Weathering the "perfect storm of multiple failures"

Passengers and crew of the Qantas A380 which recently made an emergency landing at Singapore Changi airport must bear charmed lives. In the ECONOMIST it was reported that:


Confidential preliminary reports seen by Fairfax Media reveal that high-velocity parts spat from the engine tore through a fuel line and wiring looms, punctured structural spars in the wing, struck the fuselage between the two decks of windows, hit the fuselage belly and tore through wing panels.

Patrick Smith, a pilot who writes for Salon.com, refers to a "perfect storm of multiple failures". He reckons the biggest problem the pilots faced was the need to land an overweight plane, since the system that allows them to jettison fuel was not working.

Had the plane gone off the runway and caught fire, or burst into flames because fuel was ignited by the overheated brakes, it is still entirely possible that everybody could have survived (see Air France in Toronto, et al.). However, Qantas Airways' proud record of zero fatalities, intact since the 1950s, would have been in very serious jeopardy.

The massive BP oil spill in the Gulf of Mexico was another example of a calamity resulting from the failure of multiple lesser factors.


In Hong Kong the SARS epidemic of some years ago was not simply due to SARS hitting the territory, but multiple failures in responding to the first signs and patients.


Here, in Singapore the escape of Mas Selamat, hitherto Singapore's most infamous detainee was also the culmination of multiple factors that favoured his escape.


Yesterday we read in the main stream press that the reason why he managed to get to the home of his brother was that he has over 100 relatives and it was impossible to keep all under surveillance. Surely he does not have 100 brothers and sisters - IMMEDIATE family?


All the above examples are in the past, but looking forward I am rather worried about our (mankind's) ability to learn and keep improving our ways to prevent and react to failures, both small and big.


We cannot rely on luck or good fortune to get us out of fixes.



The Department of Health in the UK published a piece on human error:
http://www.dh.gov.uk/en/Publicationsandstatistics/publications/publicationspolicyandguidance/browsable/DH_4936329


People in government, management, the armed forces and all walks of life would find it useful and interesting reading as what is said in the article has universal relevance.


I would recommend reading the next chapters which include 'Factors influencing learning from failure' and the following list of conclusions:

• Awareness of the nature, causes and incidence of failures is a vital component of prevention - ("You can't know what you don't know");

• Analysis of failures needs to look at root causes, not just proximal events; human errors cannot sensibly be considered in isolation of wider processes and systems.

• Error reduction and error management systems can help to prevent or mitigate the effects of individual failures;

• Certain categories of high-risk, high-technology medicine might be regarded as special cases. In these areas the level of endemic risk is such that serious errors or complications will never be eradicated. The evidence suggests that here a focus on compensating for and recovering from adverse events might be an important part of the approach to improving safety and outcomes;

• Organisational learning is a cyclical process, and all the right components must be in place for effective, active learning to take place. Distilling appropriate lessons from failures is not enough: there is a need to embed this learning in practice, and it is at this stage that the "learning loop" often fails;

• It is possible to identify a number of important barriers to learning which must be overcome if the lessons of adverse incidents are to be translated into changes in practice;

• Culture is a crucial component in learning effectively from failures: cultural considerations are significant in all parts of the learning loop, from initial incident identification and reporting to embedding appropriate changes in practice. Safety cultures can have a positive and quantifiable impact on the performance of organisations;

• Sound safety information systems are a precondition for systematic learning from failures. They need to take account of the fact that low level incidents or "near misses" can provide a useful barometer of more serious risks, and can allow lessons to be learned before a major incident occurs;

• Given appropriate approaches to analysis, it is possible to identify common themes or characteristics in failures which should be of use in helping to predict and prevent future adverse events;
• The NHS is not unique: other sectors have experience of learning from failures which is of relevance to the NHS.

Although written in the context of the NHS and the practice of medicine, the principles apply elsewhere.


But all this presupposes that the governments or organisations are not in denial or caught up in their own collective egos.


It may be an over-simpification but they are made up of people and people are not perfect, infallible creatures.


Or perhaps the 'chosen' people have no or insufficient regard for their populace. 


When the ruling class are hell bent on maintaining their closed circle and are arrogant to a fault, how can their minds be open to learning?


Before the enthusiasm and arrogance of young bureaucrats overwhelm them, they might take heed of this:


Those who cannot remember the past are condemned to repeat it. (George Santayana, Spanish philosopher)


A saying which is oft times quoted as, "history repeats itself".


Already in Singapore's young life we have witnessed significant flip-flops in government policy. Only history will tell if our leaders were right.


In bigger, older countries and communities substantial changes are somewhat slower and harder to effect as they have to meet with the approval of a broad base of people who might have different languages, cultures and religions. Not to mention that some countries span time zones and climates.


In the meantime we in little places like Hong Kong and Singapore will feel the buffeting of the political and governmental seas more acutely.


So, let's hope and pray that our governments learn well the lessons from the storms that have beset us in the distant and the near past.