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Understanding Accidents


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A portion of a newsletter from The Da Vinci Institute, an international centre of excellence in the Management of Technology, Innovation and People (MOTIP) and Technology Top 100, for people seeking to improve business performance through a greater understanding of technology management.

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Charles Hellyar
Managing Member.
Risk Control Rating Systems (SA) CC

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Understanding Accidents

  1. 1. Understanding what causes accidents and how to prevent them happening again A ccidents will happen. Mum He also holds a pilot’s licence, obtained in available to finding the root cause of always said so when someone 1995. accidents and the ways to prevent them spilt milk on the kitchen tiles. His work offers an essential infrastructure happening again. No harm done, she would add. Over the years, people have talked and and methods to develop a customised, Often, though, there is harm done, like when holistic ‘Root Cause Dialectic’ process for the written a lot about Root Cause Analysis. a ferryboat sinks or an airliner crashes. investigation, analysis and mitigation of The television series, ‘Seconds from disaster’, People perish. disasters, accidents and incidents. has brought the images of disaster and When accident investigators finally His thesis recently earned him a PhD in the investigation into living rooms. complete their inquiries and publish their Management of Technology and Innovation What the cameras seldom show, the speakers report, you might safely bet they will attach (MOTI) from The Da Vinci Institute. seldom say and the writers never spell out, blame solely to the last person in the chain It’s entitled ‘Nescience in aviation: a are the complexities of the investigation and of events. phenomenological study of causation and the analytical process to which disasters and Usually, it’s one or more of the individuals consequentialism’, and runs to around 500 incidents are subjected. at the work face: pilots, operators and pages of fact and argument beyond Seldom, if ever, is there any mention that maintenance crews. simplification in an article like this. these processes failed to mitigate against the Fortunately, that need no longer happen, As Hughes asked when interviewed about it: recurrence of such disasters. not just in air crashes, but in any industrial “Where to start, and how much do we talk Yet, during the 30 years of development the or commercial accident, large or small. about?” thesis spans, the process of Root Cause Human factors authority, Joel Hughes, It would have been nice to offer ‘10 easy Analysis has evolved from rudimentary has developed research that sets out a steps’ to finding out what caused an elements being used sporadically, into a topography that is essential to understanding accident’ and 10 more to preventing it highly complex, holistic process that colours the complex nature of cause and happening again, but its not that easy, the very fabric of an organisation and consequence. if possible at all. becomes an essential part of its core. Hughes (61), who holds PhD in Human The value to readers is probably greatest in Hughes argues that, fundamentally, any Factors, is a consultant in systems analysis outlining the problems that the dissertation incident has just two major components: and human performance analysis, and in solves, rather than explaining how it does so. bionomical (human) factors and technical accident investigation and occurrence That said, the dissertation constitutes factors. PAGE 1 1 management. arguably the most pertinent guidelines If initial investigation shows an incident to fit
  2. 2. definitively into one or the other, overall It’s the one which, had it been timeously And academic ignorance of root cause analysis is relatively undemanding. identified and eliminated, would have analysis, he says, remains a crisis of Things become tricky when the root cause is prevented the sequence of events that led endemic proportions. arduously elusive and appears to have both to the undesirable, destructive, costly and During the investigation of an incident, human and technical features. often fatal occurrence. the analyses of the technical components In a complex incident where the root cause Stereotypically, general industry resorts to and human characteristics as a holistic is intangible, the psychologist will ‘putting out fires’ - what Hughes terms undertaking, are inconsistent and characteristically not involve himself in reactive dialectics - to establish the root unaccomplished. analysing its technical aspects. cause of an incident. The void between technical and Conversely, the engineer, with his Industry’s apathy and recklessness in psychological fraternities works against fundamental analytical background, will cohesively pre-empting the root cause of championing investigations done by almost without thinking describe the poor the incident, and obliges them to share individuals qualified only by an engineering performance or failure of complex responsibility if the incident recurs. degree, or worse a national diploma, he technological components as human error. Similarly, there is a need for a universal finds unjust and contemptible. As this unforgiving situation emerges, process of integrating engineering and The immoral insensibility and unprofessional psychological disciplines, to ensure the a natural process of apportionment of blame managerial manoeuvre of apportioning holistic evaluation of the grey area that spirals into play. Invariably, it leads to finger pointing in search of a scapegoat. blame on the last person in the chain of separates them (which Hughes addresses events is unjust and inexcusable. in his disseration). As the drama unfolds, the rationale behind the investigative mechanism is lost. It’s artfully relegated in both priority and status. So the whole mechanism fails in its objective and its value. In the end, the disunion makes people liable and exposes them to punitive action. Many a budget is tested and wasted because, as distressing as it is predictable, the incident will recur, since the fundamental reason why it happened was never definitively established or resolved. Says Hughes: “This is the true quandary behind industry’s failure to prevent some of the greatest disasters of our time.” As Hughes sees it, the definitive root cause PAGE 1 2 of any incident is its most fundamental episode.
