Decoding Industrial Disasters — A Causative Analysis
Two major industrial disasters recently struck India within a month in the mid of the corona crisis. These came as shockers to the helpless population in the vicinity, and during the lock-down, causing deaths of many and with colossal damage to the environment and ecology. One was in the South-Eastern coastal district of Visakhapatnam where leakage of styrene gas from a polymer plant on 7th May killed ten persons and critically injured many hundreds. On the 27th of May, a massive fire broke out at an oil well soon engulfing a huge area near the Dibru Saikhuwa National Park in the North-East Indian state of Assam, killing two firefighters and causing extensive damage to the surrounding villages.
Such accidents, unfortunately, have found a gradual and generous acceptance in an industrializing world. These are no longer shockers to the commoners or TRP earners anymore. The conventional response in a disaster is to find a scapegoat so that the judgement can be rushed up, and the facts, which may have far-reaching implications, can be hushed up. This is sad but true.
While efforts are constantly afoot to control and curb industrial mishaps, for the known errors and the foreseeable ones, tragedy, unfortunately, strikes at random with loss of invaluable lives and resources. There are many approaches to understand and analyze the root cause of such mishaps. However, the statement “to make a system foolproof would be to underestimate the ingenuity of a fool”, though an irony, offers an interesting premise to analyze and understand the genesis of these disasters.
Interestingly though, the factors attributable to the accidents are not very many. From Chasnala to Chernobyl, from Bhopal to Visakhapatnam, the factors which compromised with operational safety leading to disasters form a small set. These are the known generic weak-links and loopholes. The procedures and the instrumented operations get corrected, but a key and a common factor linked to human psychology and organizational behavior, which forms the ‘root’ of all causes, tend to remain invisible. Even if this factor is vaguely sensed and acknowledged from a distance, its culpability is a challenge to prove. It thus continues to remain as the weakest link in the safety chain. The approach and the analysis below are kept simple and blunt for the sake of clarity, and also understanding the fact that these behavioral and related aspects would otherwise never get a space in a disaster debrief.
A fouled chain of command is an organizational liability. An industrial organization of any type will have a body of management to device policies, plans, groom the human resource to execute operations. There will be demarcated distribution and delegation of roles and responsibilities amongst the executives in the hierarchical structure; and there will be a workforce from skilled to menial workers including the supervisory staff. In a setup like this, there are no good or bad workers. It is the management that would be judged by its leadership, competence, and conduct; slippages of any type and form are not condonable even if the fault is of the youngest unskilled worker. Individually it is an executive, and collectively it is the management, who is accountable and responsible for the success or failure of a task. It would be to the credit, or to the discredit of the management that the team or the workforce performs above or below par. The lead and the role of every individual executive in the chain of command would count and contribute to this process. Now the catch here is when the incompetence and weakness of one (or few) in the hierarchical chain tend to get hidden with the competence and confidence of subordinates. This weakens the robustness of the organization, with inaccurate information flow and incorrect decisions. At a time of an imminent or an emerging crisis, this gets further complicated with the fear of attracting displeasure from the higher-ups, if the one at the helm happens to have strong dislike or intolerance for the bad news. This syndrome defeats the wisdom of “a stitch in time saves nine”. The golden hour also slips out of hand. The worsening situation is either underrated or under-reported to suit the eardrums of the senior echelons. This continues until it yields and erupts.
Though not completely off context, it will also be worthwhile to make note of an unseen or rather an ignored loophole in the age of outsourcing is the skilled and unskilled workforce employed by the agencies to execute hazardous jobs, especially in the developing world. The welders, the plumbers, or the masons employed by these outsourced agencies may lack in required skill and qualification. The agencies, which will have a natural tendency to cut corners, may resort to employing workers with a deficient skill set. The on-site quality control inspectors may also overlook a few of the many critical tasks, however trivial these may be, which may eventually lead to a constructional flaw and a potential source of disaster. Reasons for these oversights may vary or may even be controversial. However, this remains the biggest safety loophole in outsourced jobs. The fault of this omission in the safety check-list is attributable to the top management only.
The list of culpable cause of industrial disasters is unending. The nightmare of the Chernobyl meltdown because of a flawed reactor design, operated with inadequately trained personnel still sends a shiver down the spine. However, it would need to be accepted that the most challenging loophole to plug, or weakest link to strengthen in the safety chain is the command and control structure (and the regime) of an industrial organization. The foresight, competence, information flow (lateral and vertical), and correct delegation of authority will collectively answer whether the system is ‘foolproof’ or vulnerable.
