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damian2701  
#1 Posted : 23 February 2018 18:06:34(UTC)
Rank: Forum user
damian2701

I was confronted with a notable hypothesis today by a person in office.

The purpose of accident investigation is not to establish who was to blame but to establish that we weren't  to blame.

Interesting!!

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A Kurdziel on 26/02/2018(UTC)
freelance safety  
#2 Posted : 23 February 2018 18:12:13(UTC)
Rank: Super forum user
freelance safety

I’m sure that won’t have the desired outcome, but it made me chuckle none the less…lol


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damian2701 on 27/02/2018(UTC)
Roundtuit  
#3 Posted : 24 February 2018 00:12:01(UTC)
Rank: Super forum user
Roundtuit

Hasn't that always been the way of late - avoid the blame to avoid  the claim?

Our company operates "Zero Harm" so we couldn't possibly be at fault

How many recent posts ask about "liability" in the case of... anda raft of responses come forward to offer interpretation of regulation

I have seen a distinct shift in investigations over the decades between the old school who seek to prevent recurrence and the new school whose sole interest seems to be the preparation of documentation to exonerate the company

Edited by user 24 February 2018 00:14:23(UTC)  | Reason: comment on investigation

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Charlie Brown on 24/02/2018(UTC), A Kurdziel on 26/02/2018(UTC), damian2701 on 27/02/2018(UTC)
David Bannister  
#4 Posted : 24 February 2018 08:22:57(UTC)
Rank: Super forum user
David Bannister

It depends on your point of view.

If you're a H&S professional the natural instinct is to find out why & how and prevent a recurrence.

If your responsibility is the financial and reputational well-being of the organisation then avoiding any mud sticking is likely to be your hope for the outcome.

And there sits the reasons for cover-ups which are now being uncovered.

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A Kurdziel on 26/02/2018(UTC), damian2701 on 27/02/2018(UTC)
Charlie Brown  
#5 Posted : 24 February 2018 23:36:33(UTC)
Rank: Forum user
Charlie Brown

One thing that used to really rile me as a HSE Manager was the "How is that going to affect our insurance premiums?" question from the MD, usually before he asked how the ip was doing.

Yes we have (or in my case had) a responsibility to help limit liability but only to the extent that the ip was at fault, and there could be any number of reasons that they might be but we shouldn't be going all out to make a case against them as some may suggest but rather, ensure that the likelyhood of a recurrence is removed or at least minimised.

The safety and welfare of the employees should be the focal point, not the profit margin.

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A Kurdziel on 26/02/2018(UTC), lorna on 27/02/2018(UTC), damian2701 on 27/02/2018(UTC)
O'Donnell54548  
#6 Posted : 27 February 2018 07:57:35(UTC)
Rank: Forum user
O'Donnell54548

To prevent reoccurence you will need to identify fault/faults. This inevitably will mean that there will be person/persons who are at fault, and therefore are to blame, this in turn identifies what action/actions need to be implemented to prevent reoccurence. For this reason I have never had a problem with assigning blame as part of the incident investigation process.

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damian2701 on 27/02/2018(UTC)
fairlieg  
#7 Posted : 27 February 2018 09:32:19(UTC)
Rank: Forum user
fairlieg

For me it’s more important to understand how an accident happened.  To prevent a recurrence? maybe, maybe not.  I did an analysis on various body part injuries for a study at my workplace to see if there was a common thread.  I found that for example ankle injuries, the thing that related one injury to another was the ankle, for finger injuries was the finger etc.  and that was reviewing hundreds of accidents across the globe over several years.

Understanding how things happened, understanding the variability of the environments the people work in and how they interpret the situation they are in and how that understanding drives the actions the workers take is more important for me.

Understanding how a worker made sense of the situation they are in is important because putting someone in the same situation could drive them to make the same decision and arrive at the same outcome (for example that’s why they use simulations when they investigate air crash investigations).

We are all geniuses after the fact and it’s easy to point to were someone made a mistake and blame them and its emotionally satisfying (for a while at least) and it gets the premiums down but does it change anything, what do you actually fix by blaming.  Does it really make how the work is arranged safer or are you introducing a nuance to the workplace that might make them reluctant to report that an accident happened and could it be that which is driving your accident rate down.

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damian2701 on 27/02/2018(UTC)
O'Donnell54548  
#8 Posted : 27 February 2018 10:20:18(UTC)
Rank: Forum user
O'Donnell54548

fairlieg: what do you solve with a no-blame culture? Look at the casual tree in the IOSH Managing Safely course, according to this every incident is Management's fault! To take the no-blame culture further why have Civil or Statute law, are they not just looking to identify blame??? 

I am not suggesting for a moment that your incident investigation should focus on pointing blame, what I am saying is that we should not be afraid to assign blame where this is appropriate to take the necessary steps to prevent reoccurence.      

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damian2701 on 27/02/2018(UTC)
fairlieg  
#9 Posted : 27 February 2018 11:13:22(UTC)
Rank: Forum user
fairlieg

Originally Posted by: O'Donnell54548 Go to Quoted Post

fairlieg: what do you solve with a no-blame culture? Look at the casual tree in the IOSH Managing Safely course, according to this every incident is Management's fault! To take the no-blame culture further why have Civil or Statute law, are they not just looking to identify blame??? 

I am not suggesting for a moment that your incident investigation should focus on pointing blame, what I am saying is that we should not be afraid to assign blame where this is appropriate to take the necessary steps to prevent reoccurence.      


