Small Mistakes Add Up To Catastrophy

[Haironyourchest]

Recently a local man drowned in the bay near his home, not far from shore. He and a mate were rowing out to an island in foul weather, when their vessel capsized. One of the men managed to swim to a rock, where he was rescued later, suffering hypothermia. The other man’s body was found the next day.

 

My initial thoughts when I heard this news were “Life Jackets??” Word of mouth reports say the unfortunate man had not been waring a lifejacket (I don’t know about the survivor). Further reports say he was also waring waders, as the plan was to go duck hunting on the island, but I don’t know if this is true. It is certain they embarked on their expedition in foul weather - the beginning of storm Gertrude.

 

This was a very capable guy, a multi-skilled, physically strong, hyper-confident, pillar of the community. He had done this excursion many times before without consequence. So what when wrong?

 

As I pondered this, I came to the conclusion that many of you reading have already reached. Multiple things went wrong, simultaneously. To paraphrase: the catastrophic accident was caused by a convergence of small mistakes.

 

No lifejacket

Foul weather

Waders (maybe)

 

If any one of these factors had been present when the boat overturned, he might have made it to shore. But with each additional layer of error, the chance of catastrophe multiplies.

 

1 mistake = 1% chance of catastrophe

2 mistakes = 4%

3 mistakes = 16%

4 misakes - 64%

 

You get the idea (Im just trying to paint a picture here, making no claims of scientific or statistical accuracy, by the way)

 

I guess most of us have a passing knowledge of system failure theory. It's out there and anyone who does dangerous manual work will have come across it. Anyone in construction, will at some point have done a safety course where it is mentioned, etc. Im no expert, but essentially its the theory that several small things going wrong, cause a a big accident. Sometimes the small mistakes are not identifiable as such when they occur, and only become obvious in hindsight. Therefore, most industries have checklist systems.

 

Take public transport for example. Before the driver boards his bus, he must fill out a checklist - tyres, lights doors etc and so on. The vehicle DOE test is another kind of checklist that tries to eliminate risk. Its a great Idea, and very necessary, but we can’t all live our lives ticking boxes. In the rough and tumble reality of a sector like Arboriculture and forestry, the checking needs must be a mental mental habit.

 

That’s all well and good. When we have the time, we can check each piece of our gear, like we should. Make sure the ropes are rigged optimally. Be sure of footing, perfect work position, rehearse the plan of action and so on. And so we do. But what about when the pressure is on and the weather is turning? We can reduce risk, but risk can also come from outside. Some trees carry a higher risk than others. Some sites do to. Some cuts are riskier. A guy can crosscut straight logs all day with a sharp saw, in his yard, in a jig, swearing flip-flops and shorts, while driking a beer, with minimal risk. But when the ground is a rocky bog, the logs are a twisted pile, and the light is failing, the risk goes up exponentially. It is then that we must recognise the increased level of risk and take measures. The only measures we can take, realistically, in most cases like this, are to abandon the work, or work with extreme mindfulness and caution.

 

And that’s really the whole point of this thing. We are all capable and confident people, like the fellow who lost his life in the bay. Sometimes our confidence in our abilities blinds us to small mistakes and unnecessary risks. Most of the time our skill and experience overcompensates these risks, but the accumulation of small mistakes multiplies by a cube function and it only takes a straw to break the camels back. Lets be aware of the unseen risks - like fatigue and complacency.

 

Im posting this really for the benefit of lurkers and non-members, as anyone who has done forestry work professionally will already be familiar with the theories contained herein, and I wouldn’t want people to think I was teaching them to suck eggs.

 

There are others on this forum more eloquent then me, who can say this better. And I hope they will.

Edited February 12, 2016 by Haironyourchest

[Mick Dempsey]

Good post.

"Each additional layer of error"

good phrase.

[David Cropper]

Excellent post, there's nothing wrong with your eloquence, very well put. I'm sure it will ring a bell with most on here. I really have to think about what I am doing and what the next stage is. My problem is lack of concentration, always thinking of something else. It took me to fall into a disused septic tank, breaking three bones in my foot, to make me really think about what's going on around me. Best of it was that I had looked at the site before, did my assessment, actually warned the tree surgeon, Darren Shepherd of VTS to be aware of the tank before he followed on from me the next week! I now try to get through the day relatively unscathed. I think that we all think we are bulletproof until something happens. A post like this just concentrates the mind a bit more.

[Mr MEng]

 

And that’s really the whole point of this thing. We are all capable and confident people, like the fellow who lost his life in the bay. Sometimes our confidence in our abilities blinds us to small mistakes and unnecessary risks. Most of the time our skill and experience overcompensates these risks, but the accumulation of small mistakes multiplies by a cube function and it only takes a straw to break the camels back. Lets be aware of the unseen risks - like fatigue and complacency.

 

Absolutely spot on post, and the paragraph above hits the nail on the head.

 

 

Willie

[kevinjohnsonmbe]

Like lining up lemons on a fruit machine....

 

1 may not have much significance,

2 you start to get excited,

3 you may be in the money,

4 jackpot!

 

It's kind of the reverse with little errors / mistakes / problems..... The cumulative effect can have consequences far beyond the individual impact of singular issues.

[cyrustrees]

Well written, buddy, important stuff... I've climbed and done treework 35 yrs (been to intensive care with 8 broken ribs and a punctured lung!!) and like what you are saying. the college kids aren't up to spec and switched on enough (mainly coz instucters haven't got enough real time experience or first hand knowledge!??) which leaves it up to us "old" boys to show them how to stay alive.. God help them if there was another storm like '87.. The first thing I always do at base of tree is run my rope thru my hands and do a visual & physical check whilst coiling it so it goes up the tree freely. I see very few other climbers do this... WHY??? I could go on all day about the vulnerabilities of modern kit (metal fatigue etc) but would just like to say KISS- Keep It Simple, Stupid!! Have a good one and TAKE CARE out there, lads (& a few lasses I'd like to meet!!), Cyrus

[matelot]

I work in construction and we were given a training course on safety. We were told about the "safety pyramid".

 

Seemingly, there is a ratio of 600 near misses to 30 accidents to 10 serious accidents to 1 fatality. It means if you can reduce the near misses at the bottom of the pyramid you also reduce the fatalities...

 

I think we've all seen near misses and turned a blind eye..

[the village idiot]

I work in construction and we were given a training course on safety. We were told about the "safety pyramid".

 

Seemingly, there is a ratio of 600 near misses to 30 accidents to 10 serious accidents to 1 fatality. It means if you can reduce the near misses at the bottom of the pyramid you also reduce the fatalities...

 

I think we've all seen near misses and turned a blind eye..

 

You go anywhere near my misses sunshine, and I'll give you two blind eyes!

[Haironyourchest]

You go anywhere near my misses sunshine, and I'll give you two blind eyes!

 

Clever. Gotta remember that one! Near misses, how many we all have had, and how many were we unaware of? Recollecting some of the stupid stunts I pulled in my teens and twenties, Christ , Im lucky to be in one piece. Pure dumb luck. And the thing is, a lot of these times, older and wizer heads were watching the shenanigans and didn't see the danger either.

 

I remember cutting logs into firewood with my grandfather - a guy with an adamentuim skeleton. I'd hold the log on a sawhorse while he cut the end off with a 254xp, then feed it along, cut, feed, cut, feed, until I was holding a stub of a log, maybe a foot long, on the edge of the horse, and he'd make the last cut, halving it, with the chain whizzing like four or five inches from my hands. Yeah. That's the safety ethic I grew up with. The internet has schooled me.

[geoff]

Fine post, and worth reading twice.