Learning from Safety Failure
RoSPA Accident Investigation Challenge supported by TUC, CBI, IOSH and ABI
Barriers to learning from failure
Accidents and incidents often arouse powerful emotions , particularly where they have resulted in death or serious injury. On the positive side, this means everyone's attention can be focused on improving prevention. On the negative side however the same emotions can also cause organisations and individuals to become highly defensive . This is natural and understandable but needs to be addressed positively if a culture of openness and confidence is to be engendered to support a mature approach to learning from accidents and incidents.
All too often, in the wake of an accident, the tendency is to seek to attribute blame (frequently to blame the victim) rather than to search for root causes. Yet arguably, the most important thing to establish about accidents is not just how they happened but why they were not prevented . Because ultimately everyone at work has some degree of responsibility for health and safety, a totally 'blame free' approach may not be realistic. Nevertheless, organisations should endeavour to create 'fair' and 'just' cultures in which individuals are not blamed for organisational safety failures over which they have had no control.
Being able to learn from accidents and incidents presupposes that organisations have already got a health and safety management system in place, for example, along the lines suggested by the Health and Safety Executive (HSE) in their guidance, 'Successful Health and Safety Management' (HSG65). Unless they approach OS&H systematically, their approach to investigation is likely to be cursory and superficial - leading to narrow, technically focused 'quick fixes' rather than seeking a better understanding of underlying causes which could enable them to make 'root and branch' changes in management systems.
In RoSPA's view, some of the major pitfalls in accident and incident investigation include:
- no reporting of accidents and 'near misses' (often due to employee fear of consequences);
- no investigation at all (coupled with massive under-reporting to enforcing authorities);
- no clear procedures for investigation (and/or no managerial involvement);
- no workforce involvement (trades union safety representatives have a legal right to investigate accidents);
- no scaling of the level of investigation (everything investigated in the same way rather than matching investigation effort to safety significance or learning potential);
- failure to gather all the relevant facts (particularly as a result of inadequate approaches to witness interview);
- no use of structured methods to integrate evidence;
- distortions in evidence gathering and analysis due to uncritical biases;
- concluding the investigation too early (not going far enough);
- simply focusing on the errors of individuals;
- no search for 'root causes';
- in that context, no examination of safety management system failures;
- failure to think outside conventional rules and operating systems;
- poor communication of 'lessons learned'; and
- failure to secure closure on resulting recommendations
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RoSPA is a registered charity: Registered Charity No: 207823 Patron: Her Majesty the Queen RoSPA Head Office: Edgbaston Park, 353 Bristol Road, Edgbaston, Birmingham B5 7ST, UK |
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