Incident investigation findings should be shared 13


Accident reportMany people, and OHS professionals, complain about the lack of research in Australia into occupational health and safety issues.  Research is occurring but often this is inaccessible to companies, professionals and decision-makers due to unjustifiable costs for the articles and journals.  Yet there is OHS research, of a type, that can be done by any company should they choose to do so – incident investigation.

Individual investigation reports may only address one set of circumstances, those that led to an incident or, rarely but importantly, a near miss or a systems breach, but together these reports may identify a systemic problem or illustrate broader safer deficiencies in an industry sector.

It helps enormously if incident investigations follow a modern and proven template, such as ICAM (Incident Cause Analysis Method), that looks beyond the incident or for a single root cause and can indicate potential systemic or cultural issues that may have contributed to the incident, the system of work, or an unsafe act or unsafe decision.

Sometimes these investigations generate a “safety alert” that is distributed within a company or an industry sector but usually these are filtered so much by a legal adviser that the safety benefit to others is neutered. It should be possible to edit incident investigation reports in such a way that the fault(s) and relevant control measure(s) are obvious.  Safety regulators, particularly those in the transport sector, are very good on publishing findings but these are usually in the high risk, high consequence work activities.  Incident investigation reports at a company level can address the less spectacular incidents, the more frequent incidents and therefore may have a longer term benefit.

It used to be possible, in most of Australia, to rely on OHS regulators to publish summaries of incidents and prosecutions but as this avenue is increasingly closing, alternative sources of case studies are needed and investigation reports may be an option.

Of course, companies also need to be willing to release investigation findings and most legal advice would deter companies from doing so in a further example of legal risk management versus safety risk management.  If safety was a number one priority for business and they claim to have a social conscience, companies would be asking their legal advisers to draft a report that would prevent harm in their other work locations as well as sharing that report with the industry sector.  This can be done.  It only takes a company to ask for it.

Near Miss

This may seem a big ask and one reason it may seem so is that most companies only investigate (if at all) major incidents, those that are likely to end in prosecutions.  Investigations of near miss events are far less, legally, frightening because no one was injured.  However they can be as enlightening as investigations into fatalities, arguably moreso, as the “injured party” can provide evidence of the activities, thoughts and pressures around the near miss incident.  Also near miss investigation reports can be presented as a social service -

“This happened on our site as a near miss but we are sharing this information so that our near miss doesn’t become your fatality.”

The sad reality is that investigations of near misses are seen as a waste of time by most companies.  No One Injured = No Need to Investigate = No “Unnecessary” Cost.  This is a flawed equation as the benefit of learning from an incident in which no one was harmed is substantial, as discussed in a previous blog article.

If companies want to be “proactive” on workplace safety, investigating incidents in a structured manner should be the first step. Such investigations can be done quickly with minimal cost and any cost would be offset by the reduction of future incidents. ” Seek and ye shall find” leads to “Find and ye shall learn”.  And those learnings could, and should, be shared because few work activities are unique and the circumstances of your incident  or near miss are likely to be replicated somewhere else.

Lastly, companies and executives who claim that “Safety is our number 1 priority” should consider whether that safety extends beyond their own employees.  If it does, then safety lessons from one’s own errors should be shared for the greater social and economic good.

Kevin Jones

13 comments

  1. To many times, companies do not want this added research. I investigated an incident that a person was nearly killed; I was told by management to change my investigation as I found there was a previous incident of same contributing factors and root cause that had identified the same corrective actions as to my investigation (early part) but they had been closed out as completed but never implemented or reviewed.

    When I handed in the first report to senior managers, I was instructed to remove all references to the earlier incident as some manager could lose their job or even worse go to jail. I refused to do this as I explained WE NEARLY KILLED AN EMPLOYEE.

    I was then told I was a trouble maker, not a team member and forced to leave this big mining company.

