Accidents, or incidents as we prefer to call them, almost certainly occur because something has changed. Just look at the published details of any major incident and you will see details such as: a software change, a design change, a timetable change, and so on. Obviously, the key word here is change.
Large changes are easy to spot, or so one would think. However, major failures still occur. Why is this? In very many cases the change has been incremental, building up over time.
On the 21st of October 1966 at Aberfan in Wales, 144 people, mainly children, were killed when a huge coal waste tip slipped and took everything in its path, including the village school. There were two main causes:
- Over many decades, the waste material was tipped on top of a stream.
- Water ingress into the tip from the stream and rain created a ‘fluidised bed’, that is, the waste material particles were slowly lubricated, enabling the slip to occur.
This was a desperate tragedy, sadly replicated in other places in the world, including El Salvador and more recently in Brazil.
In the corporate world we now see the term ‘Creeping Change’ being introduced. The Aberfan disaster is an extreme example of how small changes can occur, unseen, all the time, until things go wrong. What about in our own organisations? Are tiny unnoticed changes occurring, in safety and every other aspect of the business?
Over twenty years ago at TOP-SET, we coined the term ‘Organisational Rust’. This is just like real rust: the oxidisation of iron and steel, slowly going on, day by day, until a failure occurs or, more hopefully, is spotted and remedial action taken.
Over several decades, countless investigations, large and small, have been conducted by TOP-SET, and change has been a factor in every one of these, and, much of this has been incremental, creeping up over time.Whether you choose to call it ‘Creeping Change’ or ‘Organisational Rust’ doesn’t matter. What does matter is what you do to spot it and take action. This requires continual vigilance. We can, and must, do risk assessments, construct BowTies, put barriers in place, but change, somewhere, will still be going on and there will never be a time to be complacent. As a director of a company in a seriously high-risk industry once said to us, “When you reach your safety goal, you still can’t afford to take your foot off the gas”.