Learning from Safety Failure
RoSPA Accident Investigation Challenge supported by TUC, CBI, IOSH and ABI
Some general points
- Accidents are extremely costly in both human and financial terms but, if investigated correctly, they also represent highly valuable safety learning opportunities .
- Effective accident investigations can provide a 'window on reality' (providing a means of discovering what was really going on).
- All organisations need to develop a strong capability to 'dig deep' following accidents in order to develop a clear understanding of their immediate and underlying causes.
- Good investigations can provide unique opportunities for achieving learning and change in organisations. As well as yielding important lessons which can help prevent recurrence of accidents and incidents, investigation can be a powerful educational experience for those directly involved, for example, by improving understanding of health and safety management principles and embedding the resulting lessons in the corporate memory .
- The 'Woolf ' civil litigation reforms, which now require full and early disclosure of the facts following accidents (for the purpose of deciding compensation claims), have helped to remove some of the barriers to a full and open approach to learning from prevention failures.
- In August 2000 the Health and Safety Commission (HSC) initiated a discussion exercise on accident investigation and subsequently published a consultation document setting out proposals for a more explicit legal requirement for employers to investigate notifiable accidents, dangerous occurrences and notifiable occupational diseases.
- Recent research Commissioned by the Health and Safety Executive (HSE) has confirmed that most accidents are not investigated and that much investigation is of poor quality (HSE Contract Research Report CRR 344: 'Accident investigation, the drivers, methods and outcomes'. June 2001.
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