A portion of a newsletter from The Da Vinci Institute, an international centre of excellence in the Management of Technology, Innovation and People (MOTIP) and Technology Top 100, for people seeking to improve business performance through a greater understanding of technology management. For more information, contact Charles Hellyar rcrsafety@hotmail.com Managing Member. Risk Control Rating Systems (SA) CC

1. Understanding what causes accidents
and how to prevent them happening again
A
ccidents will happen. Mum He also holds a pilot’s licence, obtained in available to finding the root cause of
always said so when someone 1995. accidents and the ways to prevent them
spilt milk on the kitchen tiles. His work offers an essential infrastructure
happening again.
No harm done, she would add. Over the years, people have talked and
and methods to develop a customised,
Often, though, there is harm done, like when holistic ‘Root Cause Dialectic’ process for the written a lot about Root Cause Analysis.
a ferryboat sinks or an airliner crashes. investigation, analysis and mitigation of The television series, ‘Seconds from disaster’,
People perish. disasters, accidents and incidents. has brought the images of disaster and
When accident investigators finally His thesis recently earned him a PhD in the investigation into living rooms.
complete their inquiries and publish their Management of Technology and Innovation What the cameras seldom show, the speakers
report, you might safely bet they will attach (MOTI) from The Da Vinci Institute. seldom say and the writers never spell out,
blame solely to the last person in the chain It’s entitled ‘Nescience in aviation: a are the complexities of the investigation and
of events. phenomenological study of causation and the analytical process to which disasters and
Usually, it’s one or more of the individuals consequentialism’, and runs to around 500 incidents are subjected.
at the work face: pilots, operators and pages of fact and argument beyond Seldom, if ever, is there any mention that
maintenance crews. simplification in an article like this. these processes failed to mitigate against the
Fortunately, that need no longer happen, As Hughes asked when interviewed about it: recurrence of such disasters.
not just in air crashes, but in any industrial “Where to start, and how much do we talk Yet, during the 30 years of development the
or commercial accident, large or small. about?” thesis spans, the process of Root Cause
Human factors authority, Joel Hughes, It would have been nice to offer ‘10 easy Analysis has evolved from rudimentary
has developed research that sets out a steps’ to finding out what caused an elements being used sporadically, into a
topography that is essential to understanding accident’ and 10 more to preventing it highly complex, holistic process that colours
the complex nature of cause and happening again, but its not that easy, the very fabric of an organisation and
consequence. if possible at all. becomes an essential part of its core.
Hughes (61), who holds PhD in Human The value to readers is probably greatest in Hughes argues that, fundamentally, any
Factors, is a consultant in systems analysis outlining the problems that the dissertation incident has just two major components:
and human performance analysis, and in solves, rather than explaining how it does so. bionomical (human) factors and technical
accident investigation and occurrence That said, the dissertation constitutes factors.
PAGE 1 1
management. arguably the most pertinent guidelines If initial investigation shows an incident to fit

2. definitively into one or the other, overall It’s the one which, had it been timeously And academic ignorance of root cause
analysis is relatively undemanding. identified and eliminated, would have analysis, he says, remains a crisis of
Things become tricky when the root cause is prevented the sequence of events that led endemic proportions.
arduously elusive and appears to have both to the undesirable, destructive, costly and During the investigation of an incident,
human and technical features. often fatal occurrence. the analyses of the technical components
In a complex incident where the root cause Stereotypically, general industry resorts to and human characteristics as a holistic
is intangible, the psychologist will ‘putting out fires’ - what Hughes terms undertaking, are inconsistent and
characteristically not involve himself in reactive dialectics - to establish the root unaccomplished.
analysing its technical aspects. cause of an incident. The void between technical and
Conversely, the engineer, with his Industry’s apathy and recklessness in psychological fraternities works against
fundamental analytical background, will cohesively pre-empting the root cause of
championing investigations done by
almost without thinking describe the poor the incident, and obliges them to share
individuals qualified only by an engineering
performance or failure of complex responsibility if the incident recurs.
degree, or worse a national diploma, he
technological components as human error. Similarly, there is a need for a universal
finds unjust and contemptible.
As this unforgiving situation emerges, process of integrating engineering and
The immoral insensibility and unprofessional psychological disciplines, to ensure the
a natural process of apportionment of blame
managerial manoeuvre of apportioning holistic evaluation of the grey area that
spirals into play. Invariably, it leads to finger
pointing in search of a scapegoat. blame on the last person in the chain of separates them (which Hughes addresses
events is unjust and inexcusable. in his disseration).
As the drama unfolds, the rationale behind
the investigative mechanism is lost. It’s
artfully relegated in both priority and status.
So the whole mechanism fails in its objective
and its value.
In the end, the disunion makes people liable
and exposes them to punitive action.
Many a budget is tested and wasted because,
as distressing as it is predictable, the
incident will recur, since the fundamental
reason why it happened was never
definitively established or resolved.
Says Hughes: “This is the true quandary
behind industry’s failure to prevent some of
the greatest disasters of our time.”
As Hughes sees it, the definitive root cause PAGE 1 2
of any incident is its most fundamental episode.

