Monthly Archives: February 2016

A perspective on the Bavarian train incident

Human error. A term used when companies are unable to blame systems, technology or process when things go wrong. It’s a throw away phrase which has been used as an acceptable excuse for countless major incidents and catastrophes in recent times.

Human error apparently took the lives of 11 people and injured at least 80 more when two passenger trains collided at 100kmh in Germany on the 9th of February. The man supposedly responsible is looking at involuntary manslaughter charges with a possible 5 year jail term.


So why did the seemingly experienced and qualified Area Controller, sitting in a signal box in Germany one Tuesday morning decide to open the track to two trains on a collision course only to notify both drivers afterwards?

The Chief Prosecutor Wolfgang Giese said: “if he had complied with the rules…there would have been no collision”.

Perhaps that seems slightly obvious?


Of course company audits will take place and it may even be found that he took (and passed) all the required training, was apparently aware of the correct processes and was an experienced and genuinely good employee. But how accurate a picture would this really be?

The rail industry is not alone in having invested countless millions, if not billions, embedding systems, technology and process to mitigate risk and improve efficiency.  But as we may see as the detail behind this sad case unfolds, ultimately it is people who are more likely to expose you, because it is their fundamental responsibility to build, implement and follow the processes and to work with the systems and infrastructure.

You may have come across the Swiss Cheese Model – 99.9% of the time your systems, processes and people will align and work together despite small gaps in some places, with no issues. However there will at some point be an occasion when all the “holes” align and everything can change in that instant.

The majority of people want to do their best for their company, however, rightly or wrongly, people have always found ways of navigating around standard procedure, process, and best practice. It may be they are instructed to work outside of process by their manager or peers because it’s ‘quicker’, or ‘the way we’ve always done it’. These process tweaks can be effective, but they can also expose you on a mammoth scale if not embedded appropriately.

This is what Cognisco calls exposing yourself to People Risk.


So why does this happen? You will recognise typical responses that follow incidents like the Bavarian train crash, such as ‘we’ll thoroughly review our processes’ and ‘we’ll invest in more training’. However in Cognisco’s considerable experience, that approach won’t make any difference if the process or the training wasn’t the root cause.

If the process wasn’t adhered to before, why would another more refined one work? What would be the benefit of enforcing more training on people that clearly didn’t apply it or understand how to apply it last time, and expect anything to change going forward?


A different analytic must be applied to support the infrastructure.

For example, wouldn’t it be much more effective if organisations had a view of what their people actually understood about their role from the training provided and the embedded processes, and if they had confidence in delivering in all aspects of their role?

Take the Bavarian train Signaller – and this can be applied equally to other people and roles. With this insight on him, the organisation would have been presented with a view of the exact development areas he specifically required and any risk areas would have been have flagged, meaning they could have provided tailored interventions, reduced risk and possibly pre-empted this major catastrophe.

Taking it a step further, wouldn’t organisations benefit from insight on the gaps in understanding across whole teams and indeed whole organisations and if everyone was directed to the specific learning, training or support that they actually required? In essence giving companies a ‘global view’ of the team and/or organisation’s understanding, capability and confidence rather than ‘sheep dipping’ everyone with the same “solutions”.


Having people centred data is key, i.e., data that actually aligns to people, their understanding, their capability and their confidence in real time.

The reality is that this data IS available and IS working for some of the largest and most well respected organisations globally.

Cognisco enables companies to understand not only people’s capability, but their confidence in delivering against their required competencies. Supporting the robust systems, technology and processes that organisations have invested in, it gives them critical people data which allows them to:

* Implement strategic people based decisions

* Evidence regulatory compliance

* Reduce the cost of audit and litigation

* Accurately target L&D investments

* Retain, develop and attract the very best people


We have enabled our clients to transform the way they develop their teams and given them insight into their competence and confidence, enabling them to understand the issues and challenges they face in their roles. This complete visibility of an often global workforce and accessible data at an individual, team and company level has enable organisations to identify ways to improve their performance across many disciplines in many sectors, maximising people potential and mitigating the latent People Risk.

Clearly investigations are ongoing in Germany, according to reports Prosecutors do not believe the man acted deliberately, however he needed to (and did) push the button himself in order to allow the trains through.

It’s possible that we may never know exactly why it happened, but what is clear, is that many of the incidents that are blamed on a ‘human error’ are avoidable, can be pre-empted and the risk of them re-occurring can be significantly reduced. A more in depth view and analytic on your people, their capability and their confidence quite possibly holds the key to aligning your organisations existing investments, supports an optimised workforce and significantly reduces risk.