The recent release of a report regarding the catastrophic collapse of Champlain Towers South is a “storybook” of how Latent Organizational failures set the stage for an accident. And like all the bad accidents before this one, everyone from the government to the media is looking for someone or some people to blame (i.e., Active Failures). We can use the “Swiss Cheese” or “Dominos” model of accident causation, and this tragedy fits perfectly into these models.
The catastrophic collapse of Champlain Towers South began nearly 40 years before the day of the fatal collapse with an inadequate design, construction that failed even to meet the inadequate design and many decisions and failed opportunities to identify these problems over the structure’s life. Even decisions that were considered merely cosmetic (large planters by the pool) played a role in this tragedy.
The Miami Herald has published a detailed breakdown of this 3rd Party Report. This investigation took six months to complete, and some indicate it is still not totally complete. The newspaper, knowingly or unknowingly, does an excellent job of walking us through all of the Latent Organizational Failures that led to this tragedy. Reading the article with active animations to provide a visual of what happened during this tragedy is well worth your time. As a safety professional, I hope the newspaper wins an award for this article.
How many Latent Organizational Failures can you identify from this accident?
How many Active Failures can you identify from this accident?
Keep these answers in the back of your head during your next causal analysis! I have yet to investigate a serious accident where the Latent Organizational failures far outnumbered and outweighed the Active Failures associated with the accident. But know this, it is much easier for people not directly associated with the accident to deflect any role or responsibility they may have played upon those most closest to the accident. But reality does not work like that!
https://www.miamiherald.com/news/special-reports/surfside-investigation/article256633336.html
