Walker, another thing we both have in common as well as being health and safety practitioners...or is that health and safety barristers. ;)

Prof. Trevor Kletz said on more than one occasion.
1. All error is human error because: People have to decide what to do. People have to decide how to do it. People have to do it.
2. We should be asking not what caused the accident but what should we do differently in the future.
Prof. James Reason argued that
1. the basic premise in the system approach is that humans are fallible and errors are to be expected, even in the best organisations. Errors are seen as consequences rather than causes, having their origins not so much in the perversity of human nature as in "upstream" systemic factors.
2. we cannot change the human condition but we can change the conditions in which humans work.

The responsibility for defining and designing that system is one of management. That fact does not eliminate or negate individual responsibility at any level in the organisation. That individual responsibility is defined through review of the type of failure(s) that has (have) occurred.

It seems clear to me then that some form of approach to understanding how such complex matters exist in any organisation is required. What is the best approach for the man in the street if not multiple cause analysis?

The question of bias is a bit of a red herring in my view. It is true, of course, that using the multiple cause theory may prompt questions in all sorts of areas but the relevance is determined by the investigators. If they are skilled investigators they will know only too well the dangers of bias. I accept that if they are less experienced there is a danger that they will find system errors that are not actually relevant or significant bjt then that would surely apply for any systemic approach?

Are we then concerned here that this approach forces an investigator to find errors in the definition and design of the system when there are none? Or that it will always fail to correctly identify what failures led to the event?
If multiple cause is discredited how then do Difford and others propose that we identify causes unless we also consider the system that has been defined and designed to minimise both the likelihood and more importantly the consequences of failure?

As to zero accidents and days lost since boards! I have never liked them. Zero accidents is not a target but a cultural statement. Focusing on just one headline aspect, days since last, is bound to create complacency and cannot alone show how well (or badly) an organisation performs. I well remember a site which had worked for five years without a day lost; then a major loss of containment led to several lost time injuries and the board went from 1786 to 0. Heaven to hell in one swift stroke of the pen! Not a useful picture of H&S on the site at all.
P48

Pete48. Post 84, sobering, professional and truly thought provoking.


But, should’nt viewers be asking certain contributors just exactly what sort of “scrutiny” their “proper and justified conclusions” are being subjected to such that they are always right? Who is scrutinising their conclusions and alongside what criteria or philosophy are things being confirmed?


As for bias being a red herring. You said this Jim... “Or that it will always fail to correctly identify what failures led to the event?”.


Does that not contain the assumption (what some might refer to as a bias) that multiple failures are needed before an accident can occur?

Peter – reference your post 78.

Thanks for the references provided, am fully familiar with these.

Given my previous reference (HSE 2003 p4) and yours, may I suggest that we are broadly in agreement that the HSE offer a public position that management cause most accidents?

It is this public opinion, offered to the safety profession through such publications as you list, that maintains the management failure myth.

It’s great to see how many people have viewed this thread and in that regard Pete’s comment above that “good investigation pre-supposes nothing; it seeks evidence and fact and then draws conclusions” is the only “mantra” that we need.

Peter

Just to clarify, what I actually said was "may I suggest that we are broadly in agreement that the HSE offer a public position that management cause most accidents?"

A view I do not support.

Difford

Maybe you could tell us how you approach accident investigations ?

Am I the only one getting fed up with this increasingly arcane argument? I for one tend to inhabit the canteen, not the Senior Common Room.

I am of a school that was brought up to try very hard to have no preconceptions when carrying out an accident investigation lest they cloud my mind such that I miss a key piece of information. When, and only when I feel I have exhausted the sources of information may I carry out an analysis of what I have discovered and only then can I draw justifiable conclusions. Anything less and I'm probably open to challenge. Anything less and I haven't done right by the injured party either.

The sorts of pollutants that may affect one's judgement include political standpoint (Marxist or Tory etc.) and, yes, strongly held views on the theory of causation. Accident causation theories are no more than that when it comes to individual cases, which I suggest is what most practitioners deal with.

