Posted By paul eastell All our investigations start with the statement that the investigation is not being conducted to aportion blame.....that doesn't mean a great deal,but what does, is the actual investigation that looks at real root causes and not immediate causes, this is the most important part. Remember where most root causes start. Word gets around and before you know it people start to tell you the reason why things went wrong. Honesty is the key and I have experienced 'confessions'that enable correct investigations with the right solutions being implemented......but remember root cause = key.

Posted By sagalout Good evening J, another good question for the forum. In summary, the position I outline is that there may be some worth in striving for a no blame culture but, in the same way as a zero accident target, it is an aspirational statement that should be critically assessed against where the company is culturally, both internal drivers and external ones. It is an incredibly difficult thing to acheive and I would be interested to hear from anyone who can convince me that they have ever achieved it. As a cultural statement it is fine; that is “we do not intend to carry out this investigation in order to find someone to blame”. And “the purpose of this investigation is to find the root cause”. Et al. That root cause analysis is a good baseline around which to build investigation practices is also clear, provided that the method chosen is matched to the risks within the organisation and their ability to understand it. I am less clear about why a “no-blame” statement needs to be associated with using such methodology. I agree it has been taught for many years and I guess has become more widespread in use but that does not explain why we think it is a given. If you look at the society in which we live, there are obvious examples of how “someone has to be to blame” in almost everything we do and the way that much law is administered. Why then would anyone find it easy to accept that the company really means no blame? My argument is that we live in a society that needs to lay blame somewhere; investigations will find failures if you follow the principle of root cause. Unless these are pure latent failures that are really unforeseeable then somewhere blame will be laid even if you did not intend it. Just think about Buncefield last winter, how many people set out with the view that this a no blame investigation? Then we have to consider the quality of the investigation on which the statement turns. All those affected by the accident will have an agenda and not all will be positively supportive of the process irrespective of whether there is a no blame statement or not. So the process and those carrying it out have to be robust enough to accurately determine the causes. When dealing with a well managed and positively supportive company having a no-blame statement does usually fit in nicely with the HR practices of the company. As a result you may obtain information post-accident more quickly and more freely. Employees (and my definition includes most managers) will trust the process and support it. Then when an investigation does determine that some disciplinary action (or call it blame apportionment if you wish) is required, it is more easily respected. When we come to organisations that are managed in a different way, then we have to ask what is more important; finding what is causing the accidents or trying to change a culture? Both are important but the investigations are paramount. It makes the job of investigation much more difficult and requires the consistent application of those root cause techniques, but it is possible. Please do not misunderstand my position when reading this post. I am a champion of excellence in all areas of H&S and have used root cause, working in and around "no blame" for over 25 years; I am just challenging current “received wisdom” in this post.

Posted By sagalout J, Ah, those real world examples eh? “all those affected by the accident will have an agenda and not all will be positively supportive of the process irrespective of whether there is a no blame statement or not.” One of the common agendas for the “corporate” body (usually manifested as a senior manager or the legal dept if there is one) is to concern themselves with the impact of accepting liability or blame. This is the commercial threat that they quite correctly recognise as significant in some cases. The difficulty is that root cause will, as a norm, identify the shortcomings in management O&A because that is what it is designed to do. So, trying to use it in an environment where this is not clearly understood by senior managers and executive staff is counter productive and will lead to the defensive behaviour of trying to apportion blame despite the no blame culture. “investigations will find failures”. So, let’s assume the root cause based investigation finds that the employee has had no training and there is no other way to move the loads except by use of the lift; well then that does sort of leave the company between a rock and a hard place if challenged by enforcers and completely out of the water for any civil claim because there seems to be enough evidence to almost presume guilt. And there we arrive at the paradox, they will now be to blame because that is what society wants. (It was their fault, I sued them and got £10,000 damages.) On the other hand, it may find that the employee does hav some responsibility (for the obvious reasons). Then, this will find firmer favour because it means that the compnay is not entirely "to blame" phew! Understanding this commercial risk is an important part of using a no blame culture. There are those who do and accept it on the basis that they recognise they have failed and if so they accept the “discipline” meted out by society. No different than the employee who post-investigation accepts the discipline. A solid no-blame culture operating internally. For others it may not be so easy; especially if you work in a sector where your H&S “performance” is a pre-requisite to gaining work. “so the process and those carrying it out have to be robust enough to accurately determine the causes.” Perhaps I should have added, “and understand the importance of discoverable evidence when writing investigation reports” to this paragraph. A failure to understand the importance of this area is a common cause of conflict as well as unintended/ unknowing acceptance of liability in organisations, especially where relatively junior staff record and file investigation records unaided by more senior staff or specialist legal staff. This is not saying that the report is being doctored, it is the case that how you say or write something can affect how it is judged or what liability it may attract. It has always surprised me that an organisation will freely allow an individual to produce a report, based on complex investigation techniques designed to flush out management system failures, at a relatively junior level and place it on file with no review or formal acceptance, I wonder if they do the same with a business report that could significantly affect the commercial future of the company? My view remains that this a more complex subject than just saying “trust me, I am an honest broker in this, we have a no blame policy here”

