| Understanding the strange story of Cornelia Rau - a psychologist's perspective | | Date Created: 16 Feb, 2005, 01:07 PM |
Most of the time I spent on this blog is devoted to technology based entry, in particular about Apple and its products. A voice in the wilderness perhaps.
But I always intended it to be a more encompassing blogsite, offering a psychologist's view of technology and society. Having graduated with a formal qualification in Knowledge Management from the University of Melbourne, I want to align that new career move with many years as a clinician to try to understand the world around me.
How we make sense of the world is vitally important to me, and informs how I work. Because of my diversity of interests and training, I look at current affairs issues from a perspective not shared by many perhaps.
Here in Australia, a story has been developing regarding an Australian citizen, Cornelia Rau, a 39 year old former QANTAS flight attendant, who found herself the centre of enormous media attention following her incarceration in prison in Queensland and an illegal migrant detention centre in Baxter, South Australia over the course of ten months.
She had been reported missing by her family following her leaving a Sydney psychiatric hospital where she had been esconced for some time. After decamping she made her way north into Queensland and her behaviour and appearance in the deep north aroused such concern by locals that she was reported to the Queensland police.
From there, a series of tragic miscommunications took place and her discovery in a detention centre for illegal migrants occurred more or less by accident, rather than dogged search.
How this happened is now the subject of a closed inquiry to be conducted under the auspices of the Department of Immigration, and its Minister, Senator Vanstone.
As each day goes by, more and more disturbing aspects of the story are appearing, and I can recall few stories involving an individual that will have far reaching consequences as this story will.
A second independent inquiry has been organised by Australia's peak Social Work body, Australian Council of Heads of Schools of Social Work, and its representatives with the view that detainees who may have observed any ill-treatment will be more willing to report to such a group than a closed government enquiry headed by a former federal police commissioner.
Here's an opinion piece I have put together.
"Like most Australians, I have been watching the tragedy of Cornelia Rau's life play out in our newspapers, and on our radio and television stations.
As a citizen, I have been appalled. As a psychologist, I have many questions. As a graduate in Knowledge Management studies, I have some ideas as to how to go looking for some of the answers most of us would like to know.
And as a developer of disaster management programs, having received training in best practice from airlines such as United and Continental Airlines, as well as being privy to post-TWA 800 and 9/11 efforts, I bring another understanding to what has happened to Cornelia.
It is clear from the decision of the peak social work agencies to hold an "alternative inquiry" that it expects an unsatisfying outcome to the Government's closed inquiry.
This expectation has been fuelled by the palpable twisting and bending we are seeing the Government embarassingly endure in public. It would appear to be avoiding all the advice on offer by any number of crisis consultants whose current mantra given to private corporations facing crises of trust and error making is basically to "come clean."
The same consultants, in offering their advice, will usually draw upon well-known examples of cover-ups being more damaging in the long-run than the initial ineptitude, be it human or systemic error.
The study of systemic error, such that causation is explained in the service of reducing the likelihood of future repetitions, is nowhere more profoundly understood than in the commercial aviation industry.
At anytime, there are more than 2000 commercial aircraft flying the US skies alone, all relying on complex systems of safety redundancies their passengers take for granted.
Australia's QANTAS has a well-earnt reputation for its safety record, and it is more than ironic that Ms. Rau was a small part of its safety system for some years. (What if anything QANTAS's Employee Assistance Program knew of her illness has yet to become public knowledge, although reports have suggested her colleagues were aware she was "troubled".)
It is a further irony that QANTAS's international reputation for safety probably got its biggest boost - and millions of dollars of free publicity - with the mention of its safety record in the Dustin Hoffman-Tom Cruise film, RAINMAN, a film with psychological disorder central to its plot.
Airlines frequently exchange safety related information with each other, and must meet certain standards to enter code-share alliances. The safety culture of an airline is closely scrutinized. In particular, what interests other member airlines is not so much fatalities, but the internal safety culture which is responsible for monitoring "fender-benders" - small incidents which if occurring on a frequent basis, suggests a breakdown in safety culture and knowledge sharing, meaning a "big one" is on the cards. Not far from memory is the twice grounding of Ansett's 767 fleet by civil aviation authorities for just such reasons.
