"An Organizational Accident"
It's something I've written about before, about how the media and the public tend to blame individuals, or at least we want a scapegoat. Who screwed up? Whose fault? This has been the case in airport near misses and in hospitals. The Lean mindset (going back to the Deming philosophy) teaches us to look for systemic causes of problems rather than just pointing the finger of blame. As Deming always taught, management is responsible for the system — they have the means and the authority to actually help fix the system, more than individual employees.
So, I was, in a way, pleasantly surprised to see this editorial and analysis in the Chicago Tribune today, talking about an accident on the CTA Blue Line train last year, where 150 passengers were hurt.
The federal government came and investigated the accident and the conditions that led up to it.
“…the “worst” he's ever seen. That's how one NTSB official regarded the CTA's track inspection and maintenance non-system. The train derailed because the track was deteriorating, because no one noticed, because inspections weren't done, or not done well enough, and if they were, the problems weren't getting reported and those that were, weren't getting fixed. Lucky no one was killed. Riders and taxpayers have a right to be enraged at the “Chicago Way” of doing things.
The investigation, citing a deficient safety culture, noted “a series of latent conditions and active failures at many levels through the CTA corporate structure, which is characteristic of an organizational accident.” That's bureaucratese for: This is one pathetic, dangerous operation.
It's not often when you see somebody pointing at “latent” and systemic problems. I'd say responsibility for the accident goes all the way to the top of the CTA, and the CTA leadership can probably blame the state government for lack of funding or oversight. Whose responsibility is it that tracks aren't inspected or maintained? It's not enough for leaders to say “my people didn't do their job.” It's the role of leadership to MAKE SURE their people are following Standardized Work (or it's leadership's role to make sure the Standardized Work is even there to be followed). It's the same reason Mattel can't be excused for their China quality problems by saying, “Our suppliers let us down.”
Ironically, the CTA originally responded to this train accident with blame. They fired five employees. Did those employees really have the power to impact the system? I'm sure the CTA President felt good for firing them. Problem solved, eh?
CTA officials said today that following an extensive internal investigation, five employees were terminated for rule violations that allowed track conditions to degrade and cause a derailment. The terminated employees included two track inspectors, their foreman, the engineer responsible for monitoring the foreman's
work performance and the manager of track maintenance.
The CTA President continued grandstanding:
“These employees were entrusted with jobs that are critical to providing safe,
reliable service for CTA customers and they let us all down. By abdicating their
responsibilities, they put customers and other employees at risk,” said CTA
President Frank Kruesi. “We take safety seriously at the CTA and have no room for employees who don't.”
Again, where was Mr. Kruesi? The rules were being violated before the accident took place, why wasn't anyone paying attention or holding employees accountable earlier? That's a leadership failure, I would argue.
The CTA responded to the accident with reactive repairs and other things that they should have been doing before the accident had even occurred. That would have been proactive. That would have been Lean thinking and Lean leadership. Not that I would expect to find either of those things at the CTA… it's just sad to see how common that blame thinking is.