Some of the world’s greatest disasters could have been avoided if those behind them had experienced more failure, according to research published this week.
The sinking of the Titanic, the loss of the space shuttles Columbia and Challenger, two BP oil refinery explosions with huge loss of life, and the international recall of more than eight million cars by Toyota all have in common an inflated degree of confidence.
Avoiding over-confidence is among a list of ten ‘tools’ based on the outcome of case studies of high profile disasters designed to help organisations and managers understand reasons for disasters.
The study, by Professor Ashraf Labib and Dr Martin Read, of the University of Portsmouth Business School, is published in the journal of Safety Science.
The report’s authors argue that organisations learn more effectively from failures than from successes, but organisations vary at learning from them. They also say that organisations often learn vicariously from the failures and near-failures of other organisations.
Professor Labib said: “A lack of failure can lead to over-confidence and ‘blindness’ to the possibility of problems.
“Some managers and organisations see their role as akin to re-arranging the deckchairs on the Titanic, but disasters, when you study them, are often built on futile exercises that don’t help avoid problems.”
The researchers say that for organisations to successfully avoid major disasters they need to undertake risk and reliability analyses. Policy makers also need to balance their punishment and incentive systems and ensure they are proportional to the significance of hazardous incidents. Underpinning at least five of their ten tools is a clear need for organisations to focus attention on responsibility, communication and priority.
Professor Labib said: “Failures in general and disasters in particular can stimulate a blame culture that can act as a barrier to learning from mistakes, but it is important to note human beings are naturally programmed to learn, whereas organisations are not.”
The authors have identified ten tools based on the root causes of major problems and an understanding of how those problems unfold over time for organisations to use to avoid major failure.
Tool 1: Too much belief in previous successes
Experience with success can be, and has been, counterproductive. Too much belief in the ‘unsinkable’ Titanic meant she set sail with too few life boats and those that were installed were there only to rescue people from other ships.
The Titanic sank in 1912 with the loss of 1,500 lives.
More recently, NASA’s confidence in its space shuttle programme led them to ignore warning signals related to both the o-rings damage prior to the Challenger disaster in 1986 due to cold weather before launch, and again on the fuel tank foam losses prior to the Columbia disaster in 2003. According to the investigation report NASA’s safety culture had become reactive, complacent and dominated by unjustified optimism.
Tool 2: Coping with growth
The ability or inability to cope with a high rate of growth may be another factor that can contribute to disastrous failures.
Professor Labib said: “Toyota has been regarded as the company against which other organisations benchmark their standards, but recent failures that have led to the massive recall of Toyota vehicles in the US, Europe and China.”
Tool 3: Misunderstanding fashionable paradigms
Misunderstanding of the true meaning behind fashionable paradigms including, for example, ‘lean’ management, which doesn’t mean cutting staff numbers but which it is often thought to mean, has always been a dangerous affair, Professor Labib said. “We have seen this before when Business Process Engineering (BPR) was a fashion, and it ended up by people mocking the acronym of BPR as ‘Bastards Planning Redundancies’.”
Tool 4: Legislation
One of the world’s worst industrial accidents, India’s Bhopal disaster in 1984 in which more than 3,000 died after gas leaked out of a pesticide plant into the surrounding shanty towns, is a classic example of a corporation’s callous disregard for its staff in developing countries, Professor Labib said.
He added: “Twenty-six years after the disaster the officials responsible were prosecuted, but there seems to be a need for something similar to the ‘three strikes and out’ law at a corporate level in terms of serious breaches of safety. The Corporate Manslaughter and Corporate Homicide Act 2007 in the UK is a good step in this direction, where for the first time, organisations can be found guilty of corporate manslaughter as a result of serious management failures resulting in a gross breach of a duty of care.”
Tool 5: The “I operate, you fix” attitude
In old-fashioned maintenance, a prevailing concept among operators was “I operate, You fix”. In other words, maintenance is the responsibility of the maintenance department and operators should deal only with the operation of their own machines. When dealing with a disastrous situation this attitude frequently means most people feel the responsibility for dealing with a disaster lies with someone else. But it is important everybody, especially top management, is aware that a disaster is not just ‘another issue’ and that their direct involvement is necessary.
Tool 6: No news is good news
Another prevailing attitude is ‘If it ain’t broken, don’t fix it’ which implies a passive attitude towards performing any prevention activity. In many organisations a preventive maintenance schedule might exist but is rarely put into action because breakdowns take priority. In the context of disasters, it seems that the same attitude prevails, Professor Labib said, especially in the private sector, with organisations more worried about current rates of exchange, interest rates and market shares than about the prevention of a disaster.
Tool 7: Bad news, bad person
In many organisations the manager prefers to hear good news and anyone who brings bad news about the malfunction, or even the expectation of it, is at risk of being considered an under-performer. This is similar to the old days in the army, when a soldier bringing news about casualties was in danger of being shot, as if it were his own fault. In the context of a disaster, it is common, for example, for a CEO, when asking about problems, to be told everything is under control.
Tool 8: Everyone’s own machine is the highest priority to him
In traditional maintenance, every machine is the highest priority to its operator, and the one who shouts loudest gets his job done. This lack of a systematic and consistent approach to setting priorities tends to be an important feature when dealing with a disaster. Setting priorities should attract the highest priority among different approaches to dealing with any potential disasters. Questions such as who sets priorities, what criteria are considered, and how to allocate resources based on prioritisation, urgently need to be addressed.
Tool 9: Solving a crisis is a forgotten experience
It is often the case that solving a problem does not get recorded or documented, but it is beneficial to both organisations and individuals to be able to easily access databases of mistakes or near misses.
Tool 10: Skill levels dilemma
In the maintenance function, the designer of the machine is not usually the one who fixes it, and might not even have the ability to do so. In a crisis, skill levels is a major dilemma because disasters tend to be multi-disciplinary problems needing a multidisciplinary team approach.