Welcome Guest! The IOSH forums are a free resource to both members and non-members. Login or register to use them

Postings made by forum users are personal opinions. IOSH is not responsible for the content or accuracy of any of the information contained in forum postings. Please carefully consider any advice you receive.

Notification

Icon
Error

Options
Go to last post Go to first unread
mjr1991  
#1 Posted : 20 June 2022 09:38:18(UTC)
Rank: Forum user
mjr1991

I have done a few courses on root cause analysis and every single one has pretty much said "if the root cause isn't management, you're doing it wrong". Why? 

My predecessor at work carried out an investigation a coupld of years ago after an apprentice was pushing a trolley around the site and decided he wanted to ride on it, his foot slipped and put quite a big hole in his heel. The lad had had all of his training, site safety, horseplay etc, adequate supervision was in place, and the trolley was well maintained. I had a good long think about it, and read the reports and the like, and couldn't figure out for the life of me how my predecessor determined that the root cause was management not being to commited to health and safety.

You can give someone all the training in the world, you can give him all the supervision in the world, but ultimately, if he wants to ride the trolley, he will. Surely I'm not the only person who thinks like this and disagrees that the root cause must (almost) always be management?

Kate  
#2 Posted : 20 June 2022 10:06:48(UTC)
Rank: Super forum user
Kate

The apprentice can't have had all the supervision in the world if they were riding on a trolley and no one intervened to stop this.

I'm not saying inadequate supervision was the cause - just that what you've described doesn't appear to rule out inadequate supervision as a cause.

Roundtuit  
#3 Posted : 20 June 2022 10:06:58(UTC)
Rank: Super forum user
Roundtuit

IF adequate supervision was in place, rather than just assigned, how did this apprentice come to be conducting themself other than in accordance with their training?

Adequate supervision would have spotted them about to do something wrong

Adequate supervision would have intervened to stop them doing something wrong

As the injury occurred the action was neither spotted nor halted so there was a management failure to ensure adequate supervision of an apprentice (slightly different beast to general supervision of the wider workforce).

thanks 2 users thanked Roundtuit for this useful post.
Martin Fieldingt on 20/06/2022(UTC), Martin Fieldingt on 20/06/2022(UTC)
Roundtuit  
#4 Posted : 20 June 2022 10:06:58(UTC)
Rank: Super forum user
Roundtuit

IF adequate supervision was in place, rather than just assigned, how did this apprentice come to be conducting themself other than in accordance with their training?

Adequate supervision would have spotted them about to do something wrong

Adequate supervision would have intervened to stop them doing something wrong

As the injury occurred the action was neither spotted nor halted so there was a management failure to ensure adequate supervision of an apprentice (slightly different beast to general supervision of the wider workforce).

thanks 2 users thanked Roundtuit for this useful post.
Martin Fieldingt on 20/06/2022(UTC), Martin Fieldingt on 20/06/2022(UTC)
A Kurdziel  
#5 Posted : 20 June 2022 10:08:41(UTC)
Rank: Super forum user
A Kurdziel

Because mangers are supposed to manage not pass the buck. In this case the question is why the lad decided that riding the trolley was good idea?  Was it part of the culture in the organisation? Was the apprentice not really upto the job- a bit immature?

The alternative to blaming management is to blame everybody else; the workers, the decline in moral standards, the phases of the moon etc. the buck has to stop somewhere and that somewhere is management.      

thanks 2 users thanked A Kurdziel for this useful post.
Martin Fieldingt on 20/06/2022(UTC), mjr1991 on 20/06/2022(UTC)
peter gotch  
#6 Posted : 20 June 2022 10:23:40(UTC)
Rank: Super forum user
peter gotch

Morning Mike

There will come a point where management (including supervision) has done all that is reasonably practicable, but on the basis of the limited text in the scenario you present I doubt that this has been shown to have been done.

Bear in mind that if this were to reach either criminal or civil court proceedings the onus of proof as to what is or is not reasonably practicable would fall to the defendant - usually the employer via its management - to prove that they had done all that was reasonably practicable.

In HSG265, HSE comment, inter alia:

Investigations that conclude that operator error was the sole cause are rarely acceptable. Underpinning the 'human error' there will be a number of underlying causes that created the environment in which human errors were inevitable. For example inadequate training and supervision, poor equipment design, lack of management commitment, poor attitude to health and safety.

The objective is to establish not only how the adverse event happened, but more importantly, what allowed it to happen.

The root causes of adverse events are almost inevitably management, organisational or planning failures.

thanks 3 users thanked peter gotch for this useful post.
A Kurdziel on 20/06/2022(UTC), mjr1991 on 20/06/2022(UTC), Andrew_C on 28/06/2022(UTC)
mjr1991  
#7 Posted : 20 June 2022 10:28:18(UTC)
Rank: Forum user
mjr1991

I appreciate everyones' responses. I just don't get it though. I agree that the supervision can't have been all that, but that does raise a new question, how much supervision would be considered 'adequate'? We have a single workshop manager, and a chargehand in each area of the workshop, would this be adequate?

I'm not trying to be argumentative or obtuse, I just can't get my head around how management can be blamed for another persons' free will.

