Dr Kathleen Callaghan

Lessons of the past were forgotten

Kathleen began her presentation with the sobering comment that, on one level, there was nothing new to learn from what happened at Pike River. The factors that led to the accident were all issues that should have been identified and managed – but they weren’t.

The real message for directors and senior managers is how easy it is to forget the lessons of the past, and how terrible the consequences can be if we do that.

Kathleen described what happened at Pike River using the “Swiss Cheese” accident causation model developed by renowned psychologist James Reason. She overlaid this with an understanding of “human factors” science.

Swiss Cheese Graphic

Human factors are things to do with the job, the individual and the organisation that can affect behaviour and work, and therefore safety. These human factors, and the way they inter-relate, need to be taken into account in a good safety management system. That way companies can build safety systems that are tolerant of human error, along with other risks.

The Swiss Cheese model shows how most accidents can be traced back through four levels of failure: organisational factors; supervision; preconditions; and unsafe acts.

The steps to prevent accidents are shown in the model as a series of barriers, like slices of Swiss cheese. The holes in the cheese represent the weaknesses in each part of the system. When there are holes in every slice and these holes line up, the organisation’s safety systems have failed and there’s potential for accidents to happen.

Whether an accident happens or not is then a matter of chance or “Sod’s Law”, Kathleen says. The bigger and more numerous the holes, the greater the chance of an adverse event.

Pike River’s safety defences were full of holes

By the time of the accident at Pike River, the company’s “organisational” and “supervision” slices of cheese were riddled with holes, she says. For example, there was a lack of standard operating procedures and a rapid turnover of senior executives. Supervisors failed to enforce the rules and even violated the standard operating procedures themselves.

There were also significant holes in the “preconditions” slice. Pike was a start-up mine in a challenging environment. There was worker inexperience and the company went on to suffer considerable cash flow problems.

"There were gaping holes in Pike River's safety defences"

As for the “unsafe acts” slice, there are always holes in this slice in every organisation, Kathleen says. That’s because it relates to the actions and decisions of people on the ground – and one thing we know for certain is that people will always make mistakes.

Put this together and it was clear that there were gaping holes in Pike River’s safety defences. The risks of an accident occurring should have been obvious to anyone who took a close enough look.

So what are the lessons for managers and directors in other high risk industries?

Kathleen says one of the biggest mistakes organisations make is to focus most of their incident prevention activities on the last slice of cheese – preventing unsafe acts. You are never going to close all the holes and turn this into a solid slice because no matter how many training or behavioural safety programmes you run, people are always going to “stuff up”, she says.

Error is a normal characteristic of human behaviour and safety systems need to be designed to cope with this. People make mistakes every day. We get distracted and we break the rules. Realistically, the scientific evidence shows us that there is not much we can do to stop this at the level of the individual.

As a result, there is a growing realisation that organisations need to focus on the other three slices of cheese, and design systems that are tolerant of error.

Leaders should focus on the factors they alone can influence

In particular, senior managers and directors should focus on the top two slices – “organisational factors” and “supervision” – because they and they alone have the power to influence these factors. They need to make a personal commitment to identify every hole in these two slices of cheese, and to eliminate or minimise these holes.

Kathleen says managers and directors should think of their companies as being constantly under attack from Sod’s law. Sod is random and unrelenting, and is constantly firing arrows at the company’s safety defences in the hope that one day the holes will line up, the arrow will pass through, and an accident will happen.

Christchurch Forum Seminar

Forum members at the Christchurch seminar

Sod has an inexhaustible supply of arrows and energy – which is why safety requires constant vigilance, she says. We are never going to be like Sir Edmund Hillary and “knock the bastard off”.

Senior managers should never make the mistake of thinking that when they start off their slices of cheese are made of cheddar. In reality many holes are present from day one, particularly in the pre-conditions slice.

Three things to remember

So in summary Kathleen says senior executives wanting to learn from the lessons of Pike River should remember three things:

  • Focus on the areas where you have most control – the upper two slices of cheese.
  • CEOs and directors must make a personal commitment to eliminate or minimise holes in the upper two slices. They should want to make cheddar, not Swiss cheese.
  • Never forget that Sod never rests.

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