality
Bernard Gert – moral philosopher known 5. Loss of Ability or Freedom
primarily for his work in normative ethics, as
well as in medical ethics, especially
6. Loss of Pleasure.
pertaining to psychology.
Harm
 Mechanisms of Harm

 Active Failures

 Latent Conditions – resident pathogens within a system.

1. Error provoking conditions
2. System deficiencies
Error Provoking Conditions
Example: Road Crashes
System Deficiencies
Example: Hyatt Regency Walkway Collapse
Mechanisms
of
Failure
Trajectory to Failure
• Latent conditions create risk
• Failure often results from
multiple latent conditions
Example: Tenerife Airport Disaster
Risk Triangle

• Example: Hyatt
Regency walkway
collapse
• Design changes not
properly checked
• Led to structural
failure
Outcomes
of
Failure
The Outcome Iceberg

• Potential outcomes of
failure.
• Outcomes resulting in
loss above waterline.
• Outcomes resulting in
no loss below waterline.
Failure Recognition

• More serious failures are

less accepted.
• Immature safety systems
consider only loss
failures.
• Mature safety system
also consider no-loss
failures.
Incident Reporting

• Initial poor safety culture

• Implementation of formal safety systems
• All accidents and incidents reported and
investigated
End of Presentation
Activity No. 1

Search an example of a latent condition and

explain the mechanism and outcomes of failure.
• Error provoking conditions
• System deficiencies