Kate  
#8 Posted : 20 June 2022 10:37:02(UTC)
Rank: Super forum user
Kate

Free will exists in a context and not independent of it.  It is management who recruited, trained, instructed and supervised (whether adequately or not) the trolley-rider and created the conditions in which they worked and the culture of what was considerd acceptable or not.  They did this knowing the person was an apprentice and therefore likely to be particularly vulnerable.

thanks 1 user thanked Kate for this useful post.
A Kurdziel on 20/06/2022(UTC)
Tstamps  
#9 Posted : 20 June 2022 11:06:57(UTC)
Rank: New forum user
Tstamps

The courses i have been on tend to point to management fro RCA but maybe i misunderstood as i thought they were pointing to management systems more than the managers themselves. Afetrall if the managers are not living up to their responisbilities what is contained in the management system to adress this.

Brian Hagyard  
#10 Posted : 20 June 2022 11:28:17(UTC)
Rank: Super forum user
Brian Hagyard

Originally Posted by: MikeRavenscroft Go to Quoted Post

I appreciate everyones' responses. I just don't get it though. I agree that the supervision can't have been all that, but that does raise a new question, how much supervision would be considered 'adequate'? We have a single workshop manager, and a chargehand in each area of the workshop, would this be adequate?

I'm not trying to be argumentative or obtuse, I just can't get my head around how management can be blamed for another persons' free will.

Dont forget accident investigation is not about blame - not even managers. Just because the Root Cause is lack of supervision - does not mean that extra supervision is reasonably practicable. "No Changes Needed" is an acceptable outcome in my view. However if a person makes the same "mistake" time after time and extra supervision is not reasonably practicable then other action (even displine) must be considered. While some people may try to achieve zero accidents i dont belive its reasonably practicable.

thanks 2 users thanked Brian Hagyard for this useful post.
A Kurdziel on 20/06/2022(UTC), PDarlow on 22/06/2022(UTC)
CptBeaky  
#11 Posted : 20 June 2022 12:10:44(UTC)
Rank: Super forum user
CptBeaky

In my opinion, the root cause should always come down to managment failings, is because this is where the power to make the required changes is held. In your scenerio, if managment were not to blame, how can you ensure that it doesn't happen again? Management need to look at the supervision levels, the culture, the training etc. to ensure they are complying with their duties under the HASAW etc. act 1974.

Remember

2 General duties of employers to their employees.

(1)It shall be the duty of every employer to ensure, so far as is reasonably practicable, the health, safety and welfare at work of all his employees.

This applies to all your employees, not just the ones that don't mess about

Also

(2)Without prejudice to the generality of an employer’s duty under the preceding subsection, the matters to which that duty extends include in particular—

(c)the provision of such information, instruction, training and supervision as is necessary to ensure, so far as is reasonably practicable, the health and safety at work of his employees;

If your apprentice injured themself through lack of supervision, how confident are you that you have all the supervision "necessary"?

thanks 2 users thanked CptBeaky for this useful post.
A Kurdziel on 20/06/2022(UTC), PDarlow on 22/06/2022(UTC)
achrn  
#12 Posted : 20 June 2022 12:52:55(UTC)
Rank: Super forum user
achrn

OK, I'll swim against the tide.

I don't think the root cause is always management.

First, I note that in the scenario set out (trolley-riding), most people have leapt on the 'must have been inadequate supervision'.  I don't think that follows - people do occasionally do stuff that's stupid (and that they know they shouldn't do).  Certainly, I've occasionally done stuff that I shouldn't (and have teh scarring to prove it) (though bnone of it from work).  Unless you're going to to institute 100% supervision 100% of the time (and presumably also supervise the supervisors 100% of the time) you won't prevent that 100% of the time.

People do occasionally go off on their own frolic.

In the scenario set out, I don't know if there was a reasonable (or reasonable practicable) level of supervision. It might be that there was insufficient supervision or training, but it might have been the epitome of good practice and still had this occur.

There are other accidents that can't (I think) be blamed on management - I had one where someone putting on their safety glasses basically missed and stuck the arm of the glasses quite hard into their eye (scratching the white).  I find it hard to blame management for that (no they weren't rushed, yes they knew how to don and doff their ppe - though I don't think we'd sent them on a specific putting-on-safety-glasses-without-impaling-your-own-eyeball course, yes the ppe was suitable).

Having said which, the large majority of accidents do come back to a management - if nothing else, management is paid to manage and things aren't supposed to be happening randomly.  The business is (supposedly) not just five hundred monkeys bashing keys at random (so they tell me).  Managers are supposed to be in charge of all that happens in the business, and if they take responsibilty for things going well they are presumably responsible also for things that don't go well.  That's the job - if you're managing something and it goes wrong, whose else's fault is it likely to be?

If we assume that 98% of what happens in the business is managed (with 2% of things - good and bad - actually being 'by accident') then management is going to responsible in 98% of root cause investigations, I think.

