The root causes of an incident/accident can’t be limited to just technical factors. It is the leadership and cultural factors that need greater emphasis
More than 30 years ago, Union Carbide had one of the worst industrial accidents, in Bhopal. Many countries across the world brought in legislations and many companies use the incident as a learning event that redefined the way of managing safety. It is unfortunate that major incidents continue to plague Indian industry. Over the last few years, many companies from the steel, refining, chemical, cement, power and construction sectors have suffered heavily due to such incidents. The irony is that investigation reports continue to reveal that all these incidents could have been prevented if management had exercised better controls.
Recent incidents such as those at NTPC Unchahar and Cochin Shipyard that resulted in multiple fatalities continue to be a grim reminder that a lot remains to be done. The NTPC accident, at the largest power utility in India, is especially unfortunate despite the chairman and managing director consistently demanding safety improvements to achieve performance on par with global peers—like that for other business parameters of NTPC. The incident provides an opportunity not only for NTPC, but also other industries, to reflect and act upon what needs to be done to avoid the recurrence of such painful incidents. Why do such accidents continue to happen?
Normalisation of deviations
Based on the review of past incidents, it has been seen that many major incidents have happened because knowledgeable and experienced people (including managers and engineers) chose to deviate from defined and established standards. Why does this happen? For a start, it is usually because the reward for making that decision is attractive. The reward could be saving time, money or even being recognised as a “smart manager/engineer” who can get things done by leadership. When nothing untoward happens and the reward is attractive, the desire to repeat such actions gets reinforced. Over a period, this results in “normalisation of deviations.” Smart people become oblivious to potential consequences, although the risk of such consequences themselves continue to remain the same.
As an illustration, let us consider a case of driver who is in a hurry to be on time for an appointment. He may choose to jump a signal to save time. When he does take this deviation without consequences and reaches his appointment on time, then the “reward” of having saved time weighs in future decision making. Similar situations happen all the time in industries where people tend to bypass required permits due to urgency of production and/or schedule. When they bypass and get things done, the reward associated with their behaviour is very much appreciated. Over a period of time, these behaviours get reinforced, with workers becoming oblivious of potential consequences of their actions. Maybe 999 out 1,000 times, an employee gets away without negative fallout. However, that one time when things go awry, it can be catastrophic.
As a decision maker matures and experiences the emotional feedback or “payoff” of the decision, the emotional feedback is no longer unexpected, but anticipated, and begins to factor in “shaping” the decision (Loewenstein, Vohs & Baumeister, 2012).
Shooting the messenger
The approach of leadership and management in not “entertaining” bad news and, in a way, “shooting the messenger” who delivers such news has a big impact on the organisational safety culture. Employees are encouraged to share what is good and working. Challenges and problems are not surfaced in a timely manner to appropriate level of leadership. This culture prevents proactive identification and addressing of situations that could result in major incidents.
Role of leadership and culture
I believe that investigation teams will be able to get to the bottom of incidents, such as those at NTPC and Cochin Shipyard. The root causes cannot be limited to technical factors. In fact, it is the leadership and cultural factors that need greater emphasis. Unless organisations and their leadership create a conducive culture that empowers and educates all levels of employees to understand the consequences of their actions, including accepting the deviations without risk considerations, industrial incidents will continue to occur.
By Srinivasan Ramabhadran, Managing Director, Asia Pacific – DuPont Sustainable Solutions based in Singapore