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firestar967  
#1 Posted : 28 September 2013 20:09:57(UTC)
Rank: Forum user
firestar967

I've been involved in a number of these, some very positive, if treated the right way and that is trying to find out what went wrong and how to prevent it happening again. The negatives are when the upper management get involved and in my oppinion jump the gun. Instead of awaiting the draft report they start jumping to conclusions and pointing fingers, which then makes the investigation so much harder as the walls start to go up. It also adds to the belief that if you report an accident then you are in for a very rough time, that of course then leads to no one wanting to report an accident or trying to cover it up. How do you prevent this? If the culture is to hide minor accidents then a major will follow.
JJ Prendergast  
#2 Posted : 28 September 2013 20:26:36(UTC)
Rank: Super forum user
JJ Prendergast

By developing a 'no blame' safety culture. Both the aviation industry and nuclear industry are pretty good examples. Oil & gas is getting there. Everybody is entitled to raise safety concerns without fear of retribution or assumptions being made. Difficult to achieve, but that's the aim.
malcarleton  
#3 Posted : 28 September 2013 20:48:10(UTC)
Rank: Forum user
malcarleton

I agree with JJ, though we don't encourage a "Blame Free" culture, we encourage a "Just" culture, after proper and thorough investigation if culpability is uncovered then a further board and HR will determine the outcome. Also you should get management involved in accident investigations, after all, they own the risk, so they should understand the outcomes of not managing it properly. Accident investigation is a very specialized skill and should ideally be conducted by people that have had some form of training in investigation and interview techniques.
RayRapp  
#4 Posted : 29 September 2013 22:44:41(UTC)
Rank: Super forum user
RayRapp

I don't think you can ever have a 'no blame culture' but I do believe a 'low blame culture' or 'just culture' if you prefer the Reason terminology is desirable and achievable. If the prevailing culture has a tendency to seek blame and retribution as opposed to finding out the underlying causal factors, then this will inhibit the investigation process and ultimately prevent learning from incidents. For a proper investigation there should be some basic principles which are applied. This should then prevent senior management from jumping the gun, identifying potential suspects and sometimes . The first principle is to allow the lead investigator an unfettered access to evidence including witness statements. The second principle is that no one except the investigator and his team should be allowed to review the witness statements regardless of the seniority of the managers. Witness statements must be treated as confidential documents. A thorough investigation takes a great deal of time and effort - patience is a virtue. I have on occasions been asked to provide a summary of the investigation which I am reluctant to do whilst the investigation is on going. If pressed I provide no more than the basic facts. People can speculate if the choose but ultimately it is for the full investigation report to determine the immediate and underlying factors with recommendations and subsequent actions.
cheifinspector  
#5 Posted : 30 September 2013 09:18:04(UTC)
Rank: Forum user
cheifinspector

Agree with above comments regarding a Just Culture. I worked for a company that implemented a No Blame Culture which initially worked out ok but we were finding that it was the repeat offenders for very minor breaches of safety rules where the problem was lying. (think, continually failing to keep a hand on a hand rail). Due to the No Blame Culture they were never being held accountable and carried on regardless. Just Culture was then introduced and without sounding to harse on the person involved, an example was made of him to push the message out that this type of behaviour is unacceptable. I left shortly after this was implemented so i'm not sure how sucessful it was long term but it certainly had the desired effect in the short term.
ivorheadache  
#6 Posted : 30 September 2013 09:22:26(UTC)
Rank: Forum user
ivorheadache

IMO, accident investigations should be in the H&S policy clearly stating it's propose and procedure, and conclusions not to be drawn until the investigation is complete. This should be stated clearly at the beginning of any interviews, but going back to your original point, the managers who have asked you to do the investigation.
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