An interesting point that I read some time ago, is that management failure theory would conflict with the notion of free will: if management failures are the root causes for all accidents then management failures are also the cause for human errors, and not free will. I’m not sure if this very strict reasoning is fully correct. Even if it does sound logical it doesn’t feel right to me. In my opinion at least Bird’s dominos and also Reason’s Swiss Cheese Model (proponents of multi causality) do not exclude free will from kicking in into the causal chain. The basic causes in Bird’s sequence differentiate in job factors and personal factors the latter explicitly including things like motivation which is at least one personal factor that is clearly related to free will. I’m rather sure that Reason has similar mechanisms, but I’m too lazy to check.
One might point out that still the most left ‘domino’ (management) causes the fall of the next (which includes the personal factors) and does not describe for causes materializing half way the sequence. I sometimes get the impression that models sometimes are treated as if they were laws of nature that have to apply in each and any situation, in exactly the same way and the same order (a hair-rising example is the treatment by some people of Heinrich’s ratios, expecting to find the same everywhere). But that’s hardly realistic. Heck, that’s what they’re called models for - a simplified representation of reality and thus not describing all and every possibility.
I live in the belief that nobody rises in the morning and goes to his job with the intention to screw up massively and create an accident. There are others much more qualified than me writing about human error (including violations) and its causes (and have luckily done so), but roughly I’d say that two important reasons/causes for human error or violations are found in: 1) an overly optimistic perception of their control over the situation (remember that about 90% of all drivers believe that they’re better than average drivers) and 2) especially conflicting objectives. These are ‘causes behind the cause’ for deliberate acts and for safety work it is eminent to identify those in order to determine preventive actions that keep future errors and accidents from happening.
For a legal case it may be sufficient to stop having established as a cause that someone willingly chose not to follow a safety rule. Acting on that single act (e.g. by punishing the violator, or explaining the rule to him once more) is often very ineffective from a safety point of view. The decision not to follow a safety rule may be a deliberate act of free will, but there may have been incentives and other mechanisms behind this decision. In case of conflicting objectives (e.g. the company claims ‘Safety First’, but rewards people cutting corners in order to maximize profits) it’s more effective to address those causes behind the causes.
When studying safety many of us have learned not just to focus on an error by an employee, stop the investigation there and blame the person. Instead we’re taught to look further than the person at fault. But the opposite is true as well: defaulting to management failures as causes for accidents is not the way things should be done. That’s a kind of jumping to conclusions without any basis in reality or facts that is just as bad as Heinrich’s decision to stop at the direct cause and focus on that alone. A comment recently I heard was in the line of “we’re not satisfied unless we have found at least one management cause”. I’m convinced that this is said in the very best of intentions for the improvement of safety, but even this well-meaning framing of your mind is going to bias the result in a way that should not be acceptable. Remember what Hollnagel said: WYLFIWYG! I believe he said it in relation to ‘human error’, but it applies to anything. Some causes are simply not management induced and that’s that.
Some people go a step further and reject the existence of management failures entirely, a.o. because these are human failures. Agreed, in the end, management/organisational failures are decisions of men and thus human failures, but they are of another kind. I find it helpful to distinguish between (direct) causes on a more personal level (call it sharp end/operational, if you want) and (underlying) causes on organisational or management level that are further upstream. Additionally, sometimes it’s hard or impossible to determine what the ‘deliberate act’ or more or less active failure in the management was.
Take for example the accident that happened at Sjursøya on 23 March 2010, something that has taken a considerable amount of my working hours since. The full report of the Norwegian Accident Board (a fairly good one, even though I do not support all of the recommendations) is online, check it out for details (available in English). Short version: operational error(s) directly caused a runaway set of goods wagons which went unstoppable downhill. There is a 100 meter difference in height between the point of origin and the ending point, 8 km further down in the harbour of Oslo. There the wagons, speeding at about 130 km/h crashed in a building and killed three people, injuring several others. The outcome could have been even worse, by the way, since the wagons might have hit wagons with jet fuel, had the accident happened at another point of time.
What lies behind the operational error (I’ll do the simplified version) is that over the last two decades the use of the goods terminal had slowly been changed without anyone noticing and many baby steps ended up in using the terminal differently than intended. Working procedures and local risk analysis had not followed the same development and thus safety barriers had unknowingly been eroded in such a way that a rather simple error could lead to such a drama.
I tend to be very critical towards the labeling of deficiencies in risk analysis as causes - often this is a sign of lazy or unrealistic safety people since you will almost always find something related to the accident not being in the risk analysis (a complete risk analysis being a fiction and not very helpful either). But here it certainly was the case and together with other management factors this created over many years (impossible to pin down on persons, acts or dates) the situation as it was on the date of the accident without anybody being really aware of the situation sliding towards the breaking point.
While blaming the operational personnel that had ‘violated’ long forgotten rules would have been a possibility (unnecessary because they blamed themselves enough as it is) it was decided to look at the underlying factors. I don’t want to discuss the legal part, but also the DA chose not to have a legal action against the operational personnel. The companies involved, however, were fined which my company paid without any appeal (in contrary to the other company involved). Negative side effect: several millions of Norwegian kroner down the drain that could not be used for prevention and improvement.
Comments and discussion appreciated!
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