3. Throughout industry, there are many a complex and often protracted investigation human causal factors of the accident with
autonomous, sometimes innovative, but and prepares him intellectually and the individual’s innate weaknesses or
nevertheless paradoxical approaches to affectively for the task. deficiencies.
accident investigation. What’s still needed is The analysis always begins at the technical Until recently, the level of theory used in the
a standard on which to base development of aspects. analysis of human error, or its complement,
customised methods.
As intricate as they may be, they’re definitive human performance, has been relatively
More than all else, Hughes would like to see and explicit. So they’re less complex to unsophisticated because of the simplex
industry seek proactive dialectics, a way to analyse, their design and functionality are mechanistic view of the human operative,
use analysis to prevent the accident before always logical and comprehensible. They whatever his job.
it even develops, to eliminate the possible have no personality or emotions. Hughes argues that people make mistakes
root cause before it simply becomes
For simplicity, the technical analysis is and are often not even aware that a mistake
unmanageable.
always done in isolation, with no reference to has taken place, let alone why. Worse still,
The Dialectic Paragon His dissertation provides the necessary the human or environmental constraints. even when they do recognise that something
has three parts: modus operandi to find the root cause of any has happened, they don’t understand how it
They’re reintegrated at a later stage, to give a
technical performance incident with both procedures - reactive and could have happened or why.
holistic analysis and solution.
deficiencies; proactive dialectics - using human factor
The fragility and wonder of the human mind
processes and technical factor processes. Step two is analysis of the natural
conditional constraints are the reasons why ‘perfect’ failures occur
environment, also in isolation and
(the environment) Central to the thesis is what Hughes entitles
independent of the technical and human
when we are at our optimum performance
and bionomical the Dialectic Paragon.
deficiencies. But conditional constraints are
and therefore when we least expect them to
performance deficiencies To you and me, it’s a sort of roadmap to happen.
catalogued into technical, human and
(human problems). arrive at the truth by stating a thesis, devel- environmental categories. The analyst’s failure to analyse accurately
oping a contradictory antithesis and then such an event only goes to complicate an
Technical deficiencies are routed back to the
combining and resolving them into a coher- already complex and therefore
technical analysis process; human
ent synthesis. misconstrued sequence of events.
deficiencies are recorded for later
It’s a method of argument that systematically consideration; and environmental aspects Given then that perfect failures are part and
weighs contradictory facts or ideas in an are thoroughly investigated and all relevant parcel of our everyday lives, why should we
effort to resolve their real or apparent causal factors recorded. concern ourselves with accurately analysing
contradictions. them at such cost and time?
Step three is the most complex: proactive
The Dialectic Paragon has three parts: profiling of the personnel. It’s a big help The answer is as simple as it is intrinsic.
technical performance deficiencies; when mapping an individual’s innate Human failure, the perfect failure, is
conditional constraints (the environment) and weaknesses or deficiencies. It also correlates fundamental to our learning, and therefore
bionomical performance deficiencies (human the deficiencies associated with the incident teaching, processes - our growth.
problems). with the innate deficiencies recorded during Everything we are is a direct result of what
Understanding the way the three constituents the profiling. we think. Since our every thought will have
PAGE 1 3
work allows the analyst a simple approach to The critical stage is juxtapositioning been influenced in some way by what and

4. T IPS - NOVEM BER 2 0 0 7
how we were taught, it stands to reason that
we require understanding of the evolution
of these failures so that we may positively
influence the way in which we transfer
knowledge and skill to ensure positive change
and growth.
If a competent individual makes an error,
it is often because he or she has fallen into
a hole that someone, some situation or
even management themselves, have often
unwittingly dug for him.
So what is to be done? Hughes’s work does
offer some pointers, in a chapter he calls
areas of concern.
Management must be committed to an
intellectual and pragmatic balance between
revenue and safety. A management team
cannot have conflicting interests.
A parallel team must be established with the
same authority as the management team,
but it must focus on, and take responsibility
into training systems to ensure that corrective performance but is an archaic methodology
for, safety. This will provide a platform for
actions gleaned from proactive dialectics are that requires intellectual re-thinking.
healthy debate and mature compromise
between profit for the development of the effectively incorporated and that lessons Punitive action certainly has its place but is
company and safety for its survival. learned from the reactive dialectics are decisively not the holistic solution.
implanted vigorously.
Management must also create a distinct
disunion between the traditional safety Universities need to implement a specific
discipline of ‘human factors re-engineering’,
department and a dedicated accident
to secure its academic status, and to
investigation group.
integrate psychological and engineering
The traditional safety department should disciplines. It’s essential if industry is to
retain its day-to-day management of general progress to a next generation of analysts who
safety issues while the accident investigation will be expected to work with an exponentially
group must be singularly focused on increasing level of sophistication and
accident investigation and its associated complexity.
corrective actions.
Hughes feels punitive action is still the PAGE 1 4
The ‘fire fighting’ processes must be integrated preferred method of managing poor human