How strange that when something goes wrong Safety flocks to Engineering for its reasoning. Even though Engineering has been deleted from safety association titles, it remains the raison d’être for safety. We observe this in the Coronial Enquiry into the Dreamworld Tragedy. The 274-page Dreamworld Coronial is a mono-disciplinary exploration of a mechanical world. The presumption of the Coronial Enquiry is that Engineering is THE discipline that determines safety.
The Coronial Report accepts many of the assumptions of safety Engineering including the validity of risk matrixes, Administrative controls and paper-based systems. In many ways the investigation into the tragedy reads like and examination by Engineering experts of the work of other Engineers at Dreamworld. All of the assumptions of auditing, checklists and inspections are accepted without question as are the many assumptions of the Discipline of Engineering throughout the report.
The major focus of the Report is on the technicalities of the Thunder River Rapids Ride (TRRR) at Dreamworld Theme Park. The Report is about pumps, water levels, standards, conveyors, raft contact, administrative controls, safety management systems, inspections and inductions.
At point point 912 page 239 we have this:
‘It was the view of the experts that if any of the above events had been avoided, the incident would not have occurred. It is considered that a change of any one of the engineering measures identified in Question 6 would probably have prevented the disastrous outcome. Significantly, whilst the water level drop was a primary cause of this incident, there were multiple other hazards evident on the ride, as outlined previously (conveyor slat removals, nip point etc.), which could have caused other catastrophic incidents to occur at any time.’
All the advice sought from experts in the Coronial Inquiry were Engineers. Apparently a safety problem is an engineering problem. What is fascinating about the Inquiry is the assumption that one Discipline has the insight to envision risk (https://www.humandymensions.com/product/envisioning-risk-seeing-vision-and-meaning-in-risk/). No expertise outside of Engineering is sought during the Investigation. Even the attempt at Human Factors is conducted by a Cognitive Engineer. We all know anyway that Human Factors is NOT about humans but rather humans as factors within a system. Systems is the focus of this Discipline.
When you see every problem as a nail, then your only solution is a hammer. Such is the nature of mono-disciplinary investigation. At no place in the Dreamworld Investigation is a Transdisciplinary approach (https://safetyrisk.net/transdisciplinary-thinking-in-risk-and-safety/) countenanced. The assumption is that a safety is an engineering problem.
Now, don’t get me wrong, engineering has a place in the challenges of tackling risk but the privileging of this Discipline over all others is in itself the problem. None of the weaknesses of the engineering worldview are challenged. None of the assumptions of the engineering paradigm are questioned. And yet, we know that Engineers have no expertise in a host of person-focused challenges that face the safety industry including the nature of personhood, collective unconscious and culture. Why is engineering privileged in this way? Obviously, because safety is still understood as the study of objects.
At page 260 of the Report we have this:
‘Irresponsibly, and consequently tragically, the Safety Department at Dreamworld was not structured to operate effectively, with the safety systems in place at the time of the incident correctly described as ‘immature’. Document management was poor, with no formal risk register in place, members of the Department did not conduct any holistic risk assessments of rides with the general view being that the E&T Department were responsible for such matters. There were no safety audits conducted as to the human components of the ride systems at Dreamworld.’
Embedded in such statements is the continued belief in the mythologies of safety, namely that: safety systems save lives, safety is about document management, risk registers make sense, risk assessments work and that audits manage safety. The acceptance of the mythologies and symbols of safety are never challenged in this Inquiry.
The notion of culture as a critical factor in incident causation is only mentioned once in the entire Report and at the end.
‘Such a culpable culture can exist only when leadership from the Board down are careless in respect of safety (p.270)’
This single comment is preceded by dozens of pages of discussion validating and assuming the process of safety as: identifying hazards, maintaining paperwork and enforcing administrative controls. We saw similar unquestioned assumptions in the Brady Report into fatalities in Queensland Mining (https://safetyrisk.net/brady-review-nothing-new-no-way-forward/ ). When your assumption is that safety is about objects, call in an Engineer so that the culture won’t change.
In contrast this week we saw problems associated with war crimes committed by the Australian Defence Force (https://www.theage.com.au/national/rock-star-hubris-and-a-warrior-culture-what-went-wrong-in-afghanistan-20201119-p56g5w.html) where the nature of culture was bluntly declared – ‘Rock-star Hubris and Warrior Culture’. How powerful, at least someone knows where the foundations of problems are situated.
At no place in the Dreamworld Coronial is the idea of ‘hubris’ mentioned, even though one of the assumptions of managing the TRRR was that no significant even had happened on the ride for 30 years. If I wanted to understand the nature of hubris, institutionalized overconfidence, safety arrogance, perception blindness, cultural influences, social psychological factors, envisioning risk and envisioning causality, I wouldn’t seek out an Engineer.
When you make safety an engineering problem you help those in power recede into the background. When your body of knowledge is all about objects you create an industry that has no vision for the nature of subjects. When your curriculum is focused on regulation memory and recall, checklisting, counting and paperwork, you churn out automatons who can’t think critically (https://safetyrisk.net/critical-thinking-at-risk/). One could just as easily define safety as a political problem or a social problem but that would take safety out of its comfort zone and its love of objects and zero.
The big lesson from the Dreamworld Coronial is that safety is understood as an engineering activity.
Of course we know that risk and safety is about much more than Engineering Controls which is at best the 3rd step on the journey in risk maturity (see Figure 1. Leadership and Risk Maturity – see further https://vimeo.com/377161192 https://vimeo.com/143710374)
Figure 1. Leadership and Risk Maturity
When we equate safety to the engineering of risk we limit the journey to marking time on one step, the many other steps in Headspace and Goupspace fly under the radar. In this way those in power, cultures of decision making, the politics of power, sub-cultures of non-leadership and many other non-materialist characteristics of organizing remain untouched. The perfect way to make sure that nothing changes.
Dr Rob Long
Latest posts by Dr Rob Long (see all)
- An Engineering Dreamworld - November 21, 2020
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- Critical Thinking At Risk - November 16, 2020
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- Safety Holistically a Case for Change - November 13, 2020
Bernard Corden says
The following is worth a read:
https://www.ingenia.org.uk/getattachment/Ingenia/Issue-25/Autism-and-Engineers-is-there-a-connection/Acker.pdf
Bernard Corden says
The coroner’s report does not explicitly state who owns the land on which Dreamworld is built or disclose any of the major investors with Ardent Leisure via Ariadne Australia.