  2. Drew, you illustrate part of the problem that I mentioned in the article – legal risk management.

    I believe it is possible to share findings in a timely manner and avoid legal pitfalls but the legal advisers have greater influence in corporate decisionmaking that OHS professionals are ever likely to. The safety of workers, the costs for business and productivity suffers as a result.

  3. While company management continue to force cover ups for self preservation and OHS specialist bow down for same self preservation, we will never change cultures, never really learn as any report is as good as The BROTHERS GRIMM tales and not only is this the real legal issue it is a moral issue that companies reward, promote and then pass onto others in their glorified look how good we do annual reports

  4. Continually the legislators after a serious incident fire off that we need to change behaviours and cultures; company senior management state we will investigate and then focus on shop floor behaviour and short comings as the managers are the ones leading investigations and they never do anything wrong and always have “safety as the priority”.

    The companies then say they have investigated and made the changes needed while really nothing has been done and the industry waits for a repeat of the same….. Even when fatalities have been investigated.

    There is no real follow up by legislators as they have no time or real resources.

    The only risk mitigation is LUCK as it is a factor that companies hope for….. It has now happened vs it has not happened for x time; so we should be right on the law of probabilities for that time again, and we will not be there by then as good managers with “GOOD SAFETY RECORDS” we get promoted.

  5. Safety Managers / Advisors are rarely given the level of authority and autonomy to provide the organisation with full and frank advice, without repercussions.
    Head in the sand C-suite management will not change unless this happens.

  6. Kevin,
    in companies who have adopted the investigation focus you describe, I frequently see a lasting change in workplace culture and attitudes – where people become genuinely keen to pinpoint causal factors and avoid recurrence; everyone starts to feel comfortable sharing experiences/failures/errors; and managers develop increased respect for the input/knowledge of front line workers and supervisors. A real source of ‘added benefits’.

  7. Like you,

    Kevin,

    and many readers, I’ve conducted incident investigations and many H&S inspection in Australia and overseas in a very broad range of industries, and various size workplaces.

    Not in a single case did I find ‘OHS culture’ to be the main issue at an incident. Nor did I find that incident investigation reports offered any new, ground breaking information. Though they could influence local ‘politics’ ….sometimes.

    The problems were more to do with not fixing what was known to be buggered – and everyone knew to be buggered – and running on luck, and a complicit silence.

    So far as investigation results go, you just need to look at some such classic reports of say Moura, Longford, Beaconsfield, the string of overseas’ BP’s OHS delinquencies, Pike River …. to immediately see that the investigative ‘discoveries’ were well known before the incident. Usually very well known.

    I believe that the entire notion of ‘OHS. Culture’ is an attractive illusion based on a hunger for a theory, for some real explanatory hypotheses. But devoid of any practical value at work. It does however, offer linguistic toys for verbal jousts.

    It’s much better to fix the missing machine guard (or the stressor, the roster or bully…) than to search for that cultural element that will universally fix things in a workplace. I am not happy to note here that whenever I asked managers, H&S experts or academics at a workplace what is it exactly they meant with the terms ‘safety culture’ not in any one single case did I get a relevantly useful response.

  8. The template approach is in general a reasonable approach. The problem is with those who apply the template and their competence. Asking “why” umpteen times is a waste of time if the person doesn’t actually know what it is they are asking about. I have had personal experience many times where “safety professional” and some management members have done an investigation and it was drivel. Not their fault as they were not competent to do the investigation – but it is who the company have.

    I recently did an investigation where the organisation had done a preliminary review and decided that it was “human error” but I was asked as an external consultant to do a independent formal investigation. The end result left them somewhat stunned as there were design deficiencies in the electrical distribution system of the machine, there were failures in the architecture of the PLC program that controlled all of the machines operations in that it relied on a single component that relied on the electrical system and then had a system that assumed when information was no longer being fed to the computer that in fact everything was OK – end result major incident. No -one injured but a major and very costly repair bill.
    A far cry from their original viewpoint – they even said themselves that they would never have even thought to look at some of the aspects that I did. I don’t pretend here that I am some guru on this – it just so happened that it fell within my experience in my previous life (before safety!) as an electrical and plant engineer.

