“Despite efforts to improve safety, several hundred accidents happen every year, and most such crashes are blamed on human error or outdated signaling equipment.”
Active Failures vs. Latent Organizational Failures
These conflicts are always in the spotlight after tragedies. It took me many years working for some great leaders who always challenged me to look deeper to understand WHY “they did what they did.” The key to this approach is TRUST and CREDIBILITY. When the people involved know that you just want the facts to help ensure it does not happen to someone else, it is amazing what we can LEARN from our mistakes.
I can promise you this, when we look hard enough, we will always find management system failures that allowed, created, and/or manifested the behaviors and decisions of those closest to the consequences.
In 2023, it really is quite amateurish just to consider the active failures of those directly involved. There are accidents where even the safety team plays a role in the failures leading up to the consequences. And that can be a tough pill to swallow. Suppose the SMS we developed, implemented, and managed/measured FAILED to identify the hazard or the deviation from established practices. In that case, that failure needs to be addressed by thoroughly reviewing the SMS elements, activities, and skill sets of those participating. RARELY is it ever about a single person’s behavior happening within some vacuum of reality. It needs to be understood how that behavior came about, how it manifested across crews/shifts/departments, and how it escaped all the observations, inspections, audits, etc.
We (safety pros), too, can fall into the trap of “work as we imagine it being done” vs. “work as actually done.” It is why the verification/validation of our safe work practices, operating procedures, and maintenance procedures is SO CRITICAL. We must identify these deviations BEFORE tragedy occurs or the SMS has failed us all. This responsibility lies within the SMS and is never on the shoulders of a single person.
