ABSTRACT
The human factor should never be overlooked. People make mistakes, usually because of organisational weaknesses or failures of the systems within which they have to work. The interfaces between people and the hazards, to which they may be exposed, whether they arise from machines, the working environment or the pressures of the job, can be many and complex but they are nevertheless manageable. Failure to take them into account and manage the risks of harm the hazards present can lead to disaster, whereas good training, supervision and communication of information will lead to a competent workforce who can be relied on to identify hazards, foresee and manage risks, and cope well with the unexpected in short, a robust safety culture. This chapter describes the facts, what happened and why, and what happened next, concluding with a short summary of lessons to be learned.
