The tragedy of March 22^nd, which resulted in the needless deaths of two young engineering interns in SMRT has shocked most Singaporeans into a sense of worry and concern that profit oriented companies may seem to make light of safety requirements in rail operations.

Regardless of type, all accidents have a route cause. This is usually either human error or mechanical failure. Just as you would logically have a preventive maintenance plan and scheduled maintenance on a machine to prevent failure and downtime, you also need a preventive maintenance plan and scheduled maintenance on your safety management system.

Human error has often been cited as a cause or contributing factor for numerous disasters and accidents. So what is human error? It can come in any form: unintended errors in execution, sudden lapses in attention, poor memory, or even just plain lack of motivation to do the job properly.  I would like to highlight some causes of human error in operational setups that may lead to disastrous consequences.

Poor communication often appears at the top of contributing and causal factors in accident reports, and is therefore one of the most critical human factor elements. Communication refers to the transmitter and the receiver, as well as the method of transmission. Transmitted instructions may be unclear or inaccessible. The receiver may make assumptions about the meaning of these instructions, and the transmitter may assume that the message has been received and understood. With verbal communication it is common that only 30% of a message is received and understood.

Complacencycan be described as a feeling of self-satisfaction accompanied by a loss of awareness of potential dangers. Such a feeling often arises when conducting routine activities that have become habitual and which may be “considered”, by an individual (sometimes by the whole organization), as easy and safe. A general relaxation of vigilance results and important signals will be missed, with the individual only seeing what he, or she, expects to see.

Lack of on-the-job experience and specific knowledge can lead workers into misjudging situations and making unsafe decisions.

Distraction is potentially a leading cause of problems of all kinds.  It may be difficult to pin-point and ascertain this as a direct cause of accidents. But employees can be attempting more than one task in a critical operation and thus lose focus.  We hear the mantra about the importance of being able to multitask but human capability may be wanting.

In rail operations, many tasks and operations are team affairs; no single person (or organization) can be responsible for the safe outcomes of all tasks. However, if someone is not contributing to the team effort, this can lead to unsafe outcomes. This means that workers must rely on colleagues and other outside agencies, as well as give others their support. Teamwork consists of many skills that each team member will need to prove their competence.

An interesting phenomenon to note is that human errors are categorized as such only on hindsight; in other words, sometimes they may originally be considered part of acceptable behavior.

In many accidents human failure was not the sole cause but one of a number of factors, including technical and organizational failures, which led to the final outcome.  Studies over the years have established methods to identify, categorize and mitigate against the effect of such errors occurring. It is imperative that transport organizations are required to include this vital operation in the Safety Management System.

A safety management system encompasses safety arrangements at all levels of the company and provides a process by which risks can be assessed and controlled. Organizations need to understand how human factors influence behavior and consequently safety performance. This is especially important when an organization attempts to reduce risk with operational solutions rather than by designing out the problem, for example supplying operators with ear defenders rather than reducing the noise at the source.

An accident is mainly caused by three events: careless initiation of the control system, an unacceptable level of understanding of potential accidents by the staff, and the mistakes made by controlling staff. Secondly, the system itself may be good enough; however, the operators in fact may not fully understand the system and make mistakes which the system does not expect. It is therefore vital that consideration is given to assessing and managing risks arising from human activity which may impact on the safety of the system.

When most people think about a system, they usually overlook the user of the product, the human being. We can look upon an outcome and see how something might have been prevented, but we will never see the situation from the eyes of those who experienced the moments that mattered before the accident. We can look upon an outcome and see how something might have been prevented, but we will never see the situation from the eyes of those who experienced the moments that mattered before the accident. We who look at the results have the benefit of seeing those results clearly. The moments that mattered before the accident, were filled with all manner of information, not just the telling information that is apparent after the accident.

To minimize human error, a well-designed risk management plan is required.  Firstly, organizations need to firstly identify the possible risks. It is much more difficult than it looks like. For example  in the SMRT accident of 22^nd March 2016, the engineering team and station staff may not have consciously expected the danger of working during service hours on that day or never thought of that before. Therefore, the safety lapses occurred consequently. Without proper simulation of a work safety process , a more risky operation may be initiated that finally causes the accident. Therefore, identification of risks is important and requires a high level of experience and professional conduct. Secondly, the risk should be assessed according to its frequency and consequences.   Thirdly, it is also important to choose proper solutions to different risks.

 Companies should actively and effectively implement risk management plans. Managers should invest adequate resources and workers should be trained to be able to react according to plan. Lastly, management should regularly review the risk management plan and update it to suit most recent situation. All these may eat into the bottom line, but isn’t one death in a needless accident too many?