Things are "Still Going Wrong" - Why?

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Things Are Still Going Wrong – Why?

This is one of my favourite books in my collection.

It’s by the late, great Trevor Kletz and it’s titled “Still Going Wrong”. It was a sequel to his classic book “What Went Wrong”.  I like this book and I refer back to it quite often, especially when I’m reviewing an accident or incident.

However, I am sorry to report that things are “Still Going Wrong”, but why?

With hindsight (based on my experience), I have come to the conclusion that we can fundamentally “pin it down” to 4C’s.

What are these 4C’s?

First “C”: Competency

Competency is always an interesting subject because,  what I might see as someone being competent you might see them as being not so competent. It’s not just down to training.
It’s very subjective.
When discussing competency with a Client, I recall the Client saying to me that he sees competency as “the right person for the right job”.  I thought that was quite poignant and summarised it quite well.

Second “C”: Controls

Control of hazards play a key role towards mitigating risk and hazard exposure. I am sure we are all familiar with the Hierarchy of Controls and the lower down we the triangle we go regarding the control measure selected, the greater the probability of risk exposure. 
 
Selecting the right risk control measure is key to success and when we look back at accidents or incidents, we might find that the optimum was not selected for various reasons (e.g., cost, availability, schedule etc).
 
In this context, selecting control measures should be focused on preventing “loss of life” or hazard avoidance and not be correlated to other factors. 

Third “C”: Changes

“Change is inevitable” as they say. 
If we consider the 4 areas where change management plays a pivotal role it would be:
Design, Engineering, Procedures and Peoplewhat I like to think of as the “Safety Continuum”.  
Poor Management of Change in any of these areas will undermine the risk or hazard being mitigated. 

Fourth “C”: Complacency

This is not about organisational complacency or compliance, but more related with and individual’s complacency.

The individual’s risk appetite plays an important role towards complacency. I might be risk averse, whereas someone else might be more of a risk taker.

Repetition can also contribute towards complacency because the more familiar a person is with a task, the greater the potential for overlooking key steps or taking short cuts.

As Trevor Kletz refers to in his book, human error has played a significant role in things “Still Going Wrong”.

In Conclusion

The 4C’s has been at the forefront of the majority of my incident or accident investigations when it came to Root Cause Analysis.

There might be other titles or variations, however, it was always possible to park the reason in one of the 4C’s.

For you organisation, when it come to safety performance improvement, take a step back and look at each of the 4C’s and ask yourself the question “are we where we want to be?”.

Is this what good looks like…?

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