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Ohis  
#1 Posted : 17 October 2025 07:04:06(UTC)
Rank: New forum user
Ohis

I recently attended a powerful webinar titled “After the Fall: Turning Tragedy into Action,” which explored how serious workplace incidents can and should drive real, lasting change.

What struck me most was how often organisations react strongly after a tragedy, yet over time the urgency fades and the lessons learned gradually lose their impact. We put new controls in place, update procedures, and issue safety alerts but do we really address the deeper cultural and systemic factors that allowed the incident to happen in the first place?

The session challenged us to think beyond compliance and ask:

  • How do we ensure that lessons from tragedy lead to sustained transformation, not just temporary reaction?

  • What practical steps can safety leaders take to embed change that truly honours those affected?

  • How can we encourage openness and learning rather than defensiveness and blame after serious incidents?

I’m curious to hear from fellow professionals:

peter gotch  
#2 Posted : 17 October 2025 10:51:53(UTC)
Rank: Super forum user
peter gotch

Thanks Ohis

Assume you are probably referring to this event After the fall – turning tragedy into action | IOSH

Slightly odd that this does not appear to have been made available for viewing after the event, even by IOSH Members though it was only two days ago, so perhaps it will be put onto e.g. the catalogue of IOSH Blueprint resources.

Without seeing the webinar it is impossible to tell how well "the fall" led to an effective root cause analysis to identify the underlying management causes that are usually at the heart of the matter.

Such that dealing with those underlying causes would not only prevent the next fall accident, but perhaps also an explosion, or exposure to toxic materials or many other incidents that at face value appear to be wholly different to the fall that led to the investigation.

So, it would be interesting to hear what you actually learnt from this event other than three bullets which are out of the proverbial textbook, but not necessarily elements of e.g. a typical Behavioral Safety program (both US spellings deliberate).

As  example did any investigation that followed "the fall" get down deep enough to discover that e.g. there was a shortage of enough people on site (not just immediately around the scene of the accident) or perhaps incentives that influenced taking short cuts?

To illustrate: many years ago I was running an Incident Reporting and Investigation training course and invited each delegate to jot down on a very small piece of paper the bare bones of some incident with which each such delegate was familiar.

Then I would look at all the pieces of paper and make a decision as to which ones looked like there might be something worth looking into in some depth and would use a couple of these bits of paper as the basis for case study work.

So, one of these bits of paper was about an incident where a fork lift truck pierced a container of hazardous material.

I didn't know where our classroom investigation would lead! 

Everyone fully understood that there should have been a banksman. It said so in the risk assessment, but the operator decided to do what seemed to be a very simple task without that banksman. 

VERY easy to decide that the cause was the operator's unsafe ACT!!

BUT, it transpired that the reason that the banksman wasn't around was that there were not enough staff to safely cover everything being done, so NOT just around that fork truck operation.

AND it was the last day of the month and if the task was not completed every single worker on the site would lose their monthly performance bonus. That is a lot of people who would have been out of pocket and if that is not a good incentive to take what would have seemed to be a tiny risk, then what incentive is?!?!

So, what else might have happened on that afternoon instead of the fork truck incident?

You don't actually need to know the answer to that question if by doing an in depth investigaiton you fix the underlying unsafe CONDITIONS.

Finally, do you think that some scenario other than a "fall from height" might have made for a more productive webinar?

According to the International Labor Organization's latest estimates, 2.93 million people died prematurely from work-related causes in 2019. Of those 2.6 milllion died from occupational health risks and 330,000 from accidents at work.

Hence less than one in seven (11.3%) of the (mostly preventable) premature work-related deaths were from accidental causes if we accept that the ILO estimates are relatively authoritative.

Of those a substantial proportion, perhaps one in three would be from falls from heights. So, perhaps, at an upper estimate, 4% of the total number of such premature deaths.

Might it have been better to choose a scenario that would illustrate one of the much more common reasons for such deaths?

Would picking some e.g. exposure to an occupational health risk that results in respiratory harm have been more likely to raise attention to what is much more likely to kill or substantially harm people than going for "falls from height" yet again? 

We have known about the risks from falls from height since the begining of the Industrial Revolution and actually much earlier - there's even a bit in the Bible and Torah which tackled safety in design!

Wording varies according to which translation but as example:

"When you build a new house, make a parapet around your roof so that you may not bring the guilt of bloodshed on your house if someone falls from the roof."

Deuteronomy 22:8

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