HOW CAN the civil engineering industry become safer and more reliable? Judging by the events of two weeks ago when a runaway railway trailer in Cumbria killed four track workers, the question needs to be addressed.
Research carried out by strategic consultants Mouchel Parkman and Cranfield University School of Management has concluded that the industry's poor safety record is down to its attitude towards risk.
According to Mouchel Parkman director Richard Jemmett a history of 'tolerating' failure is to blame - the classic snowballing effect.
'Small errors are tolerated or go unnoticed and gather pace within an organisation, eventually increasing the likelihood of a high impact failure occurring.
'Finally, there is often an external event or catalyst which turns the rolling series of errors into a high impact failure.
'The build up to the Hatfield rail disaster followed this pattern, ' said Jemmett.
These findings were revealed to industry at the ICE last month in a meeting attended by infrastructure operators including the Highways Agency and London Underground.
Adopting the principles of High Risk Organisations (HROs) is one way of arresting escalating errors. The nuclear energy industry, air traffic control, and car manufacturing follow HRO principles.
Cranfield University deputy research director Professor David Tranfield says HROs maintain reserve capacity to deal with accidents. Critical tasks are duplicated and backup systems are used to catch, contain and recover from errors.
He said that HROs could not learn by trial and error because mistakes were not tolerated. He gave the example of the nuclear industry where accidents are simulated to allow personnel to learn how to cope 'offline'.
During normal and emergency operating conditions, HROs change their hierarchy of responsibility, he said.
'Under stress the HRO structure inverts so that the people closest to the accident are empowered to take action, ' said Tranfield.
To implement these principles, Jemmett believes that it may not be simple enough just to say 'let's improve reliability'. A whole organisational change has to take place.
Characteristics of HROs include:
Strong organisational culture of reliability.
Continuous learning through simulating disasters.
Effective and varied patterns of communication.
Human resources management to encourage open discussion about errors.
Adaptable decision making dynamics.
Flexible organisational structures.
System and human redundancy The assumption is that higher safety standards and reliability can be achieved, but at a huge cost. But Jemmett argues that the cost of failure can far outweigh the initial cost of preventing it.
'Railtrack essentially lost its company because of the Hatfield crash. And then people were forced to use road transport until normal services resumed.
Some avoided trains because they didn't feel they were safe.
'Consequently, there was a huge loss in revenue coupled with an increase in road traffic accidents, ' said Jemmett.
Mouchel Parkman-Cranfield is investigating how parts of some businesses can adopt HRO principles and welcomes views on the issue.