Nice of Peter Gotch to remind us of the very sound work that the HSE's APAU did. They don't deserve to be either forgotten or under-rated.

There is a huge assumption amongst many that the general approach to causal analysis (with its inbuilt assumption that management are invariably involved causatively) is beyond question. If it is so undeniably right, where is the evidence beyond the corroboration that believers present to each other?

Isn't this a huge assumption itself?

I don't assume anything much about causal analysis. Along with most posters in this forum I suspect.

I disagree that management will always be the underlying cause, it's like arguing that lack of police is the cause of drink drive accidents.

No comparison.
The police are not responsible for either the car, the drink or the driver. Or the road.
Employers are responsible for the safety of the workplace and, to a large extent, the worforce.

Are you now saying it can never be "the employers fault" if he has "a clear set of standards and expectations"?

'No, I'm saying that it isn't always the employers fault that an accident has occurred.'

John J, I think that is a given, but many accidents and incidents are directly attributable to management failings. As a rule of thumb minor accidents tend to be due to operator error whereas the more serious incidents tend to have latent failures associated with poor management. Of course, many accidents include both active and latent failures. A recent example is the Deepwater Horizon disaster, which included poor planning, design, equipment, training, risk management, supervision, decision making and regulation.

John, when I am describing 'minor accidents' I am referring to an operative not using a tool properly or someone tripping, where there is clearly no other causal factor. The severity is often down to good or bad luck, but that does not disguise the fact that it was a basic error of judgement. These types of incidents are usually unavoidable, have minor consequences and are not affected by hindsight bias. More complex accidents will naturally have a number of underlying causal factors.

John, don't start me going with that zero accidents nonsense. This mantra is nothing more than management brainwashing, it has no place in the real world of health and safety. Accidents do and will always happen whilst there are humans on the planet. Look at the underlying causal factors by all means, but if I have learnt anything in this industry then I realise even with all best efforts accidents will occur from time to time. Please don't compare the actions of plant managers with those of a h&s practitioner and we don't need an unrealistic target to focus our minds.

Should been 'our'

Ray, I don't think we are that far off topic. Surely the purpose of all the causation models is to allow us to identify where failures are most likely to occur in order to prevent future incidents.
The problem with many of the models, and authors, is that they seem not to be able to look beyond their own theory and so they are flawed from the start.
The way accidents are investigated can vary greatly so how can we expect the causes to be clear. Part of the reason for that is that the focus companies or individuals put on accidents and whether they are truly identifying causes or giving it 'lip service'.
Every year I look at (literally) 1000s of near misses and task observations a year. I investigate around 80 minor accidents and in a bad year up to 8 lost time or major accidents. Using six sigma techniques I try to identify commonality as part of our drive for continuous improvement.
After all that have I identified any noticeable trends that verify one model is more accurate than another. No.
What I can tell you is that our lost time accidents will generally be slips, trips and falls. Our minors will be hand injuries often though incorrect glove selection (I'm sorting it and it's reduced by a third in a year) and our near misses will be related to vehicles, equipment, procedures and unsafe behaviours.
In short no single model works on its own and there's more overlap than many seem willing to admit.

Peter. If you go to the linked document, its self explanatory.

Paul

I don't need to go to the linked document.

In the absence of a specific legal definition, the Interpretation Act tells me to defer to the Oxford English Dictionary.

The words "most" and "invariable" are simply NOT synonymous.

Indeed - it could be argued that some people are simply accident prone and should not be in the job they are in. Some people are like this before they even leave school, and yet we are expected to believe that their repeat accidents when they reach work is a management issue rather than a personal issue?

I do believe that most accidents can be traced back to a management failing of some sort, but nowhere near the proportion implied. In that respect I believe 'unsafe acts' comprises both management failings and personal failings, sometimes (usually only seen when a critical failure), it happens to be both. Likewise the 'unsafe conditions' pie can be cut-up into many different slices to suit a number of different arguments.