This is not about Billy Idol 1984 number!!
- Titanic the unsinkable ship sank on the morning of 15th April 1912.
- Hillsborough Football Stadium disaster 1989 which Killed 96 Children, Men, Women who were Liverpool fans. 15th April 1989.
Accidents, Industrial deaths are not new; they were happening before, happening as I type now and would happen in future. Where great institutions excel is they learn from such incidents and make sure such incidents never ever occur again. 28 years on Football stadium safety moved leaps and bounds and Passenger ship sinking not heard in my life time so far. They put in great systems, infrastructure, skill based training, Emergency response to Catch the fall, again. (Or perhaps never fall)
So what were Root Cause in a broader sense that lead to these events:-
- Complacency:- Both cases absence of previous incidents made leadership to believe situations are all safe. I am think of organisations which have foolishly assumed that No Incidents means all good and great, only to see a major incident wipe business clean. What also happens is in their complacency mode an arrogance creeps in, which isolates /insulates such organisations and the fall is high and mighty.
- Error in Judgement:– Authorities didn’t read the situation developing (Crowd Swelling at gate, High speed Ship) that can cause lead to a potential incident situation due to lack of judgement or lack of information, data. This is where a good pre planning (Pre Mortem as Dan PINK calls it would help) to foresee things that could go wrong and put corrective actions. Previous crowd incidents in 1980s UK football matches were never taken note to correct situations.
- Inadequate Infrastructure:– The lack of adequate life boats at the super ship, Locked stands which prevented fans from moving around thus leading to virtual stampede. I can quote numerous instances where lack of emergency exits, Exit locked from outside or lack of support system makes organisations sitting duck should things go wrong. Effective safety always comes with world-class Engineering and infrastructure. Nothing more, Nothing less. Everything else is secondary. Great organisations which value human lives, work an infrastructure focus to prevent Loss of lives and property damage in an adverse situation.
- Lack of Emergency response:- In Hillsborough, precious time was lost in even declaring and communicating emergency. When done and support systems arrived only 14 of the 96 died in the hospital or were on the way when they breathed their last.
I am not listing everything that went wrong! My thoughts are how organisations can learn lessons from such incidents and work a plan to ensure incidents that affect people do not happen in their work place. As I keep saying, No one but terrorist comes to work with an intention to get kill or lose a limb! Still we blame people for things that go wrong??
What can companies do?
- Leadership walk the talk, committment to change things, Visible felt leadership.
- Risk Assessment for Planning with Normal, Abnormal, Emergency situation, Use guidelines like ISO 31000. Establish action plans for risk mitigation with timely tracking.
- Link risks to objectives, Targets and measure. What gets measured gets done. Review.
- Establish sound Emergency procedures, practice practice, practice…
- Train Train Train, Communicate Communicate Communicate.
- Work Corrective actions when things dont appear right? Encourage people to come forward and report situations.
Good luck!! As a Liverpool fan in my teens the incident touched me personally!!! (Now EPL what’s that!!)
Take care, god bless
15/4/17. 1800 Hrs.