Culture can Kill: 3 Train Wrecks, one connection
An observation in Human Factors by Dennis Taboada.
|Lac-Megantic Quebec train crash and explosion|
|High speed train crash in Spain|
Galicia Northwestern Spain July 24: a high speed passenger train traveling more than 90 mph derails on curve killing 79 people.
|Switzerland head-on collision of two passenger trains|
Granges-pres-Marnand Switzerland July 29: At least 35 people were injured, five of them seriously, in a head-on collision of two trains in western Switzerland late Monday
Suspected Cause: Newspapers splashed photos of the wreckage across their front pages, claiming that the early departure of one of the trains may be to blame.
When investigating the root cause of an accident it is proper to look at all possible contributors defined by the Deming inputs: People, Environment, Machines, Materials, and Methods. Of course, these accidents are recent so I must be careful in my opinion as other information may surface. There is a common theme that initially arises as we look at these three separate rail incidents. It must be the fault of a person. The Spain train driver has admitted to being on the phone. The Quebec driver admitted to not applying all the brakes as required by procedure. The Swiss crash had a driver leaving a station early.
Where are the procedures? Without even knowing, I can assure you that the driver of a high speed train should not be on his cell phone during a high speed turn. Oh yeah, he was going more than twice the allowable speed. I am sure there is a procedure for leaving and returning to a station and we know all brakes should be applied to a stopped train.
I have seen this type of human factor before. Yes, it is possible for someone to error but, I am willing to bet that these companies have a “Culture” of sloppy operations. This is common when you have “seasoned” workers who know their job very well. They become lax and begin to cut corners. This is where upper management of the company comes it to communicate the importance of Safety Policy and Procedures. Where management is serious about Safety, the workers take it seriously as well. I am sure after these disasters, procedures will change, training will take place, new policy and procedures will be written. All after the fact. Another example of “Reactive” Safety. We know that management can effectively gain "control" of culture. First through hiring practice, standard operating procedures, training, and support. It is interesting to note that in all three stories the train companies have a "good" safety record. As Dr. Deming says, "The past is no indication of the future.." Safety is a "continuous improvement" process.
NOTE: "Control" is a topic of discussion at the up coming "Tools of SMS and QA" symposium held at the Coronado Resort Hotel on Disney World property. Please go to:
http://www.dtiatlanta.com/Symposium2013.html for more information.