Hurricane Survivors and Train Wrecks

This past week has seen tragedy strike Americans on two coasts; one the result of a natural disaster, Hurricane Ike; and the other man made, the head on collision between a Los Angeles Metrolink commuter train and a freight train near Simi Valley, California. Interestingly, the grim reaper’s toll is nearly the same for both. As we sort through the rubble in a search for lessons, a few items stand out. In one particularly interesting story, one brave but foolish soul found his 15 minutes of fame by being the only person in Surfside Beach, Texas who defied authorities and refused to evacuate before the oncoming hurricane. Sixty-seven year old Ray Wilkinson, a former Marine and retired carpenter refused the mandatory evacuation order from police and drank the night away as the winds and rain howled. Authorities found him Saturday morning after the storm – safe and stone drunk. When interviewed after the event, he stated “I consider myself to be stupid.” No argument there.

Further west, there was little or no warning for the victims of the worst train crash in the US since 1993. Early words from the investigation hint definitively at human error as the primary cause, with two possible threads emerging in the early investigation. The first is that recorded audio tapes from the Metrolink train seem to indicate that the required crew coordination calls between the engineer and conductor did not take place on the two signals prior to the crash. If this is indeed what occurred, it is a simple case of non-compliance with regulations and procedures. Another lead said that two teenagers reported receiving a text message from the engineer just moments before the crash, possibly indicating the engineer was not paying full attention to the task at hand. Both are errors of personal origin and both can be trained (no pun intended) out of existence. But it is unlikely that we will do so. I fully expect we will once again hide behind the oft heard refrain that "to err is human." In this case - as in many similar cases where the outcome of an avoidable mistake results in an immeasurable toll on innocent victims - to err is inhuman.

Already there are cries for technology to save the day and prevent this type of error from ever occurring again. If the past is prologue, whomever markets the “Positive Train Control” system, which supposedly stops a train if a signal is disobeyed by the humans, is about to get a new contract. But technology is never the complete answer, and I seriously doubt it will be here. Don’t get me wrong, I am all for gadgets that makes things safer, but my experience tells me that if you make something foolproof today – tomorrow someone will give birth to a more sophisticated fool. And while this is a good way to keep the wheels of the "safety-industrial complex" turning, there is a simpler and far more effective measure we can and should be taking. More on that in a moment.

So my point in bringing these two tragedies together on the same page is simply this; I’m not sure that Mr Wilkinson, currently Surfside Beach’s most famous resident, isn’t the key to understanding the human dynamic in both of these events. While I don’t advocate his Jack Daniels approach to problem solving, he at least recognizes his own human limitations and has found a way to deal with them. As the NTSB and government officials work out the details of the Metrolink disaster, perhaps someone will realize our current collective limitations in understanding the nature of error and advocate getting serious about training to control these events.

The science is available and the means are here for such error control programs to become a part of every high risk employees’ training. But that is not the typical American response to large scale disasters. Why make people learn when we can build a machine so we don’t have to think? If the past is a guide, the response to this tragedy will be to (1) blame the dead engineer, (2) sue the hell out of Metrolink, and (3) put some new technology in place to prevent this specific event from occurring again at this specific location, and (4) claim the problem is fixed . . . until the next time.

But we can do better. Error control will never be engineered out of existence with technology. Human error is a force of nature, and just like the hurricane it can be studied, its movements tracked and predicted. To be certain, there are places where technology can help, but at the end of the day error is an individual phenomena that can be measured, understood and predicted. Predictable is preventable.

The forgotten key to error control is personal responsibility and accountability. As simple as it sounds, we can teach people to make less errors. This cannot be done in the traditional sense of training against someone’s last mistake, but rather through a systemic approach to comprehending how and why we get unintended consequences from our well intended decisions and actions. It is no longer enough to train people to do things right – they must learn why they do things wrong, and these are two very different skill sets. If you want to know more about how this is being successfully accomplished today, please contact me at tony@convergentperformance.com.