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#41 Posted : 22 September 2006 19:29:00(UTC)
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Posted By Raymond Rapp A true no-blame culture can never exist because an individual or company have certain duties under health and safety legislation. However, a low-blame culture can and arguably should be sought after in an organisation. The original question asks how a no-blame doctrine can be used in an accident investgations. The only way I know to ensure a no-blame ethos is to ensure that accident investigations are only used for accident reports. I accept that a by-product of any investigation is the identification of those at fault. In effect, a completley separate investigation would have to take place for a disciplinary investigation and in theory you could have two different reports. As a health and safety practitioner I am not concerned with the aftermath of an enquiry i.e. disciplinary actions, only with establishing the facts and providing recommendations to prevent recurrence. Regards Ray
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#42 Posted : 23 September 2006 13:14:00(UTC)
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Posted By jom Pete, You said: "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" Yes, the judicial process is all about allocating blame. It doesn't make sense to talk about "no-blame" within the domain of state prosecution. But the other domain is the internal corporate investigation. We have to ackowledge there are two domains which have different purposes and powers. The unfortunate person who is implicated in the accident, and might be seen as causing it, will be examined within both domains. If the person co-operates with the corporate investigation, his/her statements might be used by the prosecutional investigation. This is why a no-blame committment from the corporation is so important. But it must be totally unambiguous and legally binding. I think this is a very important and very tough issue. Why should the implicated person co-opearate with the corporate investigation? John.
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#43 Posted : 23 September 2006 13:53:00(UTC)
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Posted By jom Ray, You said:- "A true no-blame culture can never exist" I don't think we started off talking about a "no-blame culture". It was about "no-blame investigation", which is a different thing to a culture. John. because an individual or company have certain duties under health and safety legislation. However, a low-blame culture can and arguably should be sought after in an organisation
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#44 Posted : 23 September 2006 21:55:00(UTC)
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Posted By sagalout John, you outline the paradox very well. in my memory, the no blame approach was heralded as a way to "open up" investigation so that the internal investigation would look beyond just blaming the person or persons involved. It provided a framework for full assessment of systems and challenged the "management" (both people and systems that is) of the organisation to look beyond blame. In this context it worked well at first and it is true to say that sounder and more professional investigations are now more widesapread as a result. However, the problem started to appear from two directions: from the corporate level where the results of this work created a potential conflict of duty; from the employee level where it had been interpreted as "no blame" meaning either no pain from the employer regardless of the findings and also implying some form of protection from criminal prosecution. The society we live in the UK these days has moved on a long way since the first introduction of no blame; increasing prosecution of individuals under section 7 of HASAWA; increasing levels of fimes aginst companies for H&S offences; better understanding and use of civil laws regarding compensation; less fear of employers by employees; corporate governanace within organisations to name but a few. I just thnk it has run its course and we should be looking to a better "tag". Thanks for your input to this thread. Nice to have a reasoned discussion on this forum now and again. Pete
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#45 Posted : 24 September 2006 09:04:00(UTC)
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Posted By Raymond Rapp jom - I am not sure what your point is? Yes, the orignal question was about no-blame accident investigations, which I acknowledged and went on to discuss in my second paragraph. Others have discussed a no-blame culture, implying it is required for no-blame accident invstigations. There are some tangible links between the two concepts but not necessary in their own right. Incidentally, health and safety legislation arguably encourages a 'blame culture'. For example, Sections 2-7 of HSWA are based on a strict liability doctrine. Where the accused has to prove their innocence as opposed to being innocent until proven guilty. Food for thought? Ray
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#46 Posted : 24 September 2006 09:18:00(UTC)
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Posted By Adrian Watson Raymond, Not quite; the prosecuter has to prove beyond reasonable doubt that you commited an offense under S2-9. Once the offense has been proved you have to prove the defence of reasonable practibility, on the balance of probabilities. Regards Adrian Watson
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#47 Posted : 24 September 2006 11:14:00(UTC)
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Posted By Raymond Rapp Adrain, with respect, I think you are nit-picking. I was referring to the concept as opposed to the pragmatics, which you have accurately described. Many thanks. Ray
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#48 Posted : 24 September 2006 11:45:00(UTC)
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Posted By jom Ray, "jom - I am not sure what your point is? Yes, the orignal question was about no-blame accident investigations, which I acknowledged and went on to discuss in my second paragraph." Well, let me see if I understand my own point. "Culture" says to me something pervasive throughout the organisation. So a no-blame culture would mean eliminating the notion of blame from every nook and corner of the organisation. Can't see that happening. I think the consensus here is that blaming can't be removed. Some are saying it would even be contrary to a corporation's duties to shareholders. But surely an investigation can be done within a no-blame framework, specifically structured for invetsigations? "I accept that a by-product of any investigation is the identification of those at fault. In effect, a completley separate investigation would have to take place for a disciplinary investigation and in theory you could have two different reports." Yes. Two different investigations. And the material extracted by the "no-blame" investigation cannot be used by the prosecutional investigation. (That is, statements and answers from the implicated individual cannot be used in a prosecution of that person.) This is the thing I'm trying to drill down to:- Should the implicated person submit to the corporate interview? It's a tuff nut. John.
