“It can’t happen to me” is the cause of road traffic accidents caused by people thinking that accidents only ever happen to other people; people who don’t have such good driving skills. That’s right up until the point that they realise that their driving skills weren’t quite as good as they thought and everything goes black and painful.
It is also the type of thinking that is responsible for many accidents in the workplace.
Where is the safest place in the world to work? The place where there has just been a serious accident. Because managers and staff suddenly realise that it CAN happen here and it CAN happen to me.
But are the underlying problems dealt with? You only find that out if, or when, there is another accident. I’ll give you an example that is mainly hypothetical. Note my use of the word “mainly” – there is some real-world experience behind this example.
A fork life truck reverses out of the back of a lorry and across the loading dock. In doing do so it hits a pedestrian employee, causing serious injury. Management carry out an investigation into the accident and allocate blame to either the fork lift driver or to the pedestrian, or maybe to both. Case closed. Until the next day, when a similar accident occurs.
Why did the second accident occur? Because the first accident wasn’t properly investigated. The investigating manager allocated blame, but didn’t find out WHY the accident happened. The investigating manager was examining the symptoms of the accident. He (or she) didn’t identify the “root cause”.
A safety expert investigating that hypothetical accident wouldn’t ask who was to blame, he (or she) would ask “Why was a pedestrian in an area used by fork lift trucks?” By asking that question you start to get closer to the root cause of the accident.
To put this another way, if a doctor examined a patient complaining of headaches, they might just, on the basis of the symptoms, prescribe a mild pain killer. However, if the cause of the headache was a brain tumour, the patient would die. So the doctor looks beyond the symptoms to find the root cause of the headaches in order to diagnose the problem and treat that. Medical scientists would go even further and look for the cause of brain tumours so that they could take a more prevention based approach.
How many managers do you know that talk about the PREVENTION of accidents? It is what risk assessments are supposed to be about, but even where risk assessments are done, they still don’t prevent accidents.
Part of the reason that prevention takes a low profile is because it often costs money to put in the sorts of safety systems that are truly preventative, so to save money the risks are downgraded on the basis of “likelihood”, which is the same as saying “it can’t happen here.”
Until it does.
Experts in root cause analysis suggest that you have to ask the “why” question at least 6 times before you get to the actual cause of an accident. I asked the first one above, “Why was a pedestrian in an area used by fork lift trucks?” The answer to that question would inform the formulation of next “why” question.
Hypothetically “Because he was taking a short cut to the canteen”. So, the next question might be “Why was he able to use that route as a short cut?” While the accident victim or fork lift truck driver must still take their share of the blame for the accident, the answer to that second question would point to some sort of managerial failure. Which is probably why the question is never asked.
By the time you get to the answer to the 6th “why” question you would be a long way from the fork lift driver and the pedestrian. You might have uncovered design flaws in the building, poor supervision, poor training, lack of budget for safety systems and a whole raft of other things that, together, contributed to the accident. These are the root causes and dealing with them will save more lives than just allocating blame to the fork lift driver or the pedestrian.
But this sort of thinking isn’t only prevalent in the management of health and safety, it also exists in the world of disaster planning, or business continuity as it is known in the commercial world.
As part of one of my jobs, for 3 years I held the role of Business Continuity Planner. It is taken as read that the emergency services will do their job, but when they are packing away their hose reels, rolling up the unused bandages and taking down the blue and white tape, the business continuity plan (BCP) is supposed to be put into action and managers are supposed to start dealing with the fallout from whatever has happened. They are supposed to ensure that the business continues to operate.
Each year, as part of my duties, I would run an exercise to test the BCP. I would set up a scenario, usually a fire or similar disaster, and then ask the managers at my unit to play the scenario out in terms of the actions that THEY would take to restore business activity to as near normal as possible. This usually required them to theoretically replicate operations in a new, temporary location. It might also need them to replace staff and equipment, with all that that entails.
Without fail the level of response I got from managers was abysmal.
“It can’t happen here” was the mantra. And if it can’t happen here, I (the manager) don’t have to prepare for it.
So, I wonder if the Director of IT for British Airways ever said, “it can’t happen here.”
Yes, I’m referring to the melt down of the British Airways IT system that grounded flights around the world for an entire weekend. So what happened to their BCP?
