The Eastern Freeway crash, and Chain of Responsibility.

Melbourne's Eastern Freeway disaster of 2020 could have been avoided by thinking and acting in terms of chain of responsibility instead of authority.

When management is left to structure its own organisation, naturally people at the top will acquire authority, and will shift responsibility away from themselves, downwards to the people doing the actual work.

This is why the old-school top-down approach causes so many disasters. They will not take on that responsibility, turn a blind eye and will use their authority to stop even hearing about issues of concern.

We see such authoritarian structures cause disasters like Chernobyl and NASA’s space shuttles. Management would not take on responsibility to listen to the engineers, and disaster was inevitable.

Such a thing is exactly what happened in Connect Logistics leading up to the Eastern Freeway crash of April 23, 2020.

What caused the crash?

Transport driver Mohinder Singh had slept only five hours in the previous 72, felt obliged to keep working, and was likely only awake due to drugs.

He was suffering anxiety, depression and delusions, and his erratic behaviour included talking about seeing stick figures and being chased by witches. 

Not a great set of conditions under which to drive, and the inevitable happened. After weaving all over the road he eventually smacked into a police cruiser in the service lane, killing four officers.

But with him in such an obviously poor state, what went wrong to allow him to be behind the wheel?

Chain of responsibility

Before the chain of responsibility changed the transport industry, those at the bottom didn't want to take on the risks and responsibility of being a whistleblower, and feared punishment for speaking up.

With managers now held accountable for flaws at each level of the organisation, they have incentive to foster a system in which uncomfortable information may flow upwards. There are now ways in which drivers and loaders may alert managers of a problem, and the managers welcome such news (if reluctantly) as it may save their necks.
So anyone could prevent a crash by reporting their concerns to management. 

As it happens, Singh DID report his own condition to management, who took no responsibility for it, and in a strange application of responsibility, made Singh pray in an effort to dismiss his demons, declared him fit to drive, and a tragedy was the inevitable result.

The court result

That religious component - belief that prayer would fix the fatigue - may have confounded the courts, as the result was confusing. Imagine that - trying to prove in court that the defendant knew that prayer doesn’t work. Could have been interesting.

The transport industry is varied enough as it is, making precedent difficult, and disasters so often obvious only in hindsight. A good thing is that precedent is not so strong, as with the wisdom of hindsight, the courts can make a ruling after the incident that does not match the first.

This is obviously a less than optimal strategy, as disaster would be the only way to make positive changes happen. In the meantime, companies can claim to not know of their responsibilities.

So it is unfortunate that, in this case, while the court may have known that Connect Logistics should never have let Singh drive, they could not find his boss, Simiona Tuteru responsible for Singh’s poor state.

Instead they could only find him guilty of mechanical maintenance of the trucks, finding two trucks with major defects, and issuing four charges of heavy vehicle infringement.

This was a case that could have been used to ensure that the whole industry sharpens up and establishes the chain of responsibility to prevent a disaster caused by ignoring driver fatigue. It was not the lesson it could have been.

Hopefully the post-hoc legal action will empower the courts to come down hard on the next company that ignores driver fatigue, no matter their religious conviction.

In the meantime, we have our compliance laws. Some say that they are harsh, but compared to sifting through the wreckage of a fatal crash, this is the kinder approach.

The compliance laws make responsibility flow upwards, as it should, and the sooner we get the whole industry on board with the chain of responsibility, the sooner we can have years without disaster.

Image Source: https://www.abc.net.au/news/2020-04-22/police-officers-killed-in-crash-on-eastern-freeway-melbourne/12174586