Posted By jom But what exactly does "no-blame" mean with respect to investigation of an accident/incident? Surely, to have any substantial meaning, when applied to interviewing persons involved in the accident, it has to be accompanied with a legally binding statement that anything said cannot be used against them? J.

Posted By jom Sagalout, That was my first post to this thread. There is another “J”. I agree it is a complex topic. I wonder - does it make a difference whether the accident was minor or serious? If it was minor, then everyone might be open and fully co-operative. If it was major and there is the possiblity of serious repercussions – perhaps prosecution – then persons involved might be best advised to not co-operate with the investigators (they do not have to, do they?). >"This investigation is about understanding....” This paragraph about investigation philosophy has a couple of problems from the point of view of an interviewee who was involved. 1. It has no legal status – it doesn’t speak for the company lawyers or the company’s insurer’s lawyers or the prosecuting authority 2. It mentions “Action will only be taken” – well, if action is a possibility, then the interviewee should seek legal advice I think this is a really difficult problem. It isn’t right to discuss "no-blame" investigation without talking about the legal perspective. John.

Posted By sagalout John, welcome to the debate. Perhaps it would be helpful to cover my historical context. I remember that "no-blame" was first used ( to my personal knowledge over 30 years ago)as a means to get organisations to understand that accidents are complex matters and that just "blaming" an individual was not only counter productive but usually meant that a similar accident would occur. The method supporting this is now commonly known as root cause analysis which we all know and love so much these days. It served a purpose extremely well. What concerns me now is that it is the no-blame bit which is becoming the "proven science" and I am not so comfortable with that position. My position in this debate is that it is not possible to operate a "no-blame" culture in a society that demands blame (or call it fault or responsibility or ---). What is possible is a positive, supportive company that understands and operates on the basis that blame, although I prefer words like fault or responsibility, is only ever appropriate when fault is proven through the use of methods such as root caiuse analysis. The resulting discipline may come from within or where an offence is proven, then via the justice system of this country. Therefore, I agree that an individual is always prudent to consider taking counsel, of whatever ilk, if they consider they may be liable for a personal error, omission or act etc. Of course that is a sweeping statement that will have many colours beneath it and hopefully, in a day to day sense, not many would feel it necessary to involve the legal profession.there are other ways, for example, many company procedures do allow a colleague or UASR to attend any interviews etc. Usually where someone is honest and facts emerge that suggest personal fault, it is far more likely that the organisational issues are the more significant cause and thus "blame" goes elsewhere. Do employees have to co-operate? I think the received wisdom here is that if there is a no blame culture, then they will anyway. Not in my experience, especially when they know that they are less than perfect in the areas under investigation. There are enough links to duties around H&S to suggest that there is a legal duty to do so but more significantly it is probably a condition of employment or contract anyway. You ask about minor or major. I think the motivator here is probably a thought that any discipline (or punishment) is likely to be much less severe if it is a minor incident. Again I do not see this as arising out of any no blame statement by the company, it is about the level of potential threat to the person or corporate body.

Posted By sagalout J, thanks for the response. My response to the points you raise is Q.E.D. No-blame is a meaningless term unless there is a change in the socio-legal approaches that are enshrined in much of our law. If we believe that no-blame is the best way to improve H&S then the other side of the square has to change. Now I am most definitely not competent to speak with any authority about the how and what of those changes might be. As a layman all I can see is some form of "plea bargaining on the basis of greater good" or as you say "allowed in mitigation" type of approach. It would be very interesting to hear from any of colleagues who are better placed to comment on that aspect. I am a little out of practice with the hands on stuff these days and it is useful to know how things move along. I can well imagine in the modern environment with greater and easier access to and an ever improving knowledge of the law (or maybe it is the legal system they understand better) that more people are more cautious. But why should they not be? Whether they are employees in the commonly used sense or think that they are managers or executives but are actually employees in law. After all, if you are conducting formal, recorded interviews, it must be serious eh? I stand by the view that it is the root cause analysis that reduces accidents, not no-blame. If companies use it, amd I think they should, then they must understand, at the highest level, where it can take them. By way of an amusing aside, I had an MD once who actually said to me " b*****, I thought this no-blame stuff would make it easier to find out who did it and sort them out, I never imagined it would mean me going to court". One final thought before I go for Sunday Supper. I have had more experiences where witness statements or eye witness accounts are proven to be irrelevant or inaccurate (not deliberately so) in the final analysis. People only know what they think they know Doesn't any other forum member have an input to this thread? You are all welcome cheers,

