resultant mayhem would not be the result of an error made by one person who might have been a little careless and bumped into a weakened pipe, causing the leak that allowed the fire to take place. It would be an institutional failure to deal with the real issue of aging pipes carrying combustible material. Perhaps the CEO thought that pipe replacement could wait for the next fiscal year due to a tight budget. My point is that we often set ourselves up for potential errors by neglecting to see what the real “root cause” is for the sorts of errors we are likely to make.
SMS AND ROOT CAUSE The root cause for most maintenance-related accidents isn’t that someone forgot a step or
assembled something incorrectly, even though that is what made the incident known. The root cause is found in why the step was missed or what factors allowed an assembly to be put together incorrectly. We should ask, “Why didn’t someone follow the written procedure?” rather than simply stating it is important to do so. We shouldn’t simply retrain or reprimand someone without understanding why they skipped or missed a step. The days of firing someone because they made a serious mistake, and without looking into why that happened, should be gone if they are not already. Only when we get answers to questions like this can we make appropriate changes to how we operate and thereby improve safety. We need to understand that since there are usually multiple
reasons errors are made (the “links in the chain”), if we only deal with the last link in a chain then we leave the other links in place to bite us again. Our maintenance training should not only include how to perform certain tasks but also how to recognize conditions that lead to the first (second or third) link in a chain of events causing a maintenance error. This is at the heart of what a safety management system (SMS) tries to accomplish. Having an SMS plan in place doesn’t mean it will have the desired result of fewer errors. People might still sign off work long after it was completed and inspectors might sometimes still place a stamp without really inspecting the work. Documentation does not equal safety, but we often act as though it does.
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