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.

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).

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.

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.

Originally Posted by: MikeRavenscroft

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.

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.

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

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.

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.

Originally Posted by: ajw

C&D

Another entry for the Three Letter Abbreviation dictionary

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.

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

You cannot legislate for stupidity - I guess though it will still be management failures ??

Taking personal responsibility - does it still exist ?