Posted By Derek Holt I would agree that a 'no blame culture' is a statement that is to readily refered to in company ethos and seems to be the latest 'buzz' words that in reality (my experience)do not exist. With regards to root cause analysis I am a firm believer in the systems thinking approach. We all operate within multiple systems that are generally complex in nature. The actions we do or don't take in relation to accident/incident causation can be argued to be a result of the system(s)of which we are a part. The root cause analysis should identify the deficiencies in the system that have led to the accident/incident. To put into context a person (one cog in the system) may have been one of the triggers for the events to unfold but were they influenced by the system within which they operate(other cogs or the machine as a whole). If you don't locate the problem in the system and only stop at the person then you will have difficulty in preventing reoccurence further down the line. There is always the argument (hear it all the time)that the person is wholly responsible, for example driving whilst under the influence which leads to a crash. But if we take a holistic view what made that person get behind the wheel of the vehicle in the first place? Societal system pressure perhaps? I find that if you take a systems approach then people more readily accept that they won't be totally held to blame and therefore are more forthcoming to aid the investigation. The difficulty is educating management in this respect.

Posted By Stuart Bower Interesting debate. I was always under the impression that the 'no blame' bit referred to the investigation process itself. It should be carried out in an open and honest manner. The problem comes when the investigation shows a failure on the part of an individual to adequately discharge their responsibilities. If no blame is taken to some peoples logical conclusion you could literally almost get away with murder at work, - something I'm sure not intended. Is there also confusion about blame and accountability? Inseparable in some peoples minds but in mine completely unconnected. For example, - X happened because Y didn't do what they were supposed to do. In this type of scenario is it reasonable to hold Y 'accountable' for their actions and if so does this 'transgress' the no blame approach? There is of course the need to discover why Y didn't do what they were supposed to do and address any shortfall. It doesn't necessarily mean that disciplinary action must take place. I believe that 'no blame' is a misnomer and its far better to address open and honest investigations linked with responsibility and accountability issues. It will to a large extent depend on organisational culture. What about a 'responsible culture'?

Posted By sagalout Rob &Stuart &Simon. Many thanks for your contributions to this thread. Rob, I totally agree with your notes. You have struck at the heart of this debate and your note outline the position very well. I wish that this understanding was more widespread. I do believe that the passive following of the no-blame approach does lead to this risk being left uncontrolled and is just one reason why I do not like it. Stuart, I am much more comfortable with the sense of responsibility or accountability. I have worked in systems that use statements such as: Personal Responsibility. We understand and accept what should be done and know what is expected of us. Individual Consequences. We understand and accept that there is a fair system for reward and discipline. These, in my experience, have generally been more successfull than any iconical no-blame statement. Simon, I do not recognise the circumstances you describe. What is the benefit to the employees or employer of just receiving a report that is "to be actioned" and one that may include the sort of information that Rob identified in his post?

Posted By Ron Hunter Jom: legal duties are enshrined in UK H&S Legislation HASAWA & MHSWR. Personally, I find the "no blame" statement to be less than honest - circumstances will arise where individuals are found to be liable and subject to disciplinary action. The sad facts may be that the humble employee is harshly dealt with for failure or non-compliance, whereas managers are less likely to be dealt with in a similar fashion for in-house failings in 'root cause' areas. I suggest a "blame last" culture is a more honest approach. i.e. "The last thing on our minds when investigating an accident is to find someone to blame, rather our focus is on identifying potential organisational or system failures, and on finding effective ways to prevent the accident happening again............"

Posted By Jonathan Sandler CMIOSH Firstly I must thank all those who have contributed to this thread, it is so refreshing to read the constructive points all of you have made. With the impending change to the CDM regs next year, would it be possible for the Client to lead on no blame? or would the legal implications be too much? further could this be linked to an individual's risk perception towards their job/task. Maybe, as Jenny Bacon said ' as safety people we dont ask the question 'WHY,' enough.' Once again, thank you all for your valid comments. Kind regards. Jonathan

