A tram crashed in Croydon south of London on the morning of November 9 when it failed to negotiate a bend and left the track, tragically resulting in the loss of seven people’s lives.
A bulletin on a BBC news programme this morning, a day after the incident, caught my attention. It said that a ‘single cause for the tragedy was yet to be identified’ and focused coverage on the driver who they reported ‘may have fallen asleep or blacked out’. Like references to ‘pilot error’ all media covering transport crashes want to rush to the conclusion that it was the ‘nut behind the wheel’.
On the strength of this, I’m tempted to offer a ‘101’ course on incident causation to reporters. I’d probably start by rolling-out the tried and tested James Reason model, fondly called the Swiss Cheese Model. It shows slices of holey Swiss cheese, that represent a series of barriers:
- organisational influences
- specific acts or omissions
If these are in place and functioning normally, they will prevent an incident. They all need to fail in order for a hazard to result in a loss or incident.
But what has this to do with the media?
Well, I think that while journalists want to wrap a story up quickly along the lines of ‘suspected pilot error’, they may be missing the chance of being more rigorous, incisive and systemic in their reports, as the story develops. Understanding the ‘Swiss Cheese model’ and applying some basic root cause analysis principles would help them get to the heart of the story and may inform the questions they ask and the people they may want to speak to. Eyewitnesses and survivors are essential interviewees, but once they’ve been interviewed, trying to speak to other people in the company may also be productive. And even if they can’t get them to talk, knowledge of incident causation can open up productive avenues for reporters to investigate: company culture, cost savings, redundancies, audit frequency etc.
Getting to the root cause is what investigators do – and nothing is stopping journalists from taking the same approach. IF the tram was going to fast – why? IF the driver blacked out or fell asleep – WHY? Was it shifts or rostering, or another reason? Are there cost pressures? How is the company trading and so why might someone want to save money or speed up operations? Who may have wanted to save money or provide a faster service? That’s likely a management decision, so how far might this be a local management problem, or a more holistic issue affecting more than one tram, train or plane operated by the company?
I’ve worked as a reporter reporting on disasters, as a crisis manager for a corporate and as a health and safety leader and consultant. So, in a way, I’m a poacher turned gamekeeper, but my main concern has morphed into working for the prevention of incidents in the first place.
Just as an incident happens through a series of failures, I’m convinced there are multiple contributions to a safer society. The safety professional or regulator won’t solve these issues on their own. In this context, the media does play a critical role in holding companies’ and governments’ feet to the fire on safety. So if companies consistently faced the prospect of an incisive media with a real grounding in the principles of health and safety management, it may drive a greater diligence around risk management by more companies. If this results in one fewer injury or fatal incident, then it will have been worthwhile.