15-Fixing the Wrong Thing: How Post-Accident ‘Causes’ Muddle Construction Procurement

When a complex system trips over itself, the reflex is to slap a bandage on the “cause” and call it a day. Richard I. Cook’s How Complex Systems Fail skewers this approach: “Views of ‘cause’ limit the effectiveness of defenses against future events.” In construction procurement, pinning an accident on a single “human error” and bolting on a fix feels righteous, until you realise it’s like mopping the floor in a downpour. Cook warns these end-of-the-line patches muddle the system further. They add complexity and mask the real culprits—failure trajectories. Let’s unpack why this blame-game backfires, and how to dodge the trap.

The Bandage Blunder

Post-accident fixes obsessed with “human error” aim to block specific acts, say, a skipped safety check or a rushed pour, “that can ‘cause’ accidents.” In procurement, that’s a new rule, a tighter clause, a mandatory tick-box. Problem solved, right? Wrong. “These end-of-the-chain measures do little to reduce the likelihood of further accidents,” Cook says, because the exact same flop is already a long shot, because latent failures shift like sand dunes. Post-accident fixes add complexity to the system, making it a denser maze. Dependencies blur, accident pathways go dark, and practitioners are left squinting to navigate the mess.

Picture a site where a crane topples due to a missed inspection. The fix? Triple-check every lift. Sounds smart—until the paperwork bogs down the schedule, crews cut corners elsewhere, and a new weak spot festers. This “increases the coupling and complexity,” multiplying latent failures and veiling the next crash. Safety doesn’t improve; it’s just buried under a mountain of tick boxes.

The Real Culprit: Trajectories, Not Targets

Post-accident analyses must identify failure trajectories rather than a root cause. A collapse is a chain of pressure points: a tight deadline pushing overtime, a budget squeeze thinning maintenance, a vague specification misread under stress. Blocking the last link in the chain does nothing to fix the issue—the chain just reroutes. Instead, map the trajectory, and you where to loosen, reinforce, or rethink.

UK case law offers a stark lesson. In R v Swan Hunter Shipbuilders [1981], a fire killed eight workers, pinned on a welder’s “error” with oxygen gear. The fix? Stricter kit rules. But the trajectory—overcrowded shifts, lax oversight, production haste—stayed untouched. Complexity spiked with new regs, yet similar risks lingered, just wearing a different face. The “cause” fix was a plaster on a fracture.

Untangling the Knot

So, how do we stop piling knots on knots?

For clients, resist the quick patch. System errors are not lone rangers, they roam in pack. Demand a trajectory analysis and tweak the big picture: ask “where did the dominoes start?” and allow for more time, better kit, clearer briefs. Complexity very quickly turns into an enemy, so don’t feed it.

For consultants, look beyond the last straw. Regardless of the brilliance of your design, if it’s paired with a rushed rollout, it’s a fuse. Chart the failure path and push for fixes that simplify, rather than add complexity.

For contractors, adapt, but call it out. New rules post-accident? Fine, you’ll cope, but flag how they clog the works. Feed into a trajectory map; your sharp-end view spots the real pressure points. Less red tape, more real slack, keeps the next crash at bay.

Post-accident, mandate a “trajectory audit.” Skip the blame, trace the chain (resources gaps, deadline crunches, misaligned roles) and adjust the system’s bones, not its skin. It’s less sexy than a scapegoat, but it’s smarter.

The Takeaway: Ditch the Plaster, Map the Path

Rather than shoring up the system, chasing “causes” after a procurement pile-up can tie us up. Fixes add opacity, and practitioners scramble in the murk. Safety is not improved by more rules; it comes in seeing the full trajectory.

When a failure crops up, don’t just plug the hole, trace the leak. Simplify where you can, slacken where it’s tight, and give practitioners a fighting chance to spot the next snag.