When writing a business continuity plan the first thing to be done is to identify the actual risks to the business caused by different types of emergency. They can be anything from an outbreak of swine flu, to the failure of the mains electricity, to an aeroplane crashing into a building. Each type of risk is evaluated to consider its impact and likelihood and the plan is constructed accordingly. One quite obvious risk for any business, these days, is a major IT failure.
Yes, if British Airways had written its BCP properly it should have had a contingency plan in place for an IT failure. So why didn’t it?
Maybe they had a plan, but if they did, why wasn’t it put into action?
Maybe they did put it into action, but it didn’t work. In which case, why didn’t they know that it wasn’t going to work and fix it before they needed it? In other words, why didn’t they run exercises to test their plans? If I were Willie Walsh, the CEO of British Airways, I would be asking that very question. I wonder who, if anyone, in British Airways is responsible for asking the 6 “whys”.
And I wonder who in, British Airways, said “it can’t happen here.” Because it did, didn’t it.
British Airways has pinned the blame for the failure on a technician not following procedures when replacing a power supply. That may be true, but it is only the symptom. The root cause hasn't been announced.
Which brings me to the Grenfell House fire in London.
There will be an awful lot written and spoken about the terrible tragedy at Grenfell House last week. Most of it will do nothing to make sure that there isn't a repeat of the tragedy.
Every district and borough council in the UK, as well as every county council, is required by law to have an emergency planning officer (EPO). His or her job is to make sure that plans are in place to deal with whatever emergencies arise within their boundaries. Their job is essentially the same as that of the business continuity planner in a commercial enterprise. However, the EPO isn’t the person who implements the plan. The council staff as a whole do that, just as the line managers in my previous place of employment were responsible for implementing the BCP.
So, what went wrong with Kensington and Chelsea’s emergency plan? Why were volunteers able to organise and respond more quickly and more flexibly to events than the people who are actually paid to be able to respond?
While the plans are drawn up and sitting in filing cabinets and on servers, waiting for people to read them, the people who are required to respond don’t read them and don’t prepare for what might happen. Why? Because “it can’t happen here”.
Tower blocks blazing aren’t something that happens in Britain, is it? That’s the sort of things we see in third world countries, where they don’t have such robust building regulations, or where building regulations are ignored or subverted.
It can’t happen here!
But it did.
The government has announced a public inquiry into the cause of the fire and it is hoped that the 6 “whys” will be asked and the root cause of the fire will be established - and I don't mean a burning refrigerator in a 4th floor apartment..
But who is carrying out an inquiry into the abysmal response from the Royal Borough of Kensington and Chelsea. OK, the Chief Executive Officer has resigned (with a fat cheque in his pocket) but that doesn’t fix whatever it was that went wrong with their emergency plan. And if that isn’t fixed it means it WILL happen there again.
But what about the lessons the inquiry will identify? How many times have we heard public officials say that “lessons have been learnt”, only for similar tragedies to happen elsewhere?
The reason it happens again is because everyone nods wisely towards the lessons, then says “it can’t happen here”. Why? Because real change costs money and no one wants to pay for it out of THEIR budget! So, they don’t implement the recommendations, or if they do they pay lip service to them. The most common form of lip service is some sort of form filling exercise, which gives the impression of doing something while not actually doing anything.
It is behaviour that has to be modified. That doesn’t require people to fill in forms. That requires people to think and act differently. In particular it requires people to stop thinking that “it can’t happen here”.
And that, I’m afraid, is why nothing will really change as a result of the public inquiry into the Grenfell House tragedy.
Lip service is already being paid, with councils hurriedly spending lots of money replacing the cladding on high rise flats. That’s good, it removes the fuel that fed the fire at Grenfell House but, having done that, will they look at the basic safety of piling people up in high rise chicken coops in the first place?
No, they won’t. because they’ve removed the cladding, so now “it can’t happen here.” But fires have more than one cause and they feed off more than one sort of fuel. People don’t react rationally when they are in danger, which means that another fire, with another cause, could still result in loss of life.
But we’ve removed the cladding, so “it can’t happen here.”
So, who is it in government, in local authorities and in business that is responsible for saying “Don’t be so ******* stupid; of course it can happen here!”
Well, actually, it’s probably you!