Why is the airline industry as safe as it is - as a form of mass transport, only escalators and elevators are safer. And what can the two inquiries into the tragedy of Cornelia Rau learn from it?
First, stuff happens. In a system that relies heavily on human endeavour, it operates on the basis that human beings make errors. To that end, over the decades, the commercial aviation industry has studied how human beings err - the psychological, physiological and organisational capacity for error-making - and has attempted to put in place systems of practice so as to minimise the dangers human fallibility pose.
Mechanically, aircraft and its supporting systems such as Air Traffic Control build in system redundancy such that on the rare occasion a usually reliable component fails, back up systems can be seamlessly brought on line. The next stage is then to examine how the component failure took place, devise the means to minimise its re-occurrence, then share the information with the aviation community, including any competitors. (This is why no airline ever publicly competes on safety. All airlines are affected after the hull loss of a competitor by dint of public loss of confidence in airline safety).
This public sharing of safety knowledge pervades the commercial aviation industry, such that the culture expect errors to be reported in the service of prevention. Air France is one such airline which has introduced recent efforts of self-reporting errors, even from Gallic male pilots, with a no-blame policy, so that the airline can bring the data into its systems and learn from it. This can only happen in a no-fault, no-blame culture. It is about prevention and amelioration, not punishment.
One wonders about the existence of such a safety culture within the various Government departments whose members will be invited to attend the Government's inquiry.
If part of its purpose is to prevent further re-occurrences of what Cornelia Rau, and her family has endured, it must create an atmosphere of openness and sharing. Clearly, if any breaches of the law have occurred or are perceived to have occurred, this culture is unlikely to be sustained.
The questions I would want answered relate to Ms. Rau's seeming disappearance through the cracks of multiple agency communication channels. I would want to know how the early warning signs, the defenses against predictable incidents, were either ignored, filed away, passed on and neglected, or - worst of all - not even known to be present.
That long-term detention in the conditions we have come to learn about so acutely can lead to further mental deterioration seems a given the Government wishes to ignore. This is akin to saying that flying a four engine 747 on two engines will not lead to long-term danger to the two good engines. After all, the plane can still fly.
The Government's inquiry, even if it continues under the terms of reference so far made public, needs to produce satisfying answers to how these cracks were made, and how the defenses seemed not to be in place. To this end, the Government would do well to not just interview those with first hand knowledge of the events, but also those with an understanding of organisational defensive routines that permitted them to occur over such an extensive time.
They would do well to understand Psychologist James Reasons' Swiss Cheese theory of disasters. His theory explains how safety-conscious organisations have multiple layers of defenses, each like a slice of Swiss cheese. In the airline business, each slice is an element of the safety system such as recurrent training for pilots, check and backups systems, fail-safe wing construction, aircraft which can fly on one of four engines, and so on. Line up the slices and if a threat gets through the holes of one, another slice in the line will block its further passage. But if the holes in the cheese slices line up - in the airline business, an extremely rare event given the total number of aircraft annual movements - this allows the threats to safety to pass through unobserved until it is too late.
In Ms. Rau's case, the alignment was fortunately still imperfect when her identity was discovered through good fortune and diligent journalism: she didn't lose her life. But they were lined up enough that it seems her quality of life, and those of her family, and many others now enveloped in the matter, was not protected.
Finger pointing and blaming won't help us learn what happened. We need to learn from this to both prevent it from happening again as well as make improvements in learning from our errors. And if it's currently happening - if the Government suspects it is - the smell that pervades these inquiries will not be like Swiss Cheese, but more like a very strong Vieux Boulogne."
UPDATE - April 2, 2005: This story refuses to go away, and will remain not far from the public conscience until the Government's report is tabled. In today's Age newspaper, a report by Paul Osborbe contains information of alleged abuse of Ms. Rau in detention, which will be more fully detailed in an upcoming edition of the ABC's investigative TV program, Four Corners. It will air Monday, April 4 @ 2030, and repeated the next Wednesday evening @ 2300.
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