Great emergencies and crises show us how much greater our vital resources are than we had supposed
William James (1842-1910), American philosopher and psychologist
There are conflicting reports concerning the death tolls of the September 24th, 2015 stampede in the Mina area during the Hajj annual pilgrimage in Saudi Arabia. According to a recent unconfirmed report 4,173 pilgrims were killed. The victims came from some more than 30 countries around the world, among which Iran with highest total number of dead, injured and missing, 239, 14, and 241, respectively.
The aforementioned stampede during the Hajj was not the first and, if not scientifically and systematically addressed, will not be the last one; there is "a history of hajj tragedies" in Saudi Arabia. In similar stampede accidents during the Hajj, 1426 and 345 people were killed in 1990 and 2006, respectively. Thus, Hajj stampedes are not that rare or "unthinkable" phenomena any more, and as such, we should start preparing for to prevent the next one.
Saudi officials initially attributed the recent tragedy to such factors as, "high temperatures and fatigue" that may have played a large role; the Saudi health minister, Mr. Khaled al-Falih, said "the crush occurred because many pilgrims moved 'without respecting the timetables' established by authorities"; and the head of the central Hajj committee, Prince Khaled al-Faisal, has blamed the stampede on "some pilgrims with African nationalities."
This blame game, name-calling and finger pointing achieves nothing. The foregoing assertions are, at best, baseless, sheer speculations and at worst, oversimplifications which result only in blaming the victims as the root and main cause of the accident. And it will only lead, to paraphrase and quote the renowned Yale University Professor (emeritus) Charles Perrow, preserving the system "with some soporific injunctions about better training."
Saudi Foreign Minister, Mr. Adel bin Ahmed Al-Jubeir, stated, "The Custodian of the Two Holy Mosques [King Salman] has directed to launch a thorough investigation that will be transparent". And reportedly, Saudi Crown Prince Mohamed bin Nayef, has also ordered an investigation into the incident.
The Saudi initiatives are encouraging and constitute necessary steps. However, the unclear nature, unknown mandate, and unspecified composition of participating technical disciplines in the announced investigation make this process questionable and very likely insufficient. This is especially true and vital for accident investigation, dissemination of lessons learned, and hopefully prevention of future stampede accidents.
As experience shows, government ministries, bureaucratic regulatory agencies and parliamentary committees are not effective accident investigation bodies, and those in Saudi Arabia are no exception. An independent investigation commission/board, under the auspices of the Government of Saudi Arabia, with international participation provides the only way that the Kingdom can ensure that those thousands of precious lives were not lost in vain.
Drawing on my research and teaching over the last 25 years on complex systems' reliability and failures at the University of Southern California (USC), serving as member or technical advisor on several national panels in the United States investigating major accidents, I would like to share the following observations that may have important implications in this context for Saudi Arabia.
Major anthropogenic (man-made) accidents, which are often characterized as 'low probability, high consequence events', are mostly caused by a multitude of factors that compromise barriers to the loss of control or breach defenses for safe functioning of intended "systems."
These stampede accidents were all caused by the internal characteristics, components and procedures of the Hajj "system" itself that were in existence during that particular Hajj season. The components include pilgrims from many countries who spoke different languages with different mental models, risk perceptions and information process behaviors. Other components include Saudi operating and oversight agencies, their staff, procedures and protocols, as well as the physical facilities and equipment that were in use. These accidents -- stampedes -- emerged from the inherent characteristics and interactions of the "system" and not caused by an external, unforeseen, and totally unpredictable triggering mechanism, such as an earthquake, as was the case in the Fukushima accidents. [There are credible new seminal studies that contend even the Fukushima disaster, despite its unpredictable earthquake and tsunami, was "preventable".]
There is an element of predictability concerning the number of pilgrims, their national origins, and their "performance", as moderated by their physical and psychological needs, limitations, and capabilities. Experience has shown that predictability would greatly help and improve preparedness which could lead to prevention, or at least mitigation of consequences, by incorporating, for instance, interlock mechanisms to preempt, direct, or correct or activating barriers - soft or hard - a to prevent undesirable course of "system" action, namely, loss of control.
It is now known that both the performance and the inherent accident potential of complex human-technological systems are functions of the way their parts -- engineered and human -- fit together and interact. Research has shown that on many occasions, the "error", or in this context, as a Saudi journalist said on CNN, that the pilgrims might have "made a wrong turn" and "defied the order of police" , and the resultant failures are both the attribute and the effect of a multitude of factors. On many occasions, human error is caused by inadequate response to unfamiliar events. These responses depend very much on the conditioning that takes place during normal times; people's behavior is conditioned by the conscious decisions made by planners and leaders.
However, what is not always mentioned is that a good majority of "errors" or "negligence" were in fact system-induced. According to several studies, including our own, it should be remembered throughout the investigation that error should be considered as a consequence, not necessarily a cause. As the world renowned scholar, Professor James Reason of Manchester University stated (which could characterize many systems' accidents) "rather than being the main instigators of an accident, operators [in this context, pilgrims] tend to be the inheritors of system defect created by poor design, incorrect installation, faulty maintenance and bad management decisions. Their part is usually that of adding the final garnish to a lethal brew whose ingredients have already been long in the cooking." As such, it is a gross oversimplification to attribute accidents to the actions of involved people, prior to investigating all the contributing root-causes to the system's failure.
