The huge ore truck slid sideways down the slope and then rolled as its load shifted. By the time it had reached the bottom of the open pit the ore had been scattered, the truck destroyed and the driver was dead.
The investigation pointed to a number of causes:
- Driver fatigue
- Roadway too narrow
- Insufficient roadway embankment
- Possible overloading of the truck
- Possible steerage malfunction
The family was paid compensation on the basis of compassion, not acceptance of responsibility for the driver’s fatigue. The roadway was widened and the embankment heightened. Supervisors had to sign off on the loading of each vehicle. Vehicle maintenance routine regarding steerage was adjusted.
Six months later a similar accident occurred 200 metres further down the roadway. This time the driver escaped with a broken arm after jumping from the truck. Otherwise this accident appeared almost identical to the first.
The investigation pointed to the same causes, despite the adjustments made earlier. The company’s mining license was in jeopardy unless rectification was evidenced.
Organisations suffer from accidents, mistakes, conflict and dysfunction on a routine basis. They appear to be where most energy is expended by managers and leaders, as they attempt to resolve the problems.
In the example above (based on facts that have been altered to protect the identity of the company, but keeping the spirit of the message), the first incident was investigated by an operational safety investigation team.
They were correct in their findings at the operational level. The recommended modifications were implemented. Yet a similar accident occurred shortly after.
The second investigation, again done at operational level pointed to the same causes. When confronted by the prospect of losing their mining licence the situation was escalated to headquarters with board oversight. It was now being looked at from a strategic perspective.
I was mentoring a director of the firm at the time and she asked me “How do you think we should look at this?”
I asked “Do you think the two earlier investigations found causes or symptoms?” She looked at quizzically for a moment and then wisely answered “They have provided what they think are causes.”
I asked “At operational level what might seem a cause could be a symptom at a strategic level. Could this be the case here?”
She thought and said “I think I see what you mean. But how do we distinguish between cause and symptom at strategic level?”
I asked “At strategic level is it not the case that we must seek the root cause of all unwanted incidents, whether they are accidents, mistakes, conflict or dysfunction?” She thought and said “Yes, but there are things that happen outside our control, like catastrophic weather.”
I asked “OK, let’s place root cause into two categories – human and nature, where we have capacity to resolve the human issues and a possible capacity to diminish the challenges of nature, does that work for you?”
She said “Yes and our duty of care is to remedy that caused by humans, integrated with mitigating possible natural causes”.
I asked “OK, Is it not the case that we humans create, operate and maintain the plant and equipment; the systems and processes; the services and products as well as all the interaction between ourselves physically and verbally?” She answered “Yes”.
“So at a root cause level, what is the source of all human accidents, mistakes, conflict and dysfunction?” I asked. No answer.
I asked “Aren’t all cases of human accident, mistake, conflict and dysfunction caused only by fear, habits and ignorance or a combination of them?” She thought about that and eventually said “I’ve just run a number of scenarios through my mind and I think you are right, they are all caused by one or more of those three.”
I said “I’ve never found any other root cause for any problem where humans are responsible. If we were to look at those two accidents from this perspective we will find a strategic solution which will rectify the root causes.”
The company looked at their challenge strategically and made adjustments which commenced in headquarters and had a positive impact on site. The main changes took place at a cultural level. That impacted on project design, engineering, leadership and supervision and ultimately production.
Instead of talking about safety being most important and yet acting for more production, the conversation and action became about “maximising safe production”.
By a more disciplined and engaged approach to effective leadership and supervision, a positive approach to accountability, where acknowledgement and recognition were the preferred consequences, performance lifted without undue stress. They worked smarter not harder.
The company hasn’t had another similar accident, nor has their licence been in jeopardy since.
However, like most organisations, they remain needing to improve their ability to identify root causes at the human level, for that is where the greatest leverage can occur for improvement in all areas of endeavour.
What are your thoughts about the root causes of all unwanted human based outcomes?
