Lessons to be learnt from hospital fire

Hospital Sultanah Aminah

By Wong Chee Tuck

The fire at Sultanah Aminah Hospital (HSA) claimed six innocent lives. Something must be learnt fully from this tragedy.

The fire was a social-technical disaster. It has something to do with technical issues like sparks from electrical short circuits as reported, and yet it is something deeply social in terms of organisation, managerial control, safety culture and responsible governance.

Short circuits are not the cause of fires. They are the effect of loss of management or governmental control. Short circuits merely provide the link in the complex chain of cause and effect.

Decision-making bodies have the power and responsibility to avert disasters of this nature, which most probably arises from something as low tech as switch socket outlets and something very cheap to fix.

No knowledge of quantum physics is required. And yet common sense is becoming so uncommon that it is the sheer lack of it that kills.

The basic causes of electrical fires are design defects, manufacturing defects, installation defects, and maintenance defects besides the management defects in risk control.

The proximate causes are the more obvious insulation failures leading to short circuits and the less obvious seed defects (failure of pressure contacts, loose connections and fractures in conductors germinating into a major problem).

A properly designed and maintained protective system is good enough to provide early warning from tripping.

However, if equipment is defective or bypassed or modified to save the trouble of trouble-shooting the real causes of tripping, then the stage is set where a simple insulation failure may develop into a full-fledged disaster.

The HSA fire is unique to its own circumstances; however, it should not be seen as something different from other man-made disasters in terms of fatalities within its own field and other industries.

A few studies of major importance were undertaken in the late 1990s to establish the relationship between serious and minor accidents and other dangerous events. It was found that less serious events are consistently greater than serious ones.

It means that less serious events like minor injuries, property damage accidents and non-injury/damage incidents or near misses must be taken seriously. Otherwise, it can lead to fatal or serious injury.

The Tye-Pearson study (1974-75) based on 1,000,000 accidents in British industry, found a 1:3 ratio of fatal or serious injury to minor injury, and 1:80 for property damage accidents.

At HSA, it was reported that more than seven fires had occurred over the past four years. Ample and explicit warning of a looming disaster had been given. It seems that there is a lack of ethical commitment to prevent tragedy from happening.

Putting aside the statistical law of fatal incidents, the last warning came less than two weeks before, with a small fire in the ICU 10 days before the disaster struck last Tuesday.

The relevant parties seemed not to have read the sinister signs. A missed opportunity? Possibly, but not exactly.

If there is a consistent pattern of unsafe thinking and unsafe behaviour by people, then no matter what the signs are staring at them, the warnings would be unthinkingly and habitually ignored.

Any audit on technical matters should also enquire into the psychology of safety, as in why people do and act that way and what drives their behaviour.

Why does the hospital consistently and consciously choose to ignore the obvious telltale signs? Is this a hardware, software (safe systems and practices) or human-ware problem? This raises the question of professional management and competence in managing safety involving risk to human lives.

The ultimate responsibility of safety lies with the government and hospitals, and not with the outsourced concessionaire.

However, with disaster involving innocent lives, there must be consequence to the concessionaires. Otherwise, it is condoning unsafe behaviour which may lead to a much bigger catastrophe.

Before one can draw any conclusive lessons, one needs to establish the facts. The responsible parties need to come up with findings and recommendations and follow up with implementation.

The question is what would be the better way to conduct a fact finding exercise to identify the cause of the fire. The Heath Minister proposes a special task force to be formed. It is unclear who would sit in the committee and what the procedures will be. The question of independent investigation must be clearly defined.

If it is formed just to pacify public anger, it would be meaningless.

As lives are lost in government hospitals, it would be most appropriate to have a public enquiry.

Internal investigation by the hospital itself, relevant government departments and the outsourced service providers, contractors and consultants, though helpful, may not be enough as each entity may be defensive on the contentious apportion of blame and responsibility.

If properly and professionally done, a public enquiry shall provide the most valuable source of information to prevent future occurrence and for others to follow. The report of the public enquiry must be made available for the public to examine.

The current technology for electrical safety is more than sufficient to prevent major injuries and deaths. Zero deaths from electrical accidents or fires is within reach.

Yet, deaths still occur. Something is seriously amiss: the respect and care for human lives, or probably a certain psychological numbing towards the possible death and injuries of others.

Those who are responsible for maintaining a safe environment have betrayed the trust placed upon them.

This fire should awaken the conscience of those who are entrusted to keep death at bay, a trust that is beyond maximisation of profits or vested interests.

It is about how to live and die in dignity and in peace.

Wong Chee Tuck is an FMT reader.

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