It is not often that a disaster has everyone forming an opinion so quickly after the event, but that has certainly happened as a result of the Costa Concordia striking rocks and running aground close to Giglio Island, off the Italian Tuscan coast. Just three hours into the cruise disaster struck, but unlike UK law, in accident investigation you seem to be guilty before being proven innocent. The passenger stories that ranged from an orderly abandonment of the ship to absolute chaos, plus the incredible pictures, have heightened the anxiety and placed increased pressure on the Costa organisation to act. The image of the Chief Executive blaming the Captain the day after the accident, to anyone involved in safety, safety management, or accident investigation, was astonishing.
The Costa Concordia accident re-emphasises the importance of the need of a positive safety culture in any transport company. The introduction of Safety Management Systems is slowly becoming the way forward, but the more interesting point is, why do people break rules?
I do not know of a pilot, engineer or air traffic controller (and putting that into marine terms Ship’s Captain or Navigating Officer) who sets off to work believing they would make a mistake or a serious error of judgement. Professionals usually start the day with the understanding that they will do their best. Generally, mistakes that are made are due to procedures not being followed. Often this is because the procedures are incorrect, unclear, or burdensome. More commonly it has become the way of doing things, or the task cannot be completed without breaking the rules.
The majority of people break rules and cut corners for what they see as good reasons, frequently in an attempt, with the best will in the world, to get the job done. Nevertheless, it is often problems with the procedures, rather than the attitude of the individuals, that form the major reason for rule breaking. These problems affect the ability of people to adhere to the rules or procedures, and may create a culture in which rule breaking becomes an accepted practice – commonly called ‘normalisation of deviance.’
We have established that errors will happen and that people will break rules so how do we prevent this from happening?
At first sight, human error appears to be quite complex and highly unpredictable. As a result, many managers surrender to the apparent inevitability that errors will happen and thus opt for the easier solution of allocating blame, which is the simplistic way of dealing with a difficult problem. Blame places the responsibility for an error with the individual making the error. This removes the need to understand why the error occurred, since it is believed future errors can be prevented by punitive measures against the unfortunate individual. If the error was actually system induced, as most errors are, then this solution to the problem will always be unsuccessful. The defective system will remain uncorrected and it is only a matter of time before another error occurs, by the next unfortunate person who happens to be exposed to it. More importantly, all systems must have defences and safeguards, so when an event occurs, the most important issue is not who made the mistake, but how and why the defences failed. This is not to say that there is no place for blame. There most certainly is, but the important point is that the blame be attributed where it is deserved. There will always be cases where the individual making the error deservedly attracts some blame. There may be an element of carelessness, inattention, negligence or deliberate violation of procedures that must be dealt with. However, it is important that this is addressed as a secondary issue subservient to a thorough investigation of the possible systemic causes of the error.
On many occasions an individual is blamed before the investigation has been completed or, as in the Costa Concordia accident, before the investigation has started. ‘It is their fault, they were in charge.’ Ritual hanging and leaving the body for all to see stopped hundreds of years ago, but the mentality remains. In the desire to make processes work quicker, expediency wins the day. It may not be right but it is to the organisation’s advantage.
All airlines and shipping companies, in fact all businesses, must appreciate that human error is unavoidable and that it is the responsibility of an organisation to effectively manage those errors, not blame individuals for making them. Moreover everyone needs to understand that the ‘Blame Game’ never benefits the cause of improved safety.
RTI has highly experienced and well qualified safety management experts presently available. These experts have collectively conducted doctoral research and been responsible for developing post graduate level safety management courses, organizing and implementing safety audit schemes, and running major safety departments.
RTI Ltd, as the London office for RTI Group LLC, with all the high-value capabilities that entails, is in a commanding position to produce and deliver effective Safety Management Services. RTI’s involvement will always introduce decade’s worth of hand-on operational time, industry experience, and expertise to any project or case; experiences that will span industry sectors and the globe.