Learning from safety failure
Introduction
Although many businesses have made progress in getting to grips with risk assessment (looking forwards to anticipate and prevent harm before it occurs), many are still failing to gain maximum benefit from their approach to the investigation of accidents and incidents.
Consequently, they are still failing to learn vital lessons, which could help them, improve their overall management of health and safety.
RoSPA, challenges all organisations to review their approach to accident and incident investigation. Here we discuss essential aspects of investigation and provide a ten point prompt list designed to help organisations identify ways in which they can improve their ability to learn from their safety failures.
Some general points
- Accidents are extremely costly in both human and financial terms but, if investigated correctly, they also represent highly valuable safety learning opportunities.
- Effective accident investigations can provide a 'window on reality' (providing a means of discovering what was really going on).
- All organisations need to develop a strong capability to 'dig deep' following accidents in order to develop a clear understanding of their immediate and underlying causes.
- Good investigations can provide unique opportunities for achieving learning and change in organisations. As well as yielding important lessons which can help prevent recurrence of accidents and incidents, investigation can be a powerful educational experience for those directly involved, for example, by improving understanding of health and safety management principles and embedding the resulting lessons in the corporate memory.
- The 'Woolf ' civil litigation reforms, require full and early disclosure of the facts following accidents (for the purpose of deciding compensation claims), have helped to remove some of the barriers to a full and open approach to learning from prevention failures. 1
Essential steps
Although in practice they may be telescoped together, the essential steps involved in investigation can be described as follows:
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Step 1
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taking prompt emergency action (providing first aid, making things safe);
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Step 2
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prompt reporting within the organisation and to other agencies where necessary;
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Step 3
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securing the scene (preventing disturbance of vital evidence..);
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Step 4
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deciding on the level of investigation required (e.g. according to safety significance, learning potential etc) and establishing terms of reference and allocating responsibilities in the investigation process;
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Step 5
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gathering the evidence (establishing the facts by gathering physical evidence, conducting witness interviews, identifying documentation etc);
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Step 6
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analysing and integrating the evidence (putting the facts together);
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Step 7
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identifying gaps in the evidence (significant unknowns) and seeking further evidence and/or clarification (for example, by studying previous events that may be relevant);
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Step 8
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developing and testing hypotheses - what happened, how, why etc (again looking further evidence if necessary);
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Step 9
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generating conclusions and recommendations; and
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Step 10
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communicating recommendations and tracking closure with stakeholders.
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Barriers to learning from failure
Accidents and incidents often arouse powerful emotions, particularly where they have resulted in death or serious injury. On the positive side, this means everyone's attention can be focused on improving prevention. On the negative side however the same emotions can also cause organisations and individuals to become highly defensive. This is natural and understandable but needs to be addressed positively if a culture of openness and confidence is to be engendered to support a mature approach to learning from accidents and incidents.
All too often, in the wake of an accident, the tendency is to seek to attribute blame (frequently to blame the victim) rather than to search for root causes. Yet arguably, the most important thing to establish about accidents is not just how they happened but why they were not prevented. Because ultimately everyone at work has some degree of responsibility for health and safety, a totally "blame free" approach may not be realistic. Nevertheless, organisations should endeavour to create fair and just cultures in which individuals are not blamed for organisational safety failures over which they have had no control.
Being able to learn from accidents and incidents presupposes that organisations have already got a health and safety management system in place, for example, along the lines suggested by the Health and Safety Executive (HSE) in their guidance Managing for Health and Safety HSG65. Unless they approach OS&H systematically, their approach to investigation is likely to be cursory and superficial - leading to narrow, technically focused "quick fixes" rather than seeking a better understanding of underlying causes which could enable them to make "root and branch" changes in management systems.
In RoSPA's view, some of the major pitfalls in accident and incident investigation include:
- No reporting of accidents and near misses (often due to employee fear of consequences)
- No investigation at all (coupled with massive under-reporting to enforcing authorities)
- No clear procedures for investigation (and/or no managerial involvement)
- No workforce involvement (trades union safety representatives have a legal right to investigate accidents)
- No scaling of the level of investigation (everything investigated in the same way rather than matching investigation effort to safety significance or learning potential)
- Failure to gather all the relevant facts (particularly as a result of inadequate approaches to witness interview)
- No use of structured methods to integrate evidence
- Distortions in evidence gathering and analysis due to uncritical biases
- Concluding the investigation too early (not going far enough)
- Simply focusing on the errors of individuals
- No search for "root causes"
- In that context, no examination of safety management system failures
- Failure to think outside conventional rules and operating systems
- Poor communication of lessons learned
- Failure to secure closure on resulting recommendations.
Team-based investigation
Research carried out for RoSPA has confirmed that a 'team approach' to learning from accidents, involving employees, including safety representatives (where they have been appointed), can be extremely powerful, particularly if it is led by senior managers and supported by OS&H professionals acting as facilitators.
Team-based investigation can:
- provide access to local, 'expert' knowledge, particularly about operational issues;
- support the building of trust and the development of 'just' (open, fair) cultures;
- develop participants' understanding of risk management in practice;
- promote learning about how to investigate in general (i.e. not just H&S failures);
- create workforce 'champions' for OS&H, particularly informal support for closure on recommendations; and it can
- provide a check of safety management standards (acting as a complement to formal audit of management systems).
Team-based investigation works best where organisations have clear and well used 'near miss' procedures. Daily, informal investigation of lower risk safety issues and problems is important in creating a positive climate for more structured investigation when major safety failures occur.
Check out your organisation's approach to accident investigation!
Looking ahead
Accident investigation has been a RoSPA Occupational Safety 'key issue' since 1997 in pursuit of it's vision of a life, free from serious accidental injury.
RoSPA believes that refocusing attention on accident investigation will provide a further stimulus for organisations to improve their approach to organisational learning about health and safety generally.
Some of the challenges include:
- providing training for senior managers to help them to develop a much richer understanding of accidents as complex multi-factorial events and to avoid over-simple explanations such as 'operator error';
- improving training for employees and others involved in investigation work, for example, training in essential investigation skills such as witness interview techniques and using structured methods . (Many of these skills are transferable beyond accident investigation into other areas such as investigating failures in quality, environment and business management failures generally.);
- improving access to necessary support services such as photography (particularly digital photography which can be quickly networked) to help capture accident scene data;
- encouraging insurers to improve support services to their clients so they can learn lessons from accidents and incidents, focusing on their shared, long term goal of improving standards of OS&H management; and
- finding new ways to help small firms to learn from the accident experiences of other similar businesses, for example, through web-based case studies.
Accident investigation resources and guidance
Technical guidance
The USA Dept of Energy - http://energy.gov/ehss/environment-health-safety-security
The US Dept of Energy provides accident investigation literature freely available via Internet. This is more appropriate for larger businesses and do require the user to translate documents prepared with a particular corporate audience in mind. For many users, the value of the materials far outweighs the encumbrance of unusual phraseology and DOE specific instructions.
Resources:
Regulatory requirements for accident investigation
There are specific requirements for investigation in the following regulations:
References:
1. Access to Justice: Final report by the Right Honourable Lord Woolf, Master of the Rolls July 1996