Incident investigation findings should be shared
Posted on January 8, 2014
Many 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.
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.