When there’s an accident at work, it’s often the worker involved who is blamed.
Sometimes – after lengthy and thorough investigations – the multiple causes of accidents are revealed to be much broader than ‘someone doing something stupid’ and the hope is that the BA IS system crash investigation will be as thorough.
Just like in a safety investigation, the discipline of applying ‘root cause analysis’ will seek to find out what happened to cause the failure and more importantly, why it happened. The ‘why’ is critical because it identifies systemic, cultural and management failures – the root causes.
Fixing root causes permanently makes a company more resilient – first it’s less likely to face a similar problem and second, if it does, its resulting contingency planning will mean it ‘bounces back’ from problems and recovers faster in future.
As an example of some ‘why’ issues: why did the contractor re-connect power without going through a process and or without authority? Why did they not know about the process, or if they did, why was it ignored. And digging a little deeper: how is the process developed and who has management responsibility for the process and for reviewing and auditing that it’s applied properly. How are ‘near misses’ reported, recorded and shared to the benefit of refining the process? In terms of culture, are contractors pushed to get things done in double-quick time in order to reduce downtime, do they regularly feel they have to resort to short-cuts in order to meet management expectations?
In manufacturing companies – this is characterised by ‘productivity over everything’; do what you have to do to get it done fast. Is there constant squeeze on costs? Is there little interest among management in hearing about the consequences of the squeeze, or do they just insist that all activities must continue, but that they must be done more efficiently.
Capital cost reduction, combined with reduction in staff may also result in a situation where the margin for error or the presence of back-up systems compounded the effect of the error. Was the cost of failure factored-in to financial decisions and how much did management think a failure – with all its attendant brand damage – would cost?
And a proper root cause analysis of BA’s outage will get to the heart of the culture that created the circumstances in which a contractor did what they did – either because they didn’t know what the correct procedure was, or felt pressured to override the process.
All this ‘digging into the issue’ may seem tedious, but it’s as tedious as a pilot doing a pre-flight check in the same way, before every flight. As yet, the total cost of the BA outage is not known, but creating a culture that avoids future incidents will certainly save a fortune.
The culture of the flight deck would be a good aspiration for many companies.