Learning and follow-up – Faisal Bari


MORE than 65 people died in the Ghotki train accident. This is not the first train crash we have had, and, sadly, one has to say, this will not be the last. While there are demands for investigations and accountability, if we go by past government record, it is unlikely there will be much of an investigation and even less likely there will be any accountability for any errors of omission or commission.

How many plane crashes have we had in Pakistan in the last many years? What has been the investigation and accountability process in each? How many train accidents have we seen in the last few years alone? What has been the result in terms of findings and who has been held accountable?

And it is not just in the area of train or air travel. When a bus full of schoolchildren overturned in the Kallar Kahar area and many children died, there was a lot of talk of investigations and accountability to figure out how the chassis of the bus could collapse so easily and how the regulatory framework around approving bus chassis needed to be improved. Has any action been taken on that front?

Incidents of CNG cylinder explosions take place frequently and we have lost dozens of lives because of that. But has there been any improvement in the process of cylinder installation to minimise the number of such events?

After a mishap, are the relevant authorities able to learn from their mistake and improve the system?

We hear of medical malpractice cases with frightening regularity. How many medical practitioner licences have been revoked or how many errant physicians have been jailed or fined? Even in more critical areas, like policing, we keep hearing about cases of torture and death in custody, fake encounters, illegal shootings and so on, but hardly ever is there any report on investigations and accountability. I am not talking of impunity here, the kind that the security agencies seem to have, as that is by design. I am talking about effective follow-up.

The question is not just about investigations and accountability in terms of firing people or fining them or even putting them in jail. Certainly, that is important. There should be justice after a fair investigation. But there is another important aspect here. We need to know that the relevant authorities, after a mishap, are able to learn from it and devise ways to make systems better so that the probability of the same thing happening again goes down. It is clear that in many of the areas mentioned, this learning does not take place.

Accidents and errors of omission and commission will happen. This is inevitable in any system however well it may be designed. But the question is: after an accident/incident, can the system investigate causes properly and in a fair and transparent manner, can it hold those who made mistakes, or did something on purpose, accountable and can it learn from the accident/incident so that the system is improved over time and the probability of accidents gradually declines? This is where we run into problems of various sorts.

At the investigation stage, there is lack of trust at two levels. One is the concerned agency or organisation, eg railways or PIA etc, trying to hide the facts and protect its people. This is around issues of fairness and transparency. If the agency is trying to protect itself, its reputation, and/or its people, there will be concerns about the fairness of the investigation. If transparency is low, the concerns will be even larger. Look at how investigations into previous air crashes have been couched in secrecy and mystery. How can the public have any confidence in the process?

Two, there are issues of competence regarding investigations. Do the railways and PIA have the right investigative skills to conduct thorough probes? It would be difficult for outsiders to judge. Both issues could be addressed through the involvement of credible third parties. In most cases we have seen, there has been no effort to address these concerns.

Read: A timeline of major train accidents in the past two decades

The problem gets more complicated when we move to learning. Imagine there was a fair and thorough investigation and that causes were laid bare in an investigation report. Do these agencies have the wherewithal to be able to learn from their mistakes, the resources to make the necessary corrections, and ensure a feedback loop from outcomes to policy/practice changes that keeps on monitoring and improving outcomes? There do not seem to be many institutions in Pakistan with that ability or that could inspire that kind of confidence. This is the crucial part that is missing in most debates on investigations and accountability in Pakistan.

‘Candles in the Dark’, a book by colleagues Mahmood Ali Ayub and Syed Turab Hussain, documents cases of well-functioning organisations within Pakistan to show that these organisations can exist as islands. They also document factors that explain how these organisations come about and how they sustain themselves. In a lot of processes that the authors mention, I find that the ability to learn from mistakes is an important factor that distinguishes these ‘candles’ from the larger darkness around.

‘Unnatural Causes’, a book by Richard Shepherd, one of Britain’s top forensic pathologists, documents how after every accident (in particular he talks about two — railways and ferry) committees that sometimes worked for a decade or more, were formed to ensure that systems were re-engineered to learn from mistakes that had been made so that similar errors would not happen again or would not be as devastating in terms of loss of human life. This, more than even accountability in particular cases, was what made systems better over time.

How do we minimise the probability of Ghotki-type tragedies? This requires fair and thorough investigations that are made transparent for all to see. It requires holding people accountable for their actions or inaction. And it requires creating learning and feedback loops that allow organisations to improve over time. This last bit is important or we are bound to repeat mistakes. And it is the last part that is the most difficult to see, as of now, in most Pakistani organisations.

The writer is a senior research fellow at the Institute of Development and Economic Alternatives, and an associate professor of economics at Lums.

Published in Dawn, June 11th, 2021