| Subscribe to the Human Capital RSS feed | At the onset of the task, his supervisor talked with the fill-in operator and asked if he wanted to go over the procedure for doing the infrequent task. The operator raised his voice and angrily stated, “I’ve been working on these systems for 16 years. I know what I’m doing.” Not wanting to tee-off the operator, the supervisor backed off and said no more.
The fill-in operator went, unsupervised and unsupported by other operators, to the system and began the task. He operated the system in a way that severely stressed lifting equipment and the asset itself. The result was catastrophic failure of the system. The system failure meant that the risk to the protected species was increased dramatically. Other weather conditions beyond anyone’s control changed the behaviors of the protected species, increasing the animal’s interaction with the failed structure. A number of protected species were killed as a result.
The physical roots, of course, included the damaged system. The human roots included the actions of the overconfident fill-in operator. Latent roots included not having a written procedure for the task, as well as not having a training program and periodic refresher training. But the organization also did not have a checklist or a safety or process observer for infrequent tasks. In addition, it had poorly written standard operating procedures (SOPs) that didn’t cover operations when the system was degraded or damaged. It also didn’t have a preventive maintenance task that would have avoided the conditions that required the task being performed under duress.
At the end of the RCA, a draft report with all the facts, description of the various root causes, and recommendations was distributed to various managers and supervisors in the client organization. One supervisor returned comments that the report was factual, but it seemed to him that 90% of the fault was with the fill-in operator for not following procedures or letting his supervisor know that he needed refresher training.
The old adage that when you point a finger at someone there are three fingers pointing back at you is fully in effect here. The supervisors and managers in this organization did not provide good training, did not keep training records, did not have clearly written procedures, did not ensure people knew how to carry out the tasking or had needed support. Moreover, when the system was damaged, there was no heightened sense of awareness of the risk to wildlife. They did not have increased vigilance nor did they adjust guidance to operators on how to operate the system to reduce risk to the operators. The operators had an SOP that was poorly written and not recognized by management as deficient.
It’s easy to find a scapegoat to deflect responsibility. Senior leaders, managers, and supervisors have to ask, “Do I know what I’m doing?” Are your training programs, SOPs and oversight putting your team in a position to succeed?
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