june - july 2010
Risk Controls
Issue : 16
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The Screaming of the Lambs



The process is the same for every crisis which ends with disappointment and distress. But what is actually more painful is forgetting what has been experienced and letting the same thing happen to oneself again and again.

Date; October 2, 1998. A special Halloween celebration was held in a night club in Sweden’s city of Goteborg. Groups of cheerful high-school youth in colorful outfits began to come to the night club where the entertainment was organized.

It was a two-storey night club, not large enough for the number of invitees. According to the rules, in such organizations, the fire brigade must be notified in advance and the maximum number of invitees to be admitted must be determined according to the size of the area.

Towards midnight, the smell of smoke began coming from the west side of the building, beginning to spread. A few students smelled it, but thinking that it was cigarette smoke, they ignored it and went on with the party. While the party continued, the smoke began to increase noticeably, but either nobody thought anything of it or thought it was a simple situation which could be easily handled. So, in order not to cause a panic, no alarm was raised.

However, the fire was a serious one and started to spread rapidly. Those who became aware of the situation began a stampede, but the club was so crowded that they couldn’t escape.

There was an exit door marked with lights at each end of the hall opening to the dance floor. But there was no automatic fire alarm or sprinkler system in the hall. One of the exits was 90 cm wide and opened onto the stairway. Yet another opened through a narrow corridor to the outside of the building, but it was blocked as chairs and tables were placed there to increase the capacity of the hall.

When the fire brigade was called the address could not be understood correctly because of the noise in the club, so firefighters had a difficult time finding it. At first a crew of eight was sent to the scene. However, they realized that the fire was much greater than they anticipated, so additional teams also were called. But the unconscious and injured in front of the exit obstructed the firefighters’ entrance. Also, those who had already escaped were trying to re-enter to help those still trapped inside, impeding the work of the already hampered firemen. One of them even went so far as to hit a fireman on the head with a beer bottle to clear the firefighter out of the way, knocking him unconscious.

Inside the club was chaos. Some trapped clubgoers were attempting to steal the masks of firefighters, some were pushing others out of the way in order to be rescued, and still others were jumping from a height of seven meters to escape. Additional trucks were requested. The injured were brought to hospitals in a variety of vehicles. Despite all these efforts, the chaos ended with 63 youngsters between the ages of 14 and 20 losing their lives.

When you read this story what is the first thing that comes to your mind? When I read this and thought about the details, after experiencing a sense of grief about this terrible loss I asked myself the question, ”What could have been done to prevent these deaths?” Although tens or even hundreds of such or similar incidents have taken place, why do they continue to happen?

I guess we don’t easily take lessons from our mistakes. As our memory tends to forget bad things that happen, the lessons we learn are easily forgotten in time. We need to develop the habit of writing the things which we don’t want to forget, which we must not forget. We need to read these from time to time and remember.

In this sense, companies are like people, with many of the same features of a living organism. They also do not tire of repeating the same mistakes. Yet, companies have significant advantages in comparison to the other living beings: Their ability to live much longer and ability to prevent the chronic recurrence of negative outcomes…

TAV Airports also wishes to enjoy a long life, and in the present time is expending a great deal of effort toward this end. It is forming policies and procedures in order to not forget the information and experiences (negative or positive) which it has acquired, and to transfer this information and experience to future generations who will carry on the running of the company. By using every means of communication, including the intranet, to disseminate its policies and procedures to its employees, TAV helps them to more comfortably and easily fulfill their tasks, carrying on our corporate culture into the future.



GOOD TO KNOW!
What is policy? Action plans established to help the decision making process for achievement of rational results. The policies specify what the company management wants and why, and they are comprehensive.
What is procedure? Written instructions which explain how policies should be implemented. They include the requisite details for carrying out a task, the responsibilities, control points and processes, and they are specific.


  ETIKETLER: information    rational    plan    procedure    detail