The French train operator SNCF has discovered that 2,000 new trains it ordered at a cost of 15bn euros (£12.1bn) are too wide for many regional platforms. The BBC’s Christian Fraser in Paris says that it is an embarrassing blunder that has so far cost the rail operator over 50m euros (£40.6m). Our correspondent says that the cost is likely to rise even further.
Construction work has already started to reconfigure station platforms. The work will allow new trains room to pass through. But officials say that there are still 1,000 platforms to be adjusted. The error seems to have happened because the national rail operator RFF gave the wrong dimensions to train company SNCF. Our correspondent says that they measured platforms built less than 30 years ago, overlooking the fact that many of France’s regional platforms were built more than 50 years ago when trains were a little slimmer. The platform edges are too close to the tracks in some stations which means the trains cannot get in, officials say.
A spokesman for the RFF confirmed they had “discovered the problem a bit late”. Clearly this is a major blooper.
Where did SNCF’s and RFF’s procedures fail? Why? And what can we learn about human factors from this huge error?
The Health and Safety Executive and Energy Institute rank procedures as one of the top ten human factors issues, and establish failures in procedural management as contributing causal factors to disasters such as Bhopal in 1984 and Piper Alpha in 1988. In the USA, the BP Texas City explosion in 2005 also cited procedural issues in connection to the refinery explosion.
These facts pose the question: why over some 30 years do we continue to see procedures feature in major accidents events and significant near misses – and, like here, in mistakes that cost organisations literally millions of pounds?
Procedures can fail at one of the four key stages of their lifecycle:
- the development stage
- the implementation stage
- the usage stage
- the maintenance stage
In our case in point, there was clear procedure failure at the development stage: incorrect information relating to the task requirement was provided, and there was no procedure in place to check the information provided. There was also procedure failure at the implementation stage with employees either failing to check information or checking incompletely or the wrong things.
Procedures continue to feature in countess incidents and major accidents. They represent an organisational weakness which may not be immediately apparent unless robust systems and processes are out in place. While technology continues to advance at an increasing rate, humans continue to play a significant role and carry out a wide and varied range of tasks within organisations. Therefore, investment in procedures ad their management is an essential step towards reducing accidents, improving efficiency and removing procedures as a top ten human factors concern.
Our human factors consultancy can help you look at your existing procedures to ensure they are supporting your organisation in their aim of achieving consistently safe behaviours.
or contact us to find out how our Leadership and Management programmes
can benefit your business.
Tel: 0845 2600 126