There was no mention of "no blame culture" in my post. I think culture is culture, it exists within and organisation and is different in each level so I am not sure you can have a "no blame culture" so I can’t comment on what you can solve.  I have not completed the IOSH managing Safely course so I can't comment on that either however, if they are using a causal tree for an accident I would debate its merits, great for equipment failure but might be too simplistic for an accident investigation.

Regulators, courts etc hold people accountable, they do the "blaming" the way I see it as an employer we should therefore be focused on what we can learn from "Failure" at every level and how we can improve how work is organised and executed.  People will be accountable and or responsible for how the was done, the investigation should better equipment to exercise their accountability and responsibility

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damian2701 on 27/02/2018(UTC)
andybz  
#10 Posted : 27 February 2018 11:33:18(UTC)
Rank: Forum user
andybz

A lot of this comes down to terminology and interpretation.

Every organisation and individual should be able to defend themselves.  This could be interpreted as explaining why they were not to blame.  But I don't think this has anything to do with the initial investigation to an incident, which should be based purely on facts.

I would never apportion blame in any incident report.  But it is essential that active failures are identified, which may include human errors or violations; and by association who was responsible for those actions.  And equally essential that underlying and root causes, which determines where responsibility for the incident lies.  Blame and responsibility can defined as having the same meaning.  But, the word blame has lots of negative connotations and should not be used (in my opinion) and should not be used (in my opinion)

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O'Donnell54548 on 27/02/2018(UTC), damian2701 on 27/02/2018(UTC)
O'Donnell54548  
#11 Posted : 27 February 2018 11:51:22(UTC)
Rank: Forum user
O'Donnell54548

fairlieg: lots of good points made in your last post. My comment with reference to a no-blame culture, was in response to your question "what do you actually fix by blaming".

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damian2701 on 27/02/2018(UTC)
John J  
#12 Posted : 27 February 2018 13:55:15(UTC)
Rank: Super forum user
John J

The purpose of accident investigation is to determine causal factors (that led to the event occurring), identifiy and implement corrective actions (to prevent re-occurrence) and to identify extent of condition and lessons learned to ensure it doesn't happen again.

I've carried out plenty of investigations and not once have I considered downplaying any part of the investigation to protect any group or individual. Facts are facts.

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damian2701 on 27/02/2018(UTC)
damian2701  
#13 Posted : 27 February 2018 14:50:21(UTC)
Rank: Forum user
damian2701

Originally Posted by: John J Go to Quoted Post

The purpose of accident investigation is to determine causal factors (that led to the event occurring), identifiy and implement corrective actions (to prevent re-occurrence) and to identify extent of condition and lessons learned to ensure it doesn't happen again.

I've carried out plenty of investigations and not once have I considered downplaying any part of the investigation to protect any group or individual. Facts are facts.

John J, I really think you hit the nail on the head, the fundemental issue here is to convince persons in office to 'buy into' into and recognise the benefits and importance of a lessons learned ultimately from the upshot of a thorough investigation therefore minimising a re-occurrence as you correctly depict 


damian2701  
#14 Posted : 27 February 2018 15:05:14(UTC)
Rank: Forum user
damian2701

An important consideration in this instance, is to involve shop floor operatives into the ergocomic design of the workplace which in my opinion will improve morale across the workplace thus justifying the investment - the only hurdle here is 'change'something not all aspire to.
Originally Posted by: fairlieg Go to Quoted Post

For me it’s more important to understand how an accident happened.  To prevent a recurrence? maybe, maybe not.  I did an analysis on various body part injuries for a study at my workplace to see if there was a common thread.  I found that for example ankle injuries, the thing that related one injury to another was the ankle, for finger injuries was the finger etc.  and that was reviewing hundreds of accidents across the globe over several years.

Understanding how things happened, understanding the variability of the environments the people work in and how they interpret the situation they are in and how that understanding drives the actions the workers take is more important for me.

Understanding how a worker made sense of the situation they are in is important because putting someone in the same situation could drive them to make the same decision and arrive at the same outcome (for example that’s why they use simulations when they investigate air crash investigations).

We are all geniuses after the fact and it’s easy to point to were someone made a mistake and blame them and its emotionally satisfying (for a while at least) and it gets the premiums down but does it change anything, what do you actually fix by blaming.  Does it really make how the work is arranged safer or are you introducing a nuance to the workplace that might make them reluctant to report that an accident happened and could it be that which is driving your accident rate down.



fairlieg  
#15 Posted : 27 February 2018 15:34:36(UTC)
Rank: Forum user
fairlieg

Originally Posted by: damian2701 Go to Quoted Post
An important consideration in this instance, is to involve shop floor operatives into the ergocomic design of the workplace which in my opinion will improve morale across the workplace thus justifying the investment - the only hurdle here is 'change'something not all aspire to.
Originally Posted by: fairlieg Go to Quoted Post

I completely agree, the guys doing the work are a great source of information, they know how the work is "actually" done they know the real "priorities" and what needs to happen to meet the priorities and still get the work done.

Waz  
#16 Posted : 12 March 2018 12:41:31(UTC)
Rank: Forum user
Waz

Just left a company after only a few weeks, as they couldn't supply me with information on a serious incident that occured 11 months before my arrival, with the HSE's investigation still ongoing, there was reluctance for me to get invovled.

However, having observed one of the directors, who liked to be hands on, operating a telehandler with a mobile phone to ear and with an engineer and welding tanks in his bucket, it was time to go.  It wasn't going to matter what I did, how I did it - it was going to make no difference to the standard demonstrated.

Any investigation will always determine 'critical factors' and 'root cause', but it is how this is interpreted into fit for purpose actions to prevent recurrence.  I like to use an incident caustion analysis method, which helps to determine key issues which you can then investigate further.

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