Unless you're a politician, of course - then if you 'believed implicitly' it was OK then it must have been OK and you're obviously completely blameless.

thanks 4 users thanked achrn for this useful post.
Evans38004 on 20/06/2022(UTC), Roundtuit on 20/06/2022(UTC), PDarlow on 22/06/2022(UTC), A Kurdziel on 24/06/2022(UTC)
Roundtuit  
#13 Posted : 20 June 2022 13:05:00(UTC)
Rank: Super forum user
Roundtuit

Management are involved with recruitment (as well as training and supervision) so except for the one man band & the true family business.......

thanks 2 users thanked Roundtuit for this useful post.
A Kurdziel on 20/06/2022(UTC), A Kurdziel on 20/06/2022(UTC)
Roundtuit  
#14 Posted : 20 June 2022 13:05:00(UTC)
Rank: Super forum user
Roundtuit

Management are involved with recruitment (as well as training and supervision) so except for the one man band & the true family business.......

thanks 2 users thanked Roundtuit for this useful post.
A Kurdziel on 20/06/2022(UTC), A Kurdziel on 20/06/2022(UTC)
A Kurdziel  
#15 Posted : 20 June 2022 13:26:43(UTC)
Rank: Super forum user
A Kurdziel

OK

Forget the PLAN DO CHECK ACT virtuous circle; in reality mangers often demonstrate “slopey shoulders”, and do not take  responsibility for actions that occur on their watch. Why? Because that is the route of least resistance, and many managers  do that because in reality they have not being trained as managers. They don’t understand what their role is and think that supervision consists of  giving a set of garbled instructions and they don’t lead by example. We talk about retraining shop floor workers after an accident, but does anyone suggest that the supervisors aren’t up to it?

thanks 2 users thanked A Kurdziel for this useful post.
PDarlow on 22/06/2022(UTC), Brian Hagyard on 24/06/2022(UTC)
ajw  
#16 Posted : 23 June 2022 15:52:47(UTC)
Rank: New forum user
ajw

Clearly an apprentice will require a higher level of supervision due to the fact hey are in effect a trainee and the fact they chose to play silly beggers does suggest an issue with the culture. That said I assume there was written confirmation of site rules and apprentice  had read and signed as understanding, in whcih case  as an employee they should also have been subjec to C&D if they were breaking employers safety pocesses.

Brian Hagyard  
#17 Posted : 24 June 2022 07:48:58(UTC)
Rank: Super forum user
Brian Hagyard

Originally Posted by: A Kurdziel Go to Quoted Post

OK

 We talk about retraining shop floor workers after an accident, but does anyone suggest that the supervisors aren’t up to it?

Frequently! (unfortunatly) 

Brian Hagyard  
#18 Posted : 24 June 2022 08:08:07(UTC)
Rank: Super forum user
Brian Hagyard

Just been thinking about this (not good on Friday my head hurts) and it struck me what the question actualy said. I dont think root cause is always about management - but about management systems. There is a subtile difference. So if root cause was identified as lack of supervision - i would be looking to see what could be done to reduce the need for supervision or if not practicable that the supervsior actualy had the time, training etc to carry out the supervision - not just saying it was the supervisors fault.

Kate  
#19 Posted : 24 June 2022 09:00:29(UTC)
Rank: Super forum user
Kate

I agree - "management" really means how things are managed, not the people with the accountability for managing them.

Roundtuit  
#20 Posted : 24 June 2022 09:07:40(UTC)
Rank: Super forum user
Roundtuit

Originally Posted by: ajw Go to Quoted Post
C&D
?

Another entry for the Three Letter Abbreviation dictionary

thanks 2 users thanked Roundtuit for this useful post.
peter gotch on 24/06/2022(UTC), peter gotch on 24/06/2022(UTC)
Roundtuit  
#21 Posted : 24 June 2022 09:07:40(UTC)
Rank: Super forum user
Roundtuit

Originally Posted by: ajw Go to Quoted Post
C&D
?

Another entry for the Three Letter Abbreviation dictionary

thanks 2 users thanked Roundtuit for this useful post.
peter gotch on 24/06/2022(UTC), peter gotch on 24/06/2022(UTC)
chris42  
#22 Posted : 24 June 2022 09:09:00(UTC)
Rank: Super forum user
chris42

I have always considered it as “Senior management” opposed to just “management”. After all it is the senior management that put the systems in place, so if they are not adequate then it is their doing. Managers lower down the food chain can be just doing what they have been instructed and making the best of it.

Kate  
#23 Posted : 24 June 2022 10:40:22(UTC)
Rank: Super forum user
Kate

You've encountered different senior managers than I have, obviously ...

ajw  
#24 Posted : 24 June 2022 15:14:04(UTC)
Rank: New forum user
ajw

#20 Sorry , Conduct and Discipline (in old money) 

chris42  
#25 Posted : 24 June 2022 15:24:42(UTC)
Rank: Super forum user
chris42

Originally Posted by: Kate Go to Quoted Post

You've encountered different senior managers than I have, obviously ...

For your sake I hope so  :o)

Users browsing this topic
Guest
You cannot post new topics in this forum.
You cannot reply to topics in this forum.
You cannot delete your posts in this forum.
You cannot edit your posts in this forum.
You cannot create polls in this forum.
You cannot vote in polls in this forum.