    There are too many companies that assume that the safety guy knows about this stuff when in many cases – especially in these days of “get your diploma in a week” that they rarely have this kind of expertise and if they cannot field a “subject matter expert” as part of the investigation process – it will fail to arrive at the correct conclusion(s).

  9. Yossi, I agree that solutions always exist and are waiting to be seen even if they are under our noses but I wonder if we need an alignment of factors to see truly. And I wonder if a major element is Time – a time when a confluence of factors – society, morals, politics, economics – align to make the reality of a hazard visible and inescapable.

    Your comment also seems to be talking of power, of having sufficient political/personal/organisational power to voice the obvious.

    Perhaps a safety culture is one where people see the obvious, speak the obvious and share their lessons. The sad thing is that this implies that the opposite of a safety culture is not a culture of harm or risk but one of silence.

    And perhaps what we are living in is a entire culture of willful blindness on workplace safety.

  10. You’ll note,

    Kevin,

    that even in your brief response to my comment you use the word ‘culture’ three times. This entire presumed explanatory construct has become a black hole of ideas, little escapes its seductive horizon. In my view it destroys practical ideas.

    You make some good and significant points, but if you now drag them kicking and screaming back into ordinary workplaces their explanatory value is not all that obvious. Nor are the socio-occupational alignments you suggest likely to erupt into being any time soon.

    I believe some effective fixes for poor H&S standards can only be ‘found’ when following a worker on his/her daily tasks, even if such following is cognitive by an experienced person. The texture of the daily tasks then becomes obvious, including many of the pressures and (small daily) failures, (and some of the good things).

    There are many reasons why H&S incidents happen, but the most obvious one is continued tolerance of small daily risks. When a manager, worker, union official or H&S expert notice and tolerate a small risk when they know it makes them uncomfortable, the insidious process of standard degradation has commenced.

    This is well understood by workers at work, and that’s why there’s great scepticism of ‘accident investigations’.

    Everyone at work will know at that workplace what are the small daily risks that are tolerated … but shouldn’t be.

    So here are the choices: wait for an alignment of significant social forces; struggle with hypotheses based on the notion of ‘workplace culture'; or start by being actively and demonstrably intolerant to small daily risks.

    What would you prefer if someone you loved madly worked in a risky workplace?

  11. The benefit of conducting investigations into Near Misses and Incidents cannot be under estimated. From the perspective that today’s Near Miss is tomorrow’s fatality. Having a thorough and robust reporting and investigation mechanism with in organisations provides for transparency and demonstrates to employees that all reported incidents are taken seriously. If the investigation process is conducted in a manner so as not to abort blame but to identify the systemic causation factors which contributed to the incident or near miss, such as the Incident Cause Analysis Method (ICAM) model then the organisation will get better buy in from the employees as this process provides for engagement of stakeholders at all levels within the organisation. The ability to share this information with in industries can then provide other organisations the opportunity to mitigate similar risks without having the incidents or near misses to learn from. Information sharing with in industries has many benefits as it allows organisations to identify if there are common trends occurring within the industry which they are yet to encounter.
    The water sector with in Australia has an association known as Water Services Association of Australia (WSAA). The purpose of WSAA is to provide guidance and advice on all aspects of the water sector operations. Promote collaboration between water service utilities and set common standards within the industry. WSAA recently absorbed the Vic Water OH&S network and has reinvigorated the network. The now titled WSAA OH&S Network provides a reporting mechanism with in the Australian Water Sector where statistical data is captured so as to trend industry averages which allows for corporations to be able to benchmark their OH&S performance. This forum also allows for discussion and collaboration between member corporations to provide up to date information on issues affecting the sector.

Participate in the discussion

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s