Consciousness of Sheep
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On a cold Sunday in December a subcontract electrician makes some final changes to a railway signalling circuit. The electrician is at the end of his thirteenth consecutive week of seven day working. He is not entirely sure that the work he has done is correct. But any problems will be picked up by his supervisor, who will then ask a safety inspector to approve the work before permission is given for trains to use the line.
In the gloomy light of March evening a ship’s crewman coming to the end of a 16 hour shift decides to take a nap before it is time to load the ship and make it safe for the journey home.
Taking delivery of a new version of an aeroplane, managers at a British airline decide that there is no need to waste money sending pilots to a simulator facility in the USA, since the new plane is very similar to those already in operation.
An engineer begins making essential repairs to a critical valve, but is called away before the work is finished. When problems affect the relief valve, managers face a choice between shutting down the entire facility at enormous cost and restarting the valve that was being worked on. Without checking whether it is safe to do so, they decide to restart the valve that is down for servicing.
Despite warnings from health and safety and trade union representatives, a transport company chooses to withdraw staff – including cleaning staff – from a busy transport interchange. The result is a build up of litter that becomes the source of a devastating fire.
In the weeks prior to one of the biggest football matches of the year, the seasoned match commander is replaced by an officer with little, if any, knowledge of the stadium where the match is to be played. Meanwhile, only cursory safety inspections have been made by the licensing authority, overlooking key safety concerns that put lives at risk.
After an afternoon spent drinking heavily, the captain of a sea going freighter fails to post a proper lookout as he attempts to navigate the tidal reaches of one of Europe’s busiest rivers.
These were just a few of the fatal errors made in the run up to Britain’s cluster of disasters that struck between 1985 and 1990. None, in and of themselves was the “cause” of the respective disasters. Although all fall into a familiar pattern of pre-disaster factors that Risk Management specialist Jean-Christophe Le Coze says interact to create the conditions for a complex disaster:
- Cost-cutting
- The shift from hierarchical to decentralised management structures with a much greater use of sub-contracting
- Prioritising occupational health and safety rather than process safety
- A lack of senior management safety incentives
Cost Cutting
In the early 1980s Britain endured its worst recession since the 1940s. Vast swathes of industry were decimated as companies were allowed to fail or supported to move their activities to parts of the world that had lower wages and fewer regulations. At the same time the UK government embarked on a destructive round of austerity cuts aimed at crushing all traces of inflation from the economy, whatever the wider social costs. The result was that both public and private sector organisations were simultaneously cutting spending, creating a stubborn lack of growth in the economy that only began to ease after financial deregulation in 1986 and giveaway budgets from 1987.
Unfortunately, political interference in an economy is very like attempting to lift a brick with an elastic band – initially no matter how hard you pull the brick stays on the floor; but when it does move, it jumps up and hits you in the face. It can take several years before the impact of austerity cuts becomes apparent. In social terms, nothing much seems to be happening until disaster strikes and things start falling apart. This is because most people attempt to maintain safety for as long as it remains humanly possible to do so. Like the electrician on the side of the tracks or the crewman asleep in his bunk, however, there comes a point when a key worker has simply put in too many hours. Stress, tiredness and a lack of concentration gradually build up until they render the worker unfit to do the job. At that point everything depends upon the supervisors and inspectors whose role is to guarantee health and safety.
The shift from hierarchical to decentralised management structures with a much greater use of sub-contracting
Supervision and inspection are, sadly, the kind of “backroom functions” that politicians and managers are all too eager to cut when times get tough. Inspection is viewed as an example of unnecessary “red tape.” It is common for austerity governments to make swingeing cuts to inspectorates by reducing the number of inspectors employed and/or increasing their areas of responsibility.
The supervisory role is often tagged onto managers’ other duties. When cuts are made, managers and supervisors are usually over-extended. This sets up the conditions in which supervisors are eventually unable to meet all of their responsibilities. In effect, just as the worker is relying on the supervisor to check his or her work, so supervisors end up relying on external inspectors to spot any health and safety issues. But when everyone is stressed, tired and overworked, in practice there is no oversight at all.
The problem is made worse when the entire process is privatised and subcontracted so that lines of communication, responsibility and accountability become blurred. Crucially, in a financially pressured environment the lack of a proper chain of command can result in everyone assuming that somebody else is responsible for safety.
Prioritising occupational health and safety rather than process safety
Financially pressured environments are notorious for giving rise to box-ticking… in effect, covering one’s own back rather than worrying about the safety of an entire operation. Whether it is sailing a ship across one of the world’s busiest waterways, keeping people safe on their morning commute, or ensuring that thousands of people are safe to enjoy Britain’s most popular form of mass entertainment, all that comes to matter is that “I have ticked my box.”
Nobody goes to work wanting to kill people. It is just that we create conditions in which they no longer have the flexibility to see the whole picture. And even where they do, all too often the conditions prevent them from doing anything about it anyway – nobody likes a whistle-blower; and when jobs are being cut, few people want to put their heads above the parapet.
A lack of senior management safety incentives
It is telling that no senior manager or director of any of the organisations responsible for the disasters in the 1980s was successfully prosecuted for their actions/inactions. Even in the most promising case – against the directors of P&O Ferries for their role in the Herald of Free Enterprise disaster – the case was eventually thrown out because no “controlling mind” could be found within the company. During the court case, it turned out that directors had taken a cavalier attitude to passenger safety. For example one director’s written response to a request from ships captains that warning lights be fitted on the bridge so that they could tell if the bow doors were open was: “Bollocks! Do they need an indicator to tell them whether the deck storekeeper is awake and sober?” Less crudely, another director had written: “Assume the guy who shuts the door tells the bridge if there is a problem.” Of course on that fateful March evening, the guy who shuts the doors – who was working a double shift – was asleep in his cabin, with the result that an overloaded ferry set sail with its bow doors wide open.
