Normalising Versus Fixing & Preventing

This is a fascinating video (and hard to watch for the car enthusiast!).

Watch it before reading this article- https://www.youtube.com/watch?v=5oO226PgSkg

The long and short of it is the car had been rebuilt and heavily modified as part of that project.

Except for the brakes.

They identified during the interview and walk-around that the brakes really should be upgraded to suit the new build and power of the car.

While driving, they make a conscious decision to not wear the full harness system.

As they continue to drive, it is identified that the accelerator sticks, and it's also a known ongoing issue.

Further along the drive, they identify that the brakes smell bad from overheating because the driver is riding them because of the sticking accelerator issue.

Lo and behold, the brakes overheat and they fail, ending with a significant crash, resulting in injuries (that could be life-changing), as well as damage to multiple vehicles.

What About The Workplace?

How many times are we aware of modifications done to plant and equipment, outside of the manufacturer specs?

How often do we see deviations from procedures?

Jumping back to the video, if we look at this from an organisational perspective, I see issues here with Design, Hardware, Incompatible Goals, Management of Change, Maintenance Management, Organisational Culture, Organisational Learning, Risk Management and Vehicle Management.

Shall I go on?

At what stage do we stop normalising problems identified, and putting in place workarounds, versus doing something about them and preventing an incident from occurring?

There's no doubt this incident was preventable....