I have spent the better part of the last fifteen years of my life working with some of the best companies in the world helping them to understand failures, how failures occur,looking for ways to detect, reduce and eliminate failures. One of the first things I learned in performing Reliability Centered Maintenance and Root Cause Analysis is if you want to eliminate failures stop assigning blame.
It is failure after all that haunts us the most. No one really wants to fail, we don’t wake up each day looking forward to the failures that will occur in our lives, to our equipment or the processes we look to continuously improve. Yet failures continue to occur as if that fella named Murphy crossed paths with a black cat while walking under a ladder on Friday the thirteenth.
As we like to say when the dust settles, stuff happens. We don’t really use the word stuff but I think everyone knows what the real word is.
Just the same, I don’t buy it.
All failures have causes, failures have multiple causes and several causes aligned together undetected can result in a single failure and if we accept at any given time that stuff happens without giving thought to why something failed, we have also accepted and even welcomed that fact that these failures will happen again.
The problem I really have comes with acceptance. Especially when acceptance involves sweeping the failure that resulted in the loss of someone’s or several people’s lives into a stack of sealed documents known as a settlement. This is world where the word failure doesn’t exist, a world where we hope the client and defendant walk away comfortable with the fact that while there was a failure and someone did die, the cause or causes are no longer of interest to either party.
Well good for them! What about the rest of the world who works in that same potentially dangerous environment? Now that the court system is no longer interested in causes, liability and gross negligence, wouldn’t it be nice to determine the cause or causes of this incident so the rest of the world can seek to understand and possibly eliminate these causes?
While the investigation of failures that result in several Health, Safety and Environmental consequences can be uncomfortable, painful and even at times embarrassing, these emotions have to pale in comparison the knowledge that something could have and should have been to prevent the failure. Worse yet are the emotions endured by loved ones left behind and those of the people who survived and can’t stop thinking the word settlement really means “nothing has changed”.
No one will step up and say “I made the decision to continue on with the thought that our managers would finally make the decision to stop the next day”. Or “I noticed we had lost the primary control system but made the decision to continue on because the back-up system appeared to be functioning well once we switched.”
No one will be given the chance to offer up the fact that they were concerned in regard to the functional failures of several devices in the hours leading up to catastrophic failure or the strange and critical feedback or data they observed as potential causes and effects were ignored in hopes that a process out of control would somehow reverse its course.
Settlement of course means silence. While this event did occur that may have left a wife without a husband, children without a father or a parent to live on without their child, a settlement leaves them to always wonder; “Why did this happen, and could it have been prevented?”
No one will step up and say they were sorry.
No one will report that we have learned a lot from the mistakes we made and in performing this investigation we are confident that a failure like this will never occur again. While we are saddened by the death of our colleagues as a company we will never be the best at what we do until we accept responsibility for what has happened and work to build a culture that ensures it will never happen again.
So the rest of the world is left to wonder what went so horribly wrong that day. What caused this failure and more important could have been prevented? The rest of the world includes all the men and women who currently work in the same industry, their families and friends.
All left to wonder, will it happen again?
If it does I can assure you, Murphy had nothing to do with it!
It should be noted in many cases when a failure results in the on the job death, pro-active companies within the same industry sector will often perform investigations or analyses in attempt to determine the causes to eliminate or reduce the conditional probability of a similar occurance.
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