Things are "Still Going Wrong" - Why?Watch the video
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
It’s very subjective.
Second “C”: Controls
Third “C”: Changes
“Change is inevitable” as they say.
Design, Engineering, Procedures and People…what I like to think of as the “Safety Continuum”.
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”.
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…?