About Human Error

Big story in the Johannesburg media today was about a derailed luxury train in which three people lost their lives. In situations like this, you never get the whole story as "investigations" have to be done to establish the official course of the incident. In this case initial reports indicate that brakes were not applied on the stationery coaches when locomotive engines were being changed and the coaches rolled downhill and derailed at the bottom killing three people.

Despite the confusion that has been thrown in about signals not working properly (I am battling to understand how faulty signals can cause train coaches to roll downhill), the fact is that brakes were not applied to the coaches during the locomotive changes. This, we are told, was standard procedure. The question is why this was not followed at this time?

I guess we can ascribe this to human error. Sometime, human error is ascribed to those incidents in which someone simply did not follow procedures and regulations because they thought nothing would happen. Cutting corners without having any adverse consequences (and I am not by any account suggesting that this was the case here) creates bad habits which are only revealed when a calamity such as this one happens. This is why complacency should be guarded so much against. Cutting corners is never good.

Getting the Whole Picture

In my last post, I wrote about what seemed to be a flawed consultative process in the planning for the World Cup stadiums in South Africa. Two reports in the Johannesburg newspapers recently got me thinking about this issue a little bit more. The first was the protests by taxi-owners about the new cheap, efficient and clean bus system and the second was the recent protests by musicians against the small number of South African musicians included in the official entertainment about the world cup.

It would be easy to suggest that the exclusion of these two stakeholder groups was merely an oversight and therefore we should just forget and forgive. It would probably be so if it was not so endemic. The reason it is so endemic is because of tghe tendency to look at projects from their own perspectives alone.

Some years ago, I was associated with an organisation which employed someone full time just to travel around to look at business areas of the organisation and its customers to assess in advance where the potential problem areas were and to address these before they developed any further. The strategy worked and the reason it did was because all stakeholders shared their needs and were part of planning processes. The current situation does not seem to have the same hallmarks.

Let us hope though, that we learn from these and in future planning processes should be a bit more inclusive. There is a word for it. It is called "systems thinking". Precisely because you are building a road, you need to consult pedestrians, some of whom do not own cars, the noise and pollution from fumes will affect all.