Posted By Adrian Watson Dear All, I think the issue of whether or not there is accidents can be investigated in a "no-blame" culture is actually quite simple and boils down as to why the accident is being investigated! Unfortunately, most of the investigations that I have seen have not been carried out in an open, objective and unbiased manner, but were aimed at safeguarding the company. In this context these investigations were aimed at passing guilt from the organisation to an individual, i,e. apportioning guilt. As such they were by definition a "name-and-blame" investigation. If the accident is being investigated in this context then there must be the safeguards enshrined in law to safeguard individuals being investigated. However, if the investigation is to determine what happened and how it happened then an organisation can carry out investigations in a "no-blame" culture. In this context the names of the players need not be known to the organisation and only the facts should be reported. One further problem is that many safety practictioners think our job is to enforce the rules, i.e. act as safety policement, and this taints their investigations. Regards Adrian Watson

Posted By jom Ron wrote: >legal duties are enshrined in UK H&S Legislation >HASAWA & MHSWR. Ron, I'm in Australia, which is no longer a part of the UK. We have nine state OHS jurisdictions. Plus several industry specific Acts and Regs that might say something about accident investigation. It isn't at all consistent re investigation. Are the UK regs consistent? John.

Posted By sagalout Jom, I guess with a subject like this we will never "agree" or "conclude". I have moved beyond "no-blame" to personal responsibility and personal consequence type approach. That is much more open and honest. That was my contribution to the discussion. Others will disagree. Just having the discussion is sometimes a way to move forward. No doubt some who have read this thread will have re-thought some aspects and so on and so on. Sometimes maybe the farmers task is to just to sow the seed and watch it grow? Harvest may come much later and depend on factors he cannot control. (sorry a bit of philosophy slipped in there) Keep "oz" safe Pete

Posted By sagalout Barry, as long as your conclusions are based on finding sub-standard actions as measured against written company standards, take a deep breath, puff out your chest and stand your ground. (well a bit of ground outside of arms length plus a bit anyway) If you have found holes in the standards that need plugging because they contributed then make that clear because although the external legal considerations are still there as a motivator the message to the company is totally diffferent. Sorry if you knew this already but not possible to know from your post This is good example of a comment I made earlier in the thread, everyone involved has a motive and it is not always positive. And at this time of night I would be looking for at least a double G&T!

Posted By ddraigice Just to clarify a few points raised throught this thread - HSE could not rely upon an internal accident investigation in a prosecution and in my experience would only use it to decide if the company need any further advice/notices in order to ensure the lessons have been learned and controls put in place to reduce the likelihood of it happening again. If there is a case to answer in a court of law, the report will (in most cases) not sway the decision either way.

Posted By jom Pete, > (sorry a bit of philosophy slipped in there) owwww! I'm not saying there has to be agreement or conclusion. The exchange of ideas and challenging of ideas is great. But the discussion has been had before and will happen again. It'd be fantastic if we developed a way of boiling the issue down into its elements and collating everyone's knowledge and experience of those elements. Then identify the problems and use the collective wisdom to make progress. Wouldn't that be great? I'm just saying we need to deconstruct the chaos of the existential realities of the third millenium cyberindustrial work environment and collaboratively synthesise a new model. owwwwwwwww! John.

Posted By DJ I am sorry but I have not had time to read all the messages on this subject, so apologies to anybody who has already aired these issues. Just to add my two pennies worth, There is absolutely no reason why a company cannot accept a 'no-blame' approach to accident investigation provided that it (the company) and its directors are prepared to take the hit on any claims or criminal prosecution. I personally applaud any company that is prepared to take such steps as they are likely to find the real causes of any accident and be able to prevent it re-occurring. There is however a problem with such an approach in that under Company Law, and to a lesser extent corporate governance rules, directors who take such an approach could be regarded as acting 'ultra vires' (i.e. outside their powers) in that they may be breaching their duty of care to the company and its shareholders. Moreover, a 'no-blame' culture must be exactly that NO BLAME, even if it is found that one or more individuals were culpable or negligent. The organisation still has to take the hit as the price of learning the lessons. Sadly, I don't have the answer to this problem, if indeed there is an answer. On the one hand we could adopt a genuine "no-blame" system similar to that used by the aviation industry (in which case nobody would be prosecuted for health and safety offences) or we can have the current system. In the latter case, as organisations and individuals are at risk of prosecution, they have the right to defend themselves. Like most of you I simply try to do the best I can within the confines of the current system. Regards. DJ

Posted By sagalout John, In the UK at least, the law works in exactly the opposite way, i.e is anyone at fault, if so they are to blame. There is the paradox, just how can a no-blame approach actully exist in that legal framework? DJ outlines one of the major conflcits for a senior manager or exec who has duties under non-safety related law. I do not think it does nor can it with the existing lewgal structure that we have. It is a nice tag to use but actually means nothing. By the way, enjoyed your brief encoumter with philosophy the other night. Took me while to work out which one of us lives upside down (chuckle) Pete