Need to shun the ‘bad apple’ theory
LAST year’s crash involving three trains in Balasore, Odisha — which left 296 people dead and more than 1,000 injured — was attributed to human error. It was expected that this accident would make the Railways review its systems of operation and maintenance for enhancing safety, and specifically for minimising the possibility of accidents resulting from human error. That hope seems to have been belied.
Safety is about much more than human error. It is the outcome of constant adaptation to the complexities rather than a mere breakdown.
On the morning of June 17, a goods train hit the stationary Kanchenjunga Express in West Bengal’s New Jalpaiguri, leaving 10 dead and around 40 injured. Among those killed were the driver of the goods train and the guard of the express train. This accident, too, is being blamed on human error.
Even as the Commissioner of Railway Safety’s statutory inquiry is in progress, we can try to piece together what happened from the information available in the public domain. It is now known that automatic signalling between Rangapani and Chatterhat stations failed at 5.50 am on June 17 due to lightning; this failure was communicated to the Signal Department at 6.05 am. As the snag was likely to be prolonged, the department, as per General and Subsidiary Rules, should have declared it as such, which would have changed the mode of working from the automatic block system to the absolute block system and perhaps avoided the accident. It is not known yet why this was not done.
Consequently, the section continued to work as per automatic signal rules, which authorise drivers to pass defective signals. Since automatic territory rules were in force, the drivers were required to follow the protocol for moving at a speed not exceeding 15 kmph after stopping for a minute at every red signal. Six trains followed this protocol, including the Kanchenjunga Express, but the container goods train did not do so, which led to the mishap.
If the goods train driver had followed this instruction, he would have avoided the collision. Clearly, the speed of the goods train was well above 15 kmph. Loco drivers’ spokespersons are suggesting that the ‘paper line clear’ (a ticket issued to the loco pilot) may have been unnecessary as drivers are allowed to cross red signals, whether defective or not, at cautious speeds as the whole purpose of automatic signalling is to squeeze as many trains as close to each other as possible. According to them, the ‘paper line clear’, if given, would have implied a situation where the driver need not have followed the normal protocol and proceeded at a normal speed. Apparently, there is ambiguity in the working rules of the new system of signalling (the automatic system, opposed to the absolute block system which permits only one train between two stations). Inadequate understanding of these rules among different categories of staffers could also have been a factor.
Why is it so difficult to curb accidents attributable to human error? Despite the efforts of the Railways to bring in new technologies for reducing human intervention, like the indigenously developed automatic train protection system Kavach — which prevents an accident resulting from the human error of passing a signal ‘at danger’ — the proportion of accidents linked to human lapses continues to hover around 50 per cent. If Kavach had been installed on the section concerned, it would have prevented the collision but could not have stopped the driver from making a mistake. The reason why it is so difficult to eliminate human error is because this is not the basic cause of the failure but a symptom of a deeper problem plaguing the system. This is something that the Railways has yet to recognise. It looks at human error through the prism of the ‘bad apple’ theory — it believes that the system is basically safe but for those few unreliable people in it who should be identified and made an example of. Getting rid of these people does not remove the problem because it is systemic, and there are always others to step into the shoes of the ‘bad apple’.
To reduce accidents put down to human error, the railway top brass needs to recognise that identifying those responsible for the accident should not be the conclusion of the investigation but its starting point. The management should ask itself what factors led the employee to make the trade-off between safety and other goals. And how much of this could be the outcome of its own decisions. After all, all levels of the organisation have to negotiate multiple system goals, some of which may put undue pressure on those directly involved in running the train.
In view of the above, one wonders what compelled the driver of the goods train to ignore the protocol, knowing that in case of a collision he might lose his life (which he did). We cannot but come to the conclusion that there was more to it than what the ‘bad apple’ theory will answer. It is possible, and I am speculating here just to bring home a point, that he was inadequately trained and was not fully conversant with automatic territory signalling rules; he took the ‘paper line clear’ authority to proceed at a normal speed. Maybe the station master lacked training in how best to react to a prolonged and multiple signal failure in the automatic territory.
Safety, after all, is about much more than human error. Safety is the outcome of constant adaptation to the complexities rather than a mere breakdown or malfunctioning. Performance of individuals and the Railways must at any time be attuned to the current conditions. What makes such adjustment difficult is that the resources and time are finite. Hence, ensuring safety is a constant struggle, and success depends on the ability of the organisation, groups and individuals to anticipate the changing aspects of the risk before an accident happens. Poor safety and human failure are simply the absence of that ability.
The main objective of the safety department should be to assess the risks and provide resilience to ensure safety. When the top brass quickly blamed the goods train driver for the accident in this case too, it was acting out of the habit ingrained in the railway system. It is time the Railways abandoned the ‘bad apple’ theory. Limiting the inquiry and the action to those directly involved will not remove systemic infirmities that cause accidents.
