Learning from failure
12 September 2018 - 09:54
I have recently read a superb book by Matthew Syed called Black Box Thinking. Very, very basically it talks about how successful business sectors have embraced failure (for example the airline industry) and improved the way they think about things that go wrong. Pilots, cabin crew, ground staff are encouraged to talk about things that go wrong so it becomes the norm to tell, not to keep quiet.
Other sectors, however, such as the health sector, still duck their heads in the sand and blame ‘bad luck’ or individuals and struggle to really learn. In any one year over two jumbo jets worth of people die in hospitals through potentially negligent behaviour of surgeons or nurses and it pretty much goes unchallenged. Junior staff see senior staff making mistakes and are frightened to challenge.
What would the outrage be if two jumbo jets crashed each year in the UK?
Now I am not saying the health service is bad, what I am saying is their behaviour and philosophy isn’t set up to challenge failure in a positive way. The book goes far beyond that but generally no one likes to fail and also people don’t like to ‘air their dirty washing’, but if the airline industry still behaved in a closed and protective environment then airlines would be having similar tragic events. If they still blamed people when things went wrong then things wouldn’t be raised and companies in the same sector would also continue to have similar tragic similar events.
Companies in the same sector having similar tragic events, doesn’t that sound familiar?
Nearly every company I have work in and with have had real trouble getting good value from their near miss/hit programme and accident investigations. They may start well but have had trouble maintaining the momentum. Why is that? I believe because it is far too easy to blame. We must ask ourselves do we really want the information. Someone pokes their head up, they get shot at and I'm not just talking about health and safety here.
Do we really have a working environment where people are asked their opinion and listened to, whether it be health and safety, financial, sales or production? Only this week I was on a site where the company had material that was causing a problem operationally, but the sales department were not reacting. There was no joined-up thinking, one side was blaming the other for the issue. That behaviour spreads into the way people feel and you can't just switch that off when health and safety comes along.
How far up the management chain do we really go when we are trying to find the root cause of an incident and, as an industry, how comfortable are we with really being open and honest about why things happen? The airline industry went through a lot of heartache and debate until they really started to get it.
Hey, I haven’t and probably still don’t always get it right. I remember in the early 2000s I was involved in the investigation of an incident in the south east of England. The company I worked for had to move an HV electrical transformer. A specialist HV electrical contractor was called in to isolate the equipment and a crane used to lift and move it, so far so good. The feed to the transformer was found to be locked in the on position by the contractor and for some reason this didn’t raise any alarm bells and nothing was challenged. The lock was cut off by the contractor (very poor practice) and switched off. The transformer was lifted and whilst it was being moved one of the people on the site said that the transformer was humming. It was immediately (and gently) placed on the ground.
NO ONE WAS HURT but it could have easily have resulted in multiple fatalities. Basically, when the switch was turned off it cut the power to a local trading estate. The power company re-routed the electricity and this re-energised the transformer.
As I said no one was hurt, but as a company we investigated as if we had killed people and a whole load of stuff came out. Of our 800+ sites in the UK over 60 had HV but no one really knew who inspected, serviced or switched it. There were no robust maintenance programmes; we were exposed. As a result we employed an HV specialist to run our HV systems. But as far as I am aware that is where it stopped. We were ok as a business….
What we didn’t do is discuss it in detail with our competitors. Why not? If we had, would HV electrical safety in our sector be better managed now? Would LV electrical safety be better managed as a result?
We have some great resources such as ‘Safe Quarry’ where accident and incident alerts are distributed. But what happens???
- Changes definitely happen on sites where the incident happened
- Changes definitely happen within companies when things go wrong
- Maybe a manager from another company reads the alert and makes some change to their workplace.
But how do we react as an industry? How do we learn as an industry? How do we stop companies in our sector having similar tragic accidents.
John Crabb, HSE inspector, told me 30 years ago there are no new incidents. Is that statement as relevant today as it was back then? I think so.
2017 was a crap year in our industry from a fatal accident perspective. Worse than three years previous, five years, 10 years previous?
I know the industry, through the MPA, have been doing some great work on leadership but is now not the time for the industry to really step up and challenge the way it works, look at failure as an opportunity for the industry to learn?
Look at the successful sectors who set up groups of skilled investigators to help their industry learn from their events. Maybe do a real root cause analysis on the thousands of incident alerts that we have.
Let’s set a new path to outperform our aviation counterparts and, most importantly, encourage our personnel to see things that go wrong as a positive way to start to improve performance.
And if you do nothing else have a read of Matthew’s book.
Colin Nottage; tel: 07799 656303