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#49 Posted : 24 September 2006 19:29:00(UTC)
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Posted By Raymond Rapp John In the context described, a no-blame investigation can only be instigated by an organisation. Statutory powers can and will overrule any coproprate policy. Notwithstanding in most cases we are talking about commom accident and incident investigations and not statements taken under caution. Unless the person involved has been granted immunity which is very rare and normally only applies to Public Enquries. 'Should the implicated person submit to the corporate interview? It's a tuff nut.' Do they have a choice? Ray
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#50 Posted : 25 September 2006 10:41:00(UTC)
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Posted By ddraigice Off the pooint a bit but someone earlier said: The society we live in the UK these days has moved on a long way since the first introduction of no blame; increasing prosecution of individuals under section 7 of HASAWA; increasing levels of fimes aginst companies for H&S offences There seem to be very few cases against individuals (and HSE tends to do this only where there is good evidence as it usually looks at system failures) and attempts have been made to increase fines as generally they are thought to be too low. Are these just assumptions? I can find no evidence to the contrary. I used to be sick and tired of seeing reports from consultants saying that training and a tool box talk would be given to employees and that incident x was a result of person y not doing something or doing something silly. In some cases this was true but in most cases the person can only be blamed for being in the wrong place at the wrong time - and "there but by the grace of god go I". Where an incident occurs due to someone over-riding a safety control then that is obvious but where the safety control was not in place in the first place then should we be looking at the individual?
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#51 Posted : 25 September 2006 11:29:00(UTC)
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Posted By jom Ray, I guess I'm talking about the more serious accidents - ones that caused injury or came close to doing so. The litmus test here might be: is there a chance of prosecution? "'Should the implicated person submit to the corporate interview? It's a tuff nut.' Do they have a choice?" Yes, I think they do have the choice. The person can simply decline to submit to interview. It's the in-house investigation I'm referring to. Please tell me if this is incorrect. John. Ray
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#52 Posted : 25 September 2006 14:38:00(UTC)
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Posted By sagalout This thread has really kept running a lot longer than I ever imagined it would with new contributors arriving all the time. Must be something in it? Here is a summary of my position. I first came across this approach, about 30 years ago, linked to the introduction of systems or root or organisational based investigations. The purposes of these being to ensure that the real reasons for the accident were identified. Hence the phrase “the purpose is not to simply blame but to understand and correct……” You will note that this is something entirely different from a simple “no blame” statement and in no way offers any immunity to anyone of any kind. This is the no blame that I recognise; it is the wider use of this term that I consider to be a misleading and pointless icon. (for all the reasons covered in the many responses to the thread) The benefits that I gained from this no blame tag were the wider acceptance and use of systematic investigation. At workforce level, employees could see that the physical improvements were being made, at manager level because it gave a firmer base for discipline where it was concluded as necessary. There is no doubt that the explicit use of no blame did help in the early stages simply because at the time most industrial investigations went no further than blaming the employee. (as mentioned by others in this thread) No blame investigation can make co-operation, in company led investigations, more likely than not. This is especially so at employee level where, traditionally, blame is/was placed for all the reasons outlined in previous posts. However, this co-operation disappears as soon as the actual situation is understood. You only need refer to comments earlier in the thread with examples from both the management and workforce angles. Should employees co-operate? (at whatever level in the company they exist) Of course they should if only for moral or ethical reasons. Maybe, however, they would be wise to seek advice and guidance commensurate with the seriousness of the event. It is interesting that the more senior a person is in an organisation, the more likely they are to seek advice and guidance especially in serious accidents or incidents. Understandable for the obvious reasons but why should we not expect everyone in the organisation do the same? Getting co-operation has more to do with skills as an investigator than relying upon a no blame statement. (e.g. how many times have I heard a witness start at the point of the accident and the investigator not challenge back to the time when everything was going OK from the witness point of view ) I agree that a no blame culture is different from no blame investigation. It merely the “society” within an organisation that promotes and maintains such a view or approach to one specific aspect of the organisational management.. As a cultural statement it can cover behaviour, attitude, joint beliefs as well as systems to support the culture. They often exist alongside or within best practice HR management. If I may be forgiven for using a high impact example to demonstrate my point: When you first heard about Buncefield and in the days after, did you really think no blame naturally or was there just the slightest niggle in your mind? If it transpires that an individual has transgressed and there are no underlying causes, should he/she be allowed to walk away? Or should the companies operating the facility be allowed to walk away without discipline if failure is determined? What I do know is that having an internal no blame statement would make no difference to the responses of those interviewed and that causal analysis will define what happened and justice will be applied if and where required. For me, the use of no blame in a wider context than first introduced is one that we should not promote in any form. Until: we have persuaded the legislators that maybe there is a place for no blame associated with H&S investigations.
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#53 Posted : 25 September 2006 16:00:00(UTC)
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Posted By Raymond Rapp John, a person could decline to give an interview, but they would no doubt find that they are now on a charge of gross misconduct! The concept of a blame/no-blame culture is largely a theoretical one espoused by academics. Hence in reality neither exist. The best one can achieve is a low-blame culture by acknowledging the very existence of both doctrines. In the last decade or so the empahsis on blame has shifted from the individual to the organisation. Empirical evidence can be seen in many different forms. However, the twister, many organisations have attempted to deflect the blame back to the individual. Blame is driven by the need for self preservation. Ray
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#54 Posted : 26 September 2006 10:53:00(UTC)
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Posted By jom "John, a person could decline to give an interview, but they would no doubt find that they are now on a charge of gross misconduct!" I don't follow that, Ray. What law is involved exactly? John.
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#55 Posted : 26 September 2006 11:54:00(UTC)
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Posted By jom Pete, "Should employees co-operate? (at whatever level in the company they exist) Of course they should if only for moral or ethical reasons" I'm glad you pointed out the readiness of management to use legal protection. I posed the question as a pragmatic one, rather than one of morals/ethics. There certainly is a moral dimension to it, but the implicated person needs to know just how any information he/she gives to the investigator might be used. My own view is the person ought to consider not submitting to interview. It would be a very stressful situation and I'm not sure I would be able to say no. The solution is to make any corporate interview inadmissable. Maybe the discussion has run its course. John.
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