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Problem or solution. A Victorian legacy?

The human error debate which followed the case study of a theme park accident, with one of the Train to Safety Management courses the other day was intriguing. (The following day, one member of the group had to attend a disciplinary meeting in which an employee of the company was about to be blamed for causing an accident.) The theme park ride we studied highlighted the quick reaction by the management of the theme park to rapidly investigate and blame the staff member for making a mistake. The HSE completed their more detailed investigation and determined that the operators and engineers who attended the ride had indeed made a combination of mistakes which led to the accident, but these were all directly as a result of organisational failure. The staff were working within a system which was so badly designed that sooner or later, the conditions would certainly emerge that would lead to tragedy. The workers were effectively 'set up'.

Tony Muschara in his book, ‘Risk based thinking’, identified 72 different ways in which humans are subtly influenced to make wrong decisions, mainly to do with the the environment and organisation of the task. Safety specialist, Professor Sydney Dekker in ‘The field guide to Human error’, extol the virtues in our workforce, that workers aren’t the problem but are in fact the solution. Workers don’t set out in the morning to have an accident. The latest statistics: 123 fatalities and 565,000 estimated injuries in the UK in the most recent year, yet we have the best training companies, the best psychologists, the best technical equipment and a highly competent and skilled workforce. We know what we need to do, and we have the resources. So why are we getting it so wrong? The system doesn’t appear to be that great to me. I was at a company earlier this year to complete some risk assessments. Their notice board of accidents and near misses was exemplary with reducing trends over time. There looked to be just one blip, one stain on the board. It was a fatality. That's not how current theory is supposed to work. Is there really a mathematical relationship between near missed and serious injuries? How sad. I cant help thinking that this conscientious and well managed company had been side stepped by an outdated 'great idea' which had diverted their focus.

Maybe its time for a re-think. There are some great ways of changing the Health and Safety landscape out there but sadly I fear that possibly the one thing impeding progress may just be….. managers and directors. Don’t get me wrong, I am working with some visionary managers at the moment and some fantastic companies who really are breaking through the ceiling despite tough trading conditions. However, in the face of global competition I’m not sure as a nation we are up to the challenge. For example, in the last 12 years, Train to Safety have trained over 5,000 contractors to a rigorous CCNSG safety passport. We look at the quality and preparedness of these contractors over the last 12 years and realise that their attitude has changed dramatically, to be far more receptive and accepting of safety standards. In the same time period, how many existing managers have sat on our management courses? Maybe 3% of the number of contractors. A figure which is way out of synchronisation. How many Directors have come to find out what they really need to do to protect their businesses? I can count about 20.

Another example: A colleague who is a line manager in one of the biggest supermarket chains in the land told me their Store Manager was highly critical of their techniques (despite the fact statistically this line manager had evidence to show that their team was the most efficient with less absence than all the other shifts). The manager told them they weren’t ruthless enough with their staff. “Every day when you come into work, you must ensure that you p**s off one member of staff to show who is boss” they repeatedly said. You may think I am making this up; I assure you I am not. Has the Store Manager ever had any formal management training? Of course not. British industry unfortunately is at the mercy of (some of these) donkeys apparently tasked with taking on the role to beat off the foreign competition. People with no formal training, promoted internally, way beyond their capabilities and with no inter-personal skill whatsoever.

A different group of workers attending a supervisors course the other day watched the Spiral to Disaster film, on the Piper Alpha Oil platform disaster some years ago. The group were highly engaged and came up with all the right answers when we discussed the causes. Human error as a result of gross organisational failure and an absence of leadership (on all three platforms involved but especially Piper). We discussed alternative approaches to try and engage workers better instead. They thought if we could treat people as though it wasn't the Victorian era we could make great headway. I told them not to hold their breath.


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