NonMedical Examples Modulette G4

1
Non-Medical Examples(Modulette G4)

• Ed Dunn
• VA National Center for Patient Safety
• www.patientsafety.gov

2
NYC Subway Accidents 1996

• NYC Subway accidents in 1996 evoked media
  attention in early 1997
• 55 accidents in 1996 passengers falling out of
  car
• Doors fly open before train in station (43)
• Doors open on wrong side of car (12)
• No previous records of accidents kept by TA
• Union shortcuts in training mand. overtime
  for conductors
• TA no explanation
• TA conductors pointing fingers at each other

3
NYC Subway - Countermeasures

• Union improve conductor training diligence
• NYC TA 1) new rule conductors to look for
  black-and-white panels hanging _at_ mid-station 2)
  new trains will have switches that the driver
  must flick before conductor can open the doors
• Results pre-mature door openings dropped to
  10-17/year (from 43 in 1996) wrong-side openings
  dropped to 4-10/year (from 12 in 1996)

4
Staten Island FerrySeven Ferries that make
daily runs between the St. George Terminal on
Staten Island and Whitehall Street in Manhattan
5
Staten Island Ferry Accidents 1970-1995

• Crash of Andrew J. Barberi in October 2003
  killing 10 passengers - prompted a review of 1500
  Coast Guard records since 1970
• Dozens of Accidents w/ hundreds injured
• Investigators often attributed accidents to crew
  members
• Inattentiveness
• Poor judgment
• Negligence
• Review of inspections / disciplinary hearings
  from 1950s
• Ferry managers for years ignored safety
  recommendations that could have prevented
  injuries

6
Chronicle of High Profile Accidents

• 1995 ferry crashed into dock injuring 16
• Investigators lax safety rules it could have
  been much worse
• 1978 rush hour crash into seawall injuring 200
• Investigators good fortune that no one was
  killed
• 1963 collision sinking ferry Verrazano
• Judgecaptain failed to exhibit unremitting
  vigilance

7
New York Times Investigation via Freedom of
Information ActHuman error is the prime
suspect in the October 15, 2003 Barberi
accident.
8
US Merchant Marine Academy Review of Coast Guard
Records

• 50 accidents since 1978 ferry crashes, slips
  falls, fingers slammed in gates, etc.
• Causes attributed to accidents
• Inexperienced captains allowed to practice
  mooring skills by docking fully loaded ferry
• Poor judgment of captain eg.navigating in fog
• Failure to enforce rule keeping passengers seated
  and away from bow during landings
• Deficient voice announcements in clarity, volume,
  content
• Poor signage on ferries
• Poor equipment on ferries to keep people away
  from dangerous areas during landings

9
Coast Guard Solutions

• Automated announcements to keep passengers
  informed
• Add signs for safety precautions
• After Barberi accident, investigators concluded
  that ferry operators had not implemented the
  Coast Guards recommendations

10
NYC Transportation Authority adoption of CG
recommendations

• Deckhands will use rope barriers to keep
  passengers away from bow during landings
• Three people in wheelhouse until ferry docks
• Lookouts on each ferry
• 1958 ferry Dongan Hills collided w/ a tanker. It
  was found that 2 lookouts had abandoned their
  posts.