A shaky start leads to a terrific book on incident investigation by Michael Tooma

There is one word that should not be used as an adjective in relation to workplace fatalities – impacted. Workers fall from roofs and the concrete floor has an impact on them. Workers hit by mobile plant or crushed in machines die from the impact. An impact results from the transfer of energy and this transfer of energy in workplaces can kill.

“Impacted” is used by those who do not feel comfortable differentiating between “affect” and “effect” and it is surprising to find the term used in the opening chapter of Michael Tooma’s latest book, Due Diligence: Incident Notification, Management and Investigation.

“Unless you have been involved in a serious incident, you don’t really appreciate how an incident will affect you. For every worker killed at work, there is a grieving mother, father, spouse and/or child. Their co-workers are impacted. Their friends are impacted. Management, guilt-ridden as they are in the aftermath of an incident, sometimes for good reason, sometimes not, are also personally and emotionally impacted. The tragedy touches everyone. In the midst of it all, a group of people are tasked with managing through the chaos and trying to get answers for all those impacted by the tragedy. This book is for them.”

The sentiment is correct and true but read the paragraph aloud and it sounds absurd. And why the overuse of “impacted” when a perfectly suitable word, “affect”, was used in the first sentence?

And this clumsy opening does the book a disservice. Tooma has repeatedly stated that this is a safety book written by a lawyer and not a legal book written about safety. This is a major change from a major Australian OHS publisher. It is a recognition that the readership is not lawyers feeding on lawyers but people wanting to understand workplace safety. Tooma says that

“…this is a book about the process for responding to and investigating an incident. It takes a holistic approach – legal, safety, commercial and reputational issues are interwoven in the discussion so what emerges is a practical blueprint.” (page 3)

This multidisciplinary approach is a hallmark of Tooma’s books in this series so far.
His book deals with “lawyering up” during and after an incident – an activity that frustrates many regulators but also, ultimately, impedes the potential lessons from incidents. Accountability extends as far as a lawyer lets it.

One chapter focuses on “the court of public opinion”, an element often missed in incident investigations. It is a short chapter using the Beaconsfield mine collapse as its core and provides basic hints on preparedness but other books cover media management and these should be looked at. However, in a couple of pages Tooma puts the cogent argument that the media should not be feared but nor should it be manipulated. Business owners need an understanding of what the media wants so that they can feed the right the content. Richard Branson is particularly good at this. Sadly it occasionally reveals the shallow morality of some media but that’s not really Branson’s fault.

The significance of the media management should not be understated as many note that the profile of Bill Shorten, then of the Australian Workers’ Union, now Workplace Relations Minister, owes much to his participation in the aftermath of the Beaconsfield collapse. This was not his intention but it was certainly a result.

Tooma, thankfully, loops the techniques of incident investigation back to injury prevention, something often missed by other writers on this topic. His clarity and honesty on the corporate response is refreshing. On page 65, Tooma states that often investigation leads to new policies and new procedures. These can be effective and are attractive to executives as they are cost effective but not necessarily effective for sustainable workplace safety, or do not encourage organisational resilience. He quotes Dekker and outlines Reason’s cheesy model but suggests that Reason’s process may be too linear. Tooma does not suggest an alternative model but he comes close to ditching the cheese.

Tooma emphasises the attraction and importance of the four key elements of safety culture from James Reason but does not forget Trevor Kletz, a prominent name that has faded, unjustly, from much of modern OHS thinking. Indeed Tooma inverts the title of Kletz’s most famous book “What Went Wrong?” into asking “what went right?” Tooma believes that some investigative enlightenment may come from looking at how the good bits of a management systems minimised the impact of an incident or encouraged rapid business continuity.

It may be useful to note that Tooma’s employer, Norton Rose, has organised seminars with Reason over the last couple of years in Australia.

Tooma also explains the iABC investigation methodology, a new concept to this author. The process runs with

  • Identify,
  • Arrange,
  • Benchmark, and
  • Causation.

It is a methodology that seems to flow well into positive incident investigation and looks to have good potential.

This book, and this series, is particularly good for discussing safety management but without the legalese. There are few, if any, court case references. An overall criticism would be that too many of the examples of incidents are major disasters – Beaconsfield, Macondo, Lapindo Brantas. The book is equally applicable to the investigation of smaller incidents in smaller businesses but this is largely missed, or under-emphasised.

The books are very affordable and extremely current (Tooma is writing the next book at the moment) with a quarterly publishing schedule and should be marketed to those owners of small- to medium-sized businesses as the practical guide it intended to be.

This book does not read like an advertisement for the author’s legal services or for lawyers generally. Tooma is aware that good, clear advice sells itself and this book is full of that type of advice (just edit that horrid first paragraph).

Kevin Jones

reservoir, victoria, australia

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