Do governments kill people?
There is no doubt that periods of austerity government result in a general decline in safety which, at its worse, results in disasters in which scores of lives are lost:
In terms of the number of incidents and the death tolls from those incidents the mid to late 1980s stand out. The cluster of disasters that beset Britain in those years were the product of a complex interplay between government policies, the general state of the UK economy and the way in which organisations and individuals responded to that changing landscape.
It would be entirely wrong, therefore, to suggest that individual government ministers deliberately set out to kill members of the public. What can happen, however, is that ministers become psychologically immune to the consequences of the conditions that they help to establish. In a different context, for example, former Work and Pensions Secretary Iain Duncan Smith helped create the conditions in which thousands of disabled people have been driven to an early grave. However, initially he denied that there was a death toll. Then, when freedom of information requests finally forced the disclosure of the figures, he denied that they were anything to do with him. A similar lack of responsibility can be seen in the Secretary of State for Health’s refusal to take responsibility for the deaths that result from the growing crisis in the NHS.
In effect, in a period of austerity the entire chain of command from government ministers senior civil servants to company directors, inspectors, supervisors and individual workers can easily reach a point at which they no longer exercise sufficient concern for those they claim to serve. That isn’t murder, but it comes damned close to corporate manslaughter.
The limit of austerity?
Since 2010 Britain has been subject to a similar phase of economic depression coupled to government austerity cuts to that of the early 1980s. In the public sector, cuts have been widespread. Even where funding has increased, it has not kept pace with inflation. At the same time, the private sector – both households and firms – has been on financial life support since the banking crash in 2008. Economic growth has only risen in line with the population, and what spending there has been is debt-based. Levels of debt in the UK are back to where they were before the crash, with growing evidence that firms and households are cutting back on spending in order to service and pay down existing debt. In this general austerity climate, two seemingly unconnected recent events are particularly troubling.
First and most obviously, if official fatality numbers are correct, the Grenfell fire is going to be the fourth worst non-terror-related disaster in modern (i.e. the last 50 years) British history:
If some of the figures suggested by members of the community prove to be correct, then the Grenfell fire death toll could overtake the Hillsborough, Piper Alpha and Herald of Free Enterprise disasters of the 1980s.
The Grenfell fire has all four elements of Le Coze’s preconditions for disaster. Evidence of cost cutting was everywhere from the failure to retrofit sprinklers to the decision to save the £5,000 on fire-proof external cladding and the broken fire extinguishers and smoke alarms that added to the death toll. Management of the building was privatised and sub-contracted, leaving no sense of responsibility at the highest reaches of the local council. Insofar as health and safety was inspected and supervised, it appears to have been a tick-box exercise at best. Without wanting to prejudge the inquiry, it looks for all the world like a disaster that was waiting to happen.
Second and less obviously, the rapid spread of the WannaCry ransomware through the NHS England computer system caused headlines for different reasons. Mainstream media interest in the event was largely due to the initial belief that Britain was the victim of some kind of – presumably Russian – cyber-attack. Once it became clear that NHS England was merely one of thousands of organisations around the world to fall prey to the ransomware, media interest waned. There was, it appeared, no story. But that was the story – the fact that the NHS computer system – essential to the operation of a modern health service – was vulnerable to a low-level criminal attack of the kind that small businesses are subject to day in-day out is serious.
People died as a result of the spread of that ransomware. Not directly in the way that victims of fires, train crashes or oil rig explosions die. They died out of sight as a result of the operations that had to be cancelled and the diagnostic tests that could not be carried out. And again, Le Coze’s preconditions for disaster were present. The cost cutting was obvious enough – someone simply decided that money could be saved by no longer paying Microsoft to provide security updates for NHS England’s antiquated computers – more than two thirds were still running Windows XP, some were even stuck on Windows 95! Much of NHS England’s support services are privatised, sub-contracted and networked, removing chains of communication, command and responsibility. The workforce – including those with supervisory and inspection roles – were already overworked. And, of course, those at the top – managers and ministers – were too out of touch to be concerned with the consequences that might flow from the schoolboy error of not updating the anti-virus software. Indeed, the entire system was too focussed on the immediate and growing crisis in Accident and Emergency to even hear warnings from the computing department.
While the Grenfell fire is already causing political fallout both locally and nationally, the WannaCry Ransomware event has largely been dismissed. Nevertheless, both have all of the hallmarks of disasters that are the result of the combination of a faltering economy, government imposed cuts and the responses of individuals and organisations to that environment. It is unlikely that these incidents will be the last. Quite simply, both incidents are evidence that the system is reaching breaking point. While we cannot be sure what will come next, we cannot rule out another disaster cluster similar to the one in the 1980s that resulted in workplace accidents, transport disasters and several major fires. Moreover, unlike the 1980s, when the government made sure that the emergency services were exempted from the programme of cuts, this time around the emergency services are already stretched to breaking point.
At Grenfell we have already seen the failure of the post-disaster response, as the local council sat on its hands and central government was obliged to parachute in civil servants and charities to carry out the work that the local council had a legal responsibility to carry out (but then, disaster preparedness is just another of those “backroom functions” that managers cut in the face of financial pressure on frontline services). Recent terror events have resulted in armed troops being deployed to make up for insufficient police numbers. Firefighters are struggling in the face of cuts to maintain their effectiveness in response to ordinary day to day events. The NHS in many areas is close to breaking point. We have to question, therefore, whether British emergency services are in a position to respond to another cluster of disasters similar to the one in the 1980s or whether the UK is about to have its “Katrina moment” – the day British people wake up to find not just that austerity has caused people to die, but also that in one of the richest countries on earth, we are no longer able to respond.
