As we move towards the 21st century there is an ever-increasing awareness and expectation of the duties and responsibilities of large corporations in matters of health and safety. It is a sad fact that despite advances in modern technology from time to time major disasters occur. Often, perhaps more often than not, these are the result not of one isolated human error or technical failure, but a combination of several operating together. The corporation itself is in the best position to foresee and take steps to avoid such disasters, so why should it not be brought to book in the event of a culpable failure, so the argument runs. In one sense it can be through the strict requirements of the health and safety legislation. But a conviction does not carry the same stigma as a conviction for manslaughter and since one of the purposes of punishment is the emphatic denunciation by the community of the prohibited conduct as a crime, there is a compelling case for a company to be found guilty of manslaughter and punished accordingly when it is guilty of gross negligence that results in death.
Mr Justice Scott Baker, Regina v Great Western Trains Company Ltd 1
Introduction
The title of this book refers to a particular type of industrial accident which the author has termed âcorporate accidentâ and which, at the very start, needs to be defined. Although it is possible that this term has already been used outside the remit of this book, to the author's knowledge âcorporate accidentâ does not have any standardized or accepted meaning and he is able to begin with a clean sheet! Obviously, the meaning of âcorporate accidentâ will become clearer as the book proceeds, but for introductory purposes, here is a very simple definition:
A corporate accident is one whose ultimate root cause can be traced back to a failure of corporate systems.
In writing the book, as during most of his career in accident prevention, the author has been particularly concerned with major industrial or other accidents having severe consequence such as serious loss of life and/or asset damage. Such accidents have, in the past, tended to involve larger organizations whose operations pose a major hazard risk or some other kind of potential threat to their workforce and/or the public or environment if things go wrong. The book includes a number of case studies of corporate accidents, detailed descriptions of which are included in appendices and which are referred to extensively in the text. All these case studies happen to involve larger organizations and cover a wide range of industries as well as being international in their scope. The case studies include the US and Japanese nuclear industry, public transportation systems in the UK as well as accidents in the oil and gas, aerospace and medical sectors. They have been chosen because their root cause has been definitively established by others to be a failure of corporate systems reaching to the highest level of the organization.
Sometimes, corporate accidents are so serious that they have led to a prosecution on perhaps the most serious charge that can be brought against a company, namely a charge of corporate manslaughter. When such prosecutions occur it is usually in relation to multiple-fatality accidents, particularly when members of the public have been killed, raising the level of society's concern about safety in that particular sphere. It is natural, even if slightly sad, that the public aversion to multiple-fatality accidents is disproportionately greater than to single-fatality accidents which, in general, are much less newsworthy. The subject of societal versus individual risk and the perception of risk by the public is discussed in more detail in Chapter 5. The author does not wish to downplay in this book the seriousness of the many thousands of tragic accidents which occur every year resulting in single fatalities, serious injuries or occupational diseases. Some statistics about such accidents are included in Chapter 5 to illustrate the gravity of this problem.
In the case of the more serious accidents, which are the main subject of this book, prosecutions for corporate manslaughter have in the past been quite rare. Certainly in the UK, where charges have been successfully brought and companies found guilty this has, in every single instance, involved small companies where a senior person in the company, such as a director, has been closely associated or identified with the activities leading to the accident. The very few prosecutions for corporate manslaughter brought against large companies have always failed because of the so-called âidentificationâ principle required under common law in the UK. This principle did not allow the corporate body to be charged with a common-law offence unless a person of sufficient seniority could be identified and who could also be prosecuted for manslaughter. The reasons for this are explored in Chapter 2 of the book, which commences with an explanation of the legal basis of the corporate entity. The subject of corporate liability under the law is dealt with in the same chapter, together with a comparison of a company's vulnerability to manslaughter charges in various countries. It also explores the degree to which new corporate manslaughter legislation has brought about greater justice for those affected by a serious accident.
When commencing this book the author assumed that just as the study of workplace error is important to accident prevention (since it has been shown that about 80 per cent of accidents are due to human error), in a similar way, âmanagement errorâ at the administrative level will be important to the prevention of accidents resulting from corporate failure. This initial assumption was largely borne out, but with some surprises. It was discovered that most managers, in an analogous way to workers at the shop-floor level, are often innocent victims of the systems which are imposed upon them and which they are obliged to follow. The main difference between âshop-floor errorsâ and âmanagement errorsâ is the type of systems which govern the way work is carried out. This may be simplified to the distinction between âergonomicâ systems in the case of shop-floor errors and âcorporateâ systems in the case of management errors. This book therefore adopts a systemic approach to human error, as did the previous book.2 In this case it deals primarily with corporate system failure and how to prevent it. A basic knowledge of âhuman factorsâ principles, particularly concerning the ways in which systemic human error occurs, is essential for an understanding of this book. For those not familiar with these concepts, some basic principles are set out in the next section.
At the level of workplace tasks, safe and effective working is highly dependent upon the ergonomics of the systems of work, using the term âergonomicsâ in its widest sense. This would include working instructions and procedures which define closely and often rigidly how the work is to be carried out, the training and experience of the worker, the complexity of the task in relation to this and the quality of the humanâmachine interface (i.e. the equipment provided to carry out the work).
At the administrative or management level, conventional wisdom holds that there is a much greater degree of flexibility in the way work is carried out and the work of others is controlled. It is true that many decisions and practices at this level depend upon the professional judgement and experience of individual managers. At the same time the work of managers is often guided, or sometimes strictly limited, by corporate systems which can constrain the degree of flexibility that is possible. In some cases, the requirements of corporate systems can override professional judgement and experience. If these corporate systems fail to take account of health, safety and environmental considerations then disastrous consequences can ens...
