The Weekly Reflektion Week 21/2021
Once an organisation establishes a mindset it can be difficult to change and sometimes it takes a serious incident to realise the mindset was not good.
Do you let your mindset blind you to the causes of your next disaster?
I was just sitting down at my desk to write a Reflektion and as I looked around me trying to find this week’s inspiration my eyes glanced over these two books. Trevor Kletz has been an icon for accident prevention and his articles and books have inspired many including Mike and I. Trevor has written many books and articles including ‘What Went Wrong’ which was published in 1998. Trevor’s book ‘Still Going Wrong’ was published in 2003. The irony in the title of the sequel was perhaps a dig at the industry. It was however a reminder that we need to have a constant vigil in our quest to prevent accidents and in particular Major Accidents.
I opened the book at page 210 and section 16.10 ‘We forget the lessons learned and allow the accident to happen again’. In this section Trevor describes an all-too-typical approach to investigation into a serious incident. The investigation team carries out a good investigation, writes a clear and concise report and circulates it widely. The recipients read, file and forget. Until of course a similar incident happens again, and the next investigation team blows the dust off the previous investigation report and asks the inevitable questions.
- What actions were agreed?
- How were they followed up?
- Did they have the desired affect?
Trevor Kletz makes some suggestions on how to prevent accident recurring. I am therefore taking the liberty of sharing these with you this week.
- Include in each instruction a note on why the instruction is important and describe the incidents that would have occurred if the instruction had not been in place.
- Never delete an instruction or remove equipment until you understand why it is in place.
- Include important accidents and incidents in the training and induction of new people.
- Follow up recommendations from investigations at regular intervals.
- Devise better retrieval systems for accidents and incidents. For example, https://toolbox.energyinst.org/
- Use investigation reports as the basis for ‘what if?’ scenarios to create discussion in your teams.
- Remember that the first step down the road to an accident is turning a blind eye to something that is not right in your facility.
The last point on turning a blind eye was a factor in the fire at the Kings Cross underground station on 18th November 1987 that claimed the lives of 31 people. Rubbish had been allowed to collect underneath escalators on the London Underground. Rules on prevention of smoking in the stations were not enforced. Ineffective communication routines on fire detection had been pointed out by the London Fire Brigade. Staff were poorly trained on firefighting systems.
The management of the London Underground believed that fires on the Underground were inevitable and if they happened, they would quickly be brought under control. Their experience was that fires at other stations had been extinguished before they had escalated. This mindset blinded them. They failed to act on, what seems in hindsight, the most obvious signals. What does your mindset prevent you seeing?