By Tom Moriarty
As I write this column, I am on a flight from my home airport into Atlanta. Even with a fairly high number of frequent flyer miles, I couldn’t score an upgrade. So, the next best thing is an exit row seat. There’s a bit more legroom than what’s available in the average row of seats, so the exit row is a minor victory.
“There is never one root cause for catastrophic events.”
Prior to leaving the gate, the flight attendant stood before those of us in the exit row and recited the standard blurb asking if we were all willing and able to assist in case of emergency. She earnestly suggested that we all take the time to review the emergency-exit instruction card located in the back of the seat. Normally I would not have paid attention, but on this flight I watched the others in the exit row to see if anyone looked at the instructions for operating the emergency door. No one did.
I became interested to see if anyone read the instructions because of a series of events that had occurred during the previous few days. The first was related to a root-cause-analysis project I was hired to do for an organization that had a pretty severe environmental issue. The second event involved a major injury where a worker fell off of an 18-ft-high platform onto a concrete floor. The third event was kind of a “two-fer” as there were two observations there — workers not following PM task steps and not following proper safetypractices.
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In the root-cause project, one of the issues that led to the catastrophic event involved an old hand. Everyone knew him to be a knowledgeable and experienced operator. He had been at the site, and at similar ones, for many years. Unfortunately he developed a habit of “winging it.” One day, a series of errors caught up with him. Improper procedures in operating equipment resulted in an event that severely impacted wildlife and caused him, his facility, and the organization tremendous embarrassment.
In the second case, I was in a manufacturing facility doing a project review for a client who was installing new technology in the production facility. The worker fell off the platform, which did not have handrails around the perimeter. He was not harnessed or secured to a structural component that could have kept him from hitting the concrete. The worker survived, but he has a substantial amount of recovery time ahead of him. The plant will likely see impacts in delayed completion of the work, higher insurance costs, and probably a “regulatory colonoscopy.”
The third case was at another client location where my team had helped to implement a new work management process. This client is doing very well with the transition and so began to take a deeper look at the PM program. The client began observing how craftsmen were actually performing the PMs. What they found was that no two craftsmen were performing the PM in the same manner. There was no consistency in how the PMs were being done. In addition, the PMs were not consistent in identifying safety hazards or personal protective equipment, nor did the craftsmen seem interested in following good safety practices.
In the three client situations described above, as well as my exit row seating example, people tend to get complacent. In the plant examples, the real problems are not the individual actions, although operators and craftsmen definitely have some portion of the responsibility for their own actions. The real problem is the complacency of executives, managers, and supervisors who allow workers to cut corners.
It is human nature that individuals will seek to make things easier for themselves. Every time a person cuts a corner and there are no negative consequences, there is a pay-off. The more times it happens, the more accumulated the pay-off. But this is a game of probabilities. One person may take short cuts and go an entire career without experiencing a major issue. More likely the short cuts one person makes has a contributing effect that is combined with everyone else who is cutting corners. The more people who are complacent in an organization, the more likely there will be major accidents or events.
There is never one root cause for catastrophic events. For every person who is blamed or thought of as the person responsible, there are several executives, managers, supervisors, or other workers who were also complacent.
Eliminating complacency therefore is everyone’s job. Don’t be part of the problem. Don’t cut corners.
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