The recent Railway Accident-From the lens of Dekker and Weick-What does this tell us about our own organizations?

The recent Railway Accident-From the lens of Dekker and Weick-What does this tell us about our own organizations?

?Assuming that there is no mens rea (criminal intent) and early reports talking about human error, the para (photo attached) from the Indian Express was insightful and was reminded of the research of Sydney Dekker and Karl Weick.

In accident investigations, Dekker[i] pushes us to answer the question ‘Why did it made sense for the operator, for the action that he took at that point of time?’ Did one person suddenly go crazy?

’ The Bad Apple theory says that complex systems would be fine were it not for the wrong behavior of a few unreliable employees. Systems per se are fine. Or errors are the inevitable consequence of employees trying to do their best under circumstances with systems that have subtle vulnerabilities.’

‘The New view in contrast to the Bad Apple theory says that employees are motivated to keep themselves safe and during investigations, instead of focusing on where the employee went wrong, focus instead on how their assessments and actions could have made sense at that point of time given the circumstances that surrounded them. Human error therefore, is not the conclusion of an investigation but the start point of understanding the deeper systemic issues. People have to negotiate safety while managing multiple other goals such as productivity, speed, cost, etc and we need to understand why their actions made sense to them.’ (Dekker, Field Guide to Human Error)

?Blaming human error is a lazy explanation for an accident. Something made sense to the operator. A decision that he needed to resolve the conflicting choices confronting him. To get a good answer to the question, we need to explore the following questions:

-Do the actions imply that such actions had been taken before but not resulted in a disaster

-How did the operator get the sense that this was permissible even though strictly against safety protocols

-Are such transgressions confined to only one Railway station

-Is it more widespread while knowing that this is against the SOP

-Were senior managers aware of the occasional transgressions and winking at them,

?-Were such transgressions making sense to higher ups too

-Were these being reported in the past

-what was the safety data over months telling them

-Is there a honest reporting culture

-What made him do this? What other priority made him break a stricter safety focused process

-Were the punishments for similar transgressions in the past stringent enough?

-The employee seemed to be a choice to make. What was the other alternative

-Railways has bright people-how come they didn’t push down the protocols for 100% compliance. What makes the change so difficult-capital or technology or something else

-How do we resolve the gap between the leadership espoused values and the operating reality or culture at the most distant hierarchical level?

?One logical explanation is that the alternative choice facing the employee was to slow down the train that would have a ripple effect on other trains impacting punctuality, speed of the overall system. On previous such occasions, the decisions had worked. But today, the stress between the two choices resulted in a crack.

Speed-1, Safety 0

Weick’s[ii] research on the other hand was about High Reliability organizations (HRO). The study of HRO started from the sense that there were certain types of organizations that had complex technical operations and yet a high safety record. There was a resultant curiosity to learn from them. Initial studies were focused on aircraft carriers, electricity companies and air traffic control. Early conclusions on such studies indicated that statistical data was not sufficient to distinguish such organizations but there was certainly a different approach that they were employing to managing risk with complex technologies.

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“Other people who had examined these organisations were struck by their unique structural features. We saw something else: These organisations also think and act differently” (Weick and Sutcliffe, 2001)[iii]. Weick termed this as mindfulness.

The five characteristics that Weick has distilled from the HRO literature and demonstrates the conceptual shift from HRO to mindful organisation. “HROs manage the unexpected through five processes: (1) preoccupation with failures rather than successes, (2) reluctance to simplify interpretations, (3) sensitivity to operations, (4) commitment to resilience and (5) deference to expertise, as exhibited by encouragement of a fluid decision-making system. Together these five processes produce a collective state of mindfulness” (Weick and Sutcliffe, 2001)

Have no data to judge the overall IR safety performance in comparison to other railway systems given the scale of IR but certainly we seem to have large casualties (2/ 3 in the world’s worst 10). Interestingly, Pakistan also has high number of large train accidents that tend to be featured in such lists. Not sure whether the prevailing safety culture is a legacy of the old colonial systems.

Given the scale, complex technology and consequences of railway accidents, Railways would have to be termed as falling under the HRO category.’ Interestingly, the Presidential Inquiry into the 2003 space shuttle Columbia disaster chose to evaluate NASA against the way a high reliability organisation would have performed, and it found that NASA fell a long way short of this standard. The report was a clear invitation to NASA, and more generally to all organizations using complex, risky technologies, to examine how high reliability organizations operate and to learn from them’.[iv]

But What does this mean for us in the organizations that we work for?

An exciting but worrying shift is in the Renewable Industry. Companies are setting up not only utility scale plants of solar/wind but in recent times, working on green ammonia/hydrogen that have a higher degree of complex systems and technologies to manage. The shift will play out in different ways. Safety culture of these organizations is one of them.

The current construct of the RE industry is to set up large scale utility plants of solar and wind or smaller distributed solar set ups. The resource pool has tended to come from the Construction or Infrastructure industry and the practices have also followed. Accidents are frequent but rarely more than 1 or 2 deaths at a time. No mass casualties, no newspaper hogging headline and only impacting the lowest paid, marginal, contract construction worker. Speed of project completion is critical to profitability. Massive underreporting of accidents occurs. The operating culture on the ground irrespective of the espoused leadership values is a Construction Culture (CC)

The new construct will have green hydrogen/ ammonia plants being constructed and operated. The resource pool (early days yet) is coming from the chemical industry as they are closest in skills and knowledge. The practices will follow too. Accidents are likely to have much larger casualties and impact the community. The safety culture in chemical industries tends to give a higher priority to safety over production. Much closer to an operating belief system of prioritizing safety over production. Closer in some ways to being an HRO. A green hydrogen/ammonia culture (GHAC)

When these two cultures merge in the same company and a new culture evolves, will GHAC prevail and raise the bar of the existing CC or will it be hybrid and schizophrenic in nature? A hybrid will eventually lead to a bar lower than GHAC.

In a recent conversation, a CEO admitted that safety in ammonia would be a challenge and was graphic about the consequences, far more than I had imagined.

Does a schizophrenic culture imply a major incident a few years from now? Is this very likely ? Are the consequences such that they can be ‘managed’ as in the CC culture or would they invite stronger governmental intervention?

We need to take steps today-industry wide or organization wide to not have a schizophrenic culture but learn and create a GHAC culture. Almost move towards an imaginary HRO culture.

What does such a change management exercise during the merger of two operating cultures imply?

What do you think this score-line would evolve to?

?Production – 0, Safety-0

?Let me know if you want to chat more.

?

Ravi

([email protected])

[i] Dekker, Sydney, The Field Guide to Understanding Human Error

[ii] Weick, Karl E,?Sensemaking in Organizations

[iii] Weick, K., K. Sutcliffe & Obstfeld (1999). Organising for high reliability: processes of collective mindfulness. Research in Organisational Behaviour,

[iv] Hopkins, Anthony, The problem of defining High Reliability Organizations, 2007