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“How did this happen? Why was this allowed to happen?”
“Can’t say I was surprised. It was only a matter of time.”
The immediate aftermath of every accident elicits one of these two reactions or questions from each of us. The former reaction is one of surprise whiles the latter is one of expectancy. These two reactions cannot exist in the same individual for the same accident. They are antagonistic reactions.
For some, the Challenger disaster was one of shock, for others, it was just a matter of time. For some, the BP Deepwater Horizon accident was no act of God. For some the unimaginable death toll from Corona Virus in the UK and USA comes as no surprise.
It is rather sad to note that these countries that take pride in their extraordinary economic, historical and political status have been humbled by the COVID-19 due to their flippant and ill-prepared response to the virus (1). The United States occupies the unenviable position of fourth place for deaths per 100,000 population (2).
History is replete with numerous examples of these kinds of accidents. Unfortunately, it seems likely that the future would be witness to some more.
The question that needs answering is, “If some people knew and expected an accident to happen, why was it still allowed to happen?” For this question, there can be only one answer!
Dr. Henry Cloud & Dr. John Townsend are credited as saying:
We change our behavior when the pain of staying the same becomes greater than the
pain of changing. Consequences give us the pain that motivates us to change.
Until the person or people whose actions or inactions are required to stop the accident from happening realize that continuing with the status quo will be more painful than the effort required to change, that accident is just a ticking time bomb.
In aviation, the Heads of Quality and/or Safety are always directly accountable to the Chief Executive. These people in charge of Quality and Safety are tasked with the identification of impending accidents and putting in measures to prevent their occurrence. Most of these measures may require financing and it is their job to convince the Chief Executive of the need to implement these measures.
At least, that is how it is supposed to work. If this system had worked at Continental Airlines maintenance, the Concorde would not have had such a fiery exit.
The tyre of Air France Concorde, after running over a metal strip on 25th July, 2000, exploded and ignited a wing fire, causing both port engines to lose power. Less than a minute later the aircraft crashed, killing 113 people and leading to the suspension of the aircraft's Certificate of Airworthiness. The metal strip, found on the Paris Charles de Gaulle airport runway which caused the tyre explosion, came from a poorly executed repair to a Continental Airlines McDonnell Douglas DC-10 thrust reverser (3). The metal strip was fabricated from a titanium alloy instead of a soft alloy like aluminum. In addition, the metal strip had been improperly attached to the aircraft (4).
Organizations that seriously want to maintain safety ought to allow the communication of critical safety information to the one required to implement the change. This is a necessary step in the right direction, but it is not enough!
What is required to safeguard the future from reactions of “Can’t say I was surprised. It was only a matter of time”, is to create an atmosphere where the transmission of safety critical information is allowed to go beyond the desk of the one to act on the information if he fails to act.
73 seconds after launch on 28th January, 1986, NASA’s Challenger, ended its mission in a fiery ball. The source of the explosion was traced to a tiny rubber part, called an O-ring, which formed the seal between sections of the solid rocket boosters (5).
On April 20, 2010, 11 men were killed in the Deepwater Horizon drilling platform explosion. The explosion caused the rig to sink and started a catastrophic oil leak into the Gulf of Mexico. When the leakage was finally capped three months later, approximately 134 million gallons of oil had been spilled, the largest offshore oil spill in U.S. history (6).
Sadly, these two accidents came as no surprise to people in the know. In the case of the Challenger disaster, NASA Engineers and the contractor – Thiokol, were aware of the problem with the O-ring joint. The Report of the Presidential Commission on the Space Shuttle Challenger Accident stated:
The Space Shuttle's Solid Rocket Booster problem began with the faulty design of its
joint and increased as both NASA and contractor management first failed to recognize
it as a problem, then failed to fix it and finally treated it as an acceptable flight risk.
NASA did not accept the judgment of its engineers that the design was unacceptable,
and as the joint problems grew in number and severity NASA minimized them in
management briefings and reports. Neither Thiokol nor NASA expected the rubber O-
rings sealing the joints to be touched by hot gases of motor ignition, much less to be
partially burned. However, as tests and then flights confirmed damage to the sealing
rings, the reaction by both NASA and Thiokol was to increase the amount of damage
considered "acceptable.
A similar regrettable situation also existed in BP prior to the Deepwater explosion. Robert Bea, a professor of engineering at the University of California, Berkeley, and a well-known expert on catastrophes involving complex systems, reached the conclusion based on his own association with BP in 2002 and 2003 that “BP worried a lot about personal safety-slips, trips, and falls – high frequency, low consequence accidents. They did not worry as much (at all) about the low frequency, high consequence accidents – the real disasters (7).”
Obviously, the safety issues got to the desks of those who were supposed to implement the change – the Change Makers. However, when they failed to act and sometimes even suppressed the information, what means was available for the information to get to the “Boss” of the Change Makers? The Boss of the Change Makers is anyone above in hierarchy who can override the decision of the Change Makers. If we do not run out of time, the information should be able to go up the chain of command till you get to the person or people who can influence or override the decision of the Change Makers.