  3. 3. Throughout industry, there are many a complex and often protracted investigation human causal factors of the accident with autonomous, sometimes innovative, but and prepares him intellectually and the individual’s innate weaknesses or nevertheless paradoxical approaches to affectively for the task. deficiencies. accident investigation. What’s still needed is The analysis always begins at the technical Until recently, the level of theory used in the a standard on which to base development of aspects. analysis of human error, or its complement, customised methods. As intricate as they may be, they’re definitive human performance, has been relatively More than all else, Hughes would like to see and explicit. So they’re less complex to unsophisticated because of the simplex industry seek proactive dialectics, a way to analyse, their design and functionality are mechanistic view of the human operative, use analysis to prevent the accident before always logical and comprehensible. They whatever his job. it even develops, to eliminate the possible have no personality or emotions. Hughes argues that people make mistakes root cause before it simply becomes For simplicity, the technical analysis is and are often not even aware that a mistake unmanageable. always done in isolation, with no reference to has taken place, let alone why. Worse still, The Dialectic Paragon His dissertation provides the necessary the human or environmental constraints. even when they do recognise that something has three parts: modus operandi to find the root cause of any has happened, they don’t understand how it They’re reintegrated at a later stage, to give a technical performance incident with both procedures - reactive and could have happened or why. holistic analysis and solution. deficiencies; proactive dialectics - using human factor The fragility and wonder of the human mind processes and technical factor processes. Step two is analysis of the natural conditional constraints are the reasons why ‘perfect’ failures occur environment, also in isolation and (the environment) Central to the thesis is what Hughes entitles independent of the technical and human when we are at our optimum performance and bionomical the Dialectic Paragon. deficiencies. But conditional constraints are and therefore when we least expect them to performance deficiencies To you and me, it’s a sort of roadmap to happen. catalogued into technical, human and (human problems). arrive at the truth by stating a thesis, devel- environmental categories. The analyst’s failure to analyse accurately oping a contradictory antithesis and then such an event only goes to complicate an Technical deficiencies are routed back to the combining and resolving them into a coher- already complex and therefore technical analysis process; human ent synthesis. misconstrued sequence of events. deficiencies are recorded for later It’s a method of argument that systematically consideration; and environmental aspects Given then that perfect failures are part and weighs contradictory facts or ideas in an are thoroughly investigated and all relevant parcel of our everyday lives, why should we effort to resolve their real or apparent causal factors recorded. concern ourselves with accurately analysing contradictions. them at such cost and time? Step three is the most complex: proactive The Dialectic Paragon has three parts: profiling of the personnel. It’s a big help The answer is as simple as it is intrinsic. technical performance deficiencies; when mapping an individual’s innate Human failure, the perfect failure, is conditional constraints (the environment) and weaknesses or deficiencies. It also correlates fundamental to our learning, and therefore bionomical performance deficiencies (human the deficiencies associated with the incident teaching, processes - our growth. problems). with the innate deficiencies recorded during Everything we are is a direct result of what Understanding the way the three constituents the profiling. we think. Since our every thought will have PAGE 1 3 work allows the analyst a simple approach to The critical stage is juxtapositioning been influenced in some way by what and
  4. 4. T IPS - NOVEM BER 2 0 0 7 how we were taught, it stands to reason that we require understanding of the evolution of these failures so that we may positively influence the way in which we transfer knowledge and skill to ensure positive change and growth. If a competent individual makes an error, it is often because he or she has fallen into a hole that someone, some situation or even management themselves, have often unwittingly dug for him. So what is to be done? Hughes’s work does offer some pointers, in a chapter he calls areas of concern. Management must be committed to an intellectual and pragmatic balance between revenue and safety. A management team cannot have conflicting interests. A parallel team must be established with the same authority as the management team, but it must focus on, and take responsibility into training systems to ensure that corrective performance but is an archaic methodology for, safety. This will provide a platform for actions gleaned from proactive dialectics are that requires intellectual re-thinking. healthy debate and mature compromise between profit for the development of the effectively incorporated and that lessons Punitive action certainly has its place but is company and safety for its survival. learned from the reactive dialectics are decisively not the holistic solution. implanted vigorously. Management must also create a distinct disunion between the traditional safety Universities need to implement a specific discipline of ‘human factors re-engineering’, department and a dedicated accident to secure its academic status, and to investigation group. integrate psychological and engineering The traditional safety department should disciplines. It’s essential if industry is to retain its day-to-day management of general progress to a next generation of analysts who safety issues while the accident investigation will be expected to work with an exponentially group must be singularly focused on increasing level of sophistication and accident investigation and its associated complexity. corrective actions. Hughes feels punitive action is still the PAGE 1 4 The ‘fire fighting’ processes must be integrated preferred method of managing poor human