Moreover, the unprecedented high magnitude of the recent stampede disaster and diverse international origins of its numerous victims have made this a truly international tragedy of epic proportion. Thus, its investigation should also commensurate with its significance for and impact on the international community, and it should be done with the participation of the affected members of this mourning community. Three most noteworthy recent examples and precedence for creation and empowerment of such independent, interdisciplinary accident investigation commissions and boards in the world include:
- The "National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling", established by President Obama in response to the human and environmental disasters resulting from the explosion of the Deepwater Horizon drilling rig in the Gulf of Mexico in April, 2010, which killed 11 and seriously injured 16; the oil flow continued for nearly 3 months, during which, nearly 5 million barrels of crude oil spilled into the Gulf of Mexico. Co-chaired by (former) US Senator Bob Graham and Mr. William K. Reilly (former Administrator of the US Environmental Protection Agency).
- The "Committee on the Analysis of Causes of the Deepwater Horizon Explosion, Fire, and Oil Spill to Identify Measures to Prevent Similar Accidents in the Future" established by the US National Academy of Engineering (NAE) and National Research Council (NRC). Chaired by the Honorable Donald C. Winter (former US Secretary of the Navy).
- The "Fukushima Nuclear Accident Independent Investigation Commission", established by the Parliament of Japan (called "National Diet") in the wake of the earthquake and tsunami of March 2011. This Commission, the first one in the Constitutional Democratic Japan since 1945, was chaired by Dr. Kiyoshi Kurokawa, an internationally renowned and most distinguished statesman and public policy expert in Japan.
It should be noted, however, that because the victims of the above disasters were mostly from the same national origins - the US and Japan -the investigative panels were entirely composed of experts from the affected countries. As mentioned before, the situation is drastically different in Saudi Arabia because of the 30+ countries of origins of most of the victims.
The Saudi government should embark on the immediate creation of an independent investigation commission/panel. This interdisciplinary commission/panel should be chaired by a nationally renowned and prominent Saudi statesman or scholar, with members selected from Saudi Arabia and affected countries based on their technical expertise and to include responsible governmental entities, first responder agencies, and academics of requisite disciplines for accident investigation. This internationally staffed panel should be able to draw upon repertoire of expertise and resources of major professional accident investigation agencies in the world, such as the US National Transportation Safety Board (NTSB). And it should be empowered by the subpoena power and charged to conduct a comprehensive, systematic and interdisciplinary investigation by employing the system-oriented, robust "AcciMap" methodology to write the most technically-sound report on the root-causes of this tragedy. It should also ensure that lessons learned are understood, shared, and make specific implementation recommendations, with adequate built-in follow up mechanisms and milestones, to responsible agencies and affected entities and officials in Saudi Arabia and other countries.
The notable American philosopher and psychologist William James (1842-1910) stated with prescience in the opening epigraph that "great emergencies and crises show us how much greater our vital resources are than we had supposed" (emphasis added). This moment of great sadness and mourning also provides a moment of truth to learn lessons from the past and to consider the greater factors and human ingenuity, scientific methods, and technological resources that we have to prevent the next stampede during the Hajj and otherwise.
Saudi Arabia needs a total paradigm change and analysis of the entirety of its Hajj operations and oversight, including all engineered and administrative control mechanisms. These issues cannot be taken for granted; Saudi Arabia and more than thirty other countries paid a big price in terms of death and injury to their citizens, as well as damage to Saudi's national pride. More importantly, Saudi Arabia owes these bold accident investigation and safety improvement steps to the legacies of the 1426+345+4173+...innocent victims, whose lives were not lost in vain and whose now-silent voices demand to be heard nonetheless...
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Najmedin Meshkati is a Professor of Civil/Environmental Engineering; Industrial & Systems Engineering; and International Relations at the University of Southern California (USC). He was a Jefferson Science Fellow and a Senior Science and Engineering Advisor, Office of Science and Technology Adviser to the Secretary of State, US State Department, Washington, DC (2009-2010). For the past 25 years, Meshkati has been teaching and conducting research on risk reduction, reliability enhancement, and safety culture of complex technological systems. He has recently developed and teaches a graduate level course at USC, CE 599, entitled, "Complex Systems Safety and Resiliency: Safety Culture, Systems Design & Integration." He has been selected by the US National Academy of Sciences (NAS), National Academy of Engineering (NAE) and National Research Council (NRC) for his interdisciplinary expertise concerning human performance and safety culture to serve as member and technical advisor on two national panels in the United States investigating two major recent accidents: The NAS/NRC Committee to conduct a congressionally mandated study entitled "Lessons Learned from the Fukushima Nuclear Accident for Improving Safety and Security of U.S. Nuclear Plants" (2012-2014) which produced the report, Lessons Learned for the Fukushima Nuclear Accident for Improving safety of U.S. Nuclear Plants (National Academies Press, 2014); and the NAE/NRC Committee on the Analysis of Causes of the Deepwater Horizon Explosion, Fire, and Oil Spill to Identify Measures to Prevent Similar Accidents in the Future (2010-2011) which produced the report, Macondo Well Deepwater Horizon Blowout: Lessons Learned for Improving Offshore Drilling Safety (National Academies Press, 2012).