Most times, however, this is met with stiff resistance, marginalization and herd punishment. Michael German, a former FBI special agent met with this kind of treatment when in 2002 he reported a malfeasance within the FBI. He reported this malfeasance all the way up the chain to the Justice Department inspector general. After a year and a half passed with no resolution of the issue, he reported it all to the Senate Judiciary Committee, which forced the inspector general to begin an investigation. Knowing that the retaliation within the bureau, which began manifesting when he made the first report, would only increase because he had gone outside of it, he resigned (8).
Sometimes, the chain of command may have to go all the way to its top – the citizens! Citizens have the power to effect change by their purchasing power, votes at the ballot box, social pressure, demonstrations, amongst others.
It took public outcry for any action to be taken after a patient informed the public of the loss of his wife due to hospital negligence. He had taken to Facebook to express what he said was the “impunity” and “total disregard for accountability” displayed by some staff of the hospital (9). It is very hard to believe that amongst all the staff of the Greater Accra Regional Hospital, also known as Ridge, a leading national hospital, not a single person had identified this ticking time bomb. More so, when the Ridge Hospital had gained notoriety over claims of medical negligence amongst the populace (9).
Organizations in high-risk industries, medicine, construction, transportation, among others, must make it a point to create a system, culture and atmosphere that would enable the janitor to make a safety complaint all the way to the Board of Directors without fear of retaliation from his supervisors.
Often, First-line and Middle Managers consider it their sworn duty to protect Top-level Managers from unnecessary noise arising from the shop floor.
To quote from the Message Translation of the Bible which poses a very poignant question:
And how can they hear if nobody tells them? And how is anyone going to tell them,
unless someone is sent to do it? (Rom. 10:14B)
Which janitor would be willing to break through this line of intimidating defense to get the message of safety failure to the Boss?
It should not take a rogue or rebel to do that. Till the situation exists in your organization, where anyone can have access to the Boss without fear of retribution from Middle Managers, and till such a situation is actively encouraged, you are sitting on a ticking time bomb. Someone will one day say, “Can’t say I was surprised. It was only a matter of time.”
Author: Raynold S. K. Atadja
Safety Management & Aviation Consultant
References
1. Malik, Nesrine. It's no accident Britain and America are the world's biggest coronavirus losers. The Guardian. [Online] May 10, 2020. [Cited: April 10, 2021.] https://www.theguardian.com/commentisfree/2020/may/10/anglo-american-coronavirus-crisis.
2. John Hopkins University of Medicine. Corona Virus Resource Center. Maps and Trends Mortality Analysis. John Hopkins University of Medicine. [Online] April 11, 2021. [Cited: April 11, 2021.] https://coronavirus.jhu.edu/data/mortality.
3. Learmount, David. 'Poor repair' to DC-10 was cause of Concorde crash. FlightGlobal. [Online] October 24, 2000. [Cited: April 9, 2021.] https://www.flightglobal.com/poor-repair-to-dc-10-was-cause-of-concorde-crash-/34715.article.
4. Clark, Nicola. French Court Overturns Convictions in Concorde Crash. The New York Times. [Online] November 29, 2012. [Cited: April 9, 2021.] https://www.nytimes.com/2012/11/30/business/global/french-court-overturns-conviction-in-concorde-crash.html.
5. Teitel, Amy Shira. Challenger Explosion: How Groupthink and Other Causes Led to the Tragedy. History Stories. [Online] December 13, 2019. [Cited: April 9, 2021.] https://www.history.com/news/how-the-challenger-disaster-changed-nasa.
6. National Oceanic and Atmospheric Administration. Deepwater Horizon. NOAA Damage Assessment, Remediation, and Restoration Program. [Online] August 17, 2020. [Cited: April 12, 2021.] https://darrp.noaa.gov/oil-spills/deepwater-horizon.
7. Wilson, Andrew B. BP's Disaster: No Surprise to Folks in the Know. CBS News. [Online] June 22, 2010. [Cited: April 10, 2021.] https://www.cbsnews.com/news/bps-disaster-no-surprise-to-folks-in-the-know/.
8. German, Michael. The law is designed to punish whistleblowers like me. The Washington Post. Democracy Dies in Darkniess. [Online] October 11, 2019. [Cited: April 10, 2021.] https://www.washingtonpost.com/outlook/the-law-is-designed-to-punish-whistleblowers-like-me/2019/10/10/9eefe4da-eb71-11e9-9c6d-436a0df4f31d_story.html.
9. Lartey, Nii Larte. Ridge Hospital probes claims of negligence in death of woman at facility. Citi News Room. [Online] June 26, 2020. [Cited: April 10, 2021.] https://citinewsroom.com/2020/06/ridge-hospital-probes-alleged-death-of-woman-facility/.