Wednesday, December 27, 2006

Incompetence and Human Error Every Time

“Common things are common” is one of the things that medical students are told. So if someone has a headache, the most likely thing is that it’s just a headache, with no sinister undertones. If it goes on for a few days, then it could be something more serious, but if you’ve just had it for an hour or two, then the likeliest thing is a headache.

Sometimes, however, the likeliest thing is so dull and ordinary that we don’t want it to be the case. How could our beautiful, ethereal Princess Diana have such an everyday death as to be killed by a drunken driver who was driving too fast? Surely not. The conspiracy theories – such as that it was the Duke of Edinburgh Who Done Her In – are far more attractive. The speculation can go on for ever – when the results of the enquiry are that she was in a simple car crash, we can argue ah, but they would say that, wouldn’t they? (And, let’s face it, they would.)

I saw an interesting programme about the Potters Bar train crash of 2002 recently. The last carriage was derailed at some points as the train approached Potters Bar station. The carriage ended up horizontally across the tracks and more than twenty people were killed.

Sabotage! cried Jarvis, the company in charge of track maintenance. Which, of course, was a good theory from their point of view, since it got them entirely off the hook.

However, when Health and Safety examined the set of points, there were a mere 63 things wrong with them. Only some of the faults could have caused a major problem, granted, but 63 faults would seem to be quite a few.

At the time there were more than forty companies nationally looking after track maintenance, and these were sub-contracting all over the place to smaller companies, such as Reg, who got the job because he owned his own fluorescent jacket and a spanner, and a van with Ring Reg: I’ll Get You Back on Track written on the side - - and you think I’m exaggerating? Well, only a bit.

Health and Safety had some film of Reg supposedly maintaining the track, clearly having no clue what screwed into where or why.

So it turned out to be a national problem, with trains likely to career off the rails all over the place. Oops. As a result the track maintenance was brought back in-house, and Reg went back to bodging Mrs Hedgley’s central heating.

It wasn’t anything as glamorous as sabotage, then: it was caused by human error and incompetence. Common things are common, in train crashes as in illness.

But how on earth did the Powers that Be ever think that subcontracting the maintenance of the tracks could work? If the idea had been explained to you, or to me, beforehand, we would have said no, it's a really bad idea, how can you think of it, there’ll be a disaster and people will be killed.

But nobody asked us. Common things are common – but common sense, it seems, is rare indeed.


Post a Comment

<< Home