Learning from safety failure
The following prompt list has been developed by RoSPA to help 'competent persons' in organisations check out where they are now:
Ten point prompt list – Accident investigation
1. Commitment to learning
Does everyone understand and accept that the organisation is fully committed to learning from its health and safety failures (i.e. that it is more interested in learning lessons which can help it improve its management of OS&H than it is in merely allocating blame)?
Does every employee feel obliged and empowered to report promptly and accurately all accidents, incidents and safety significant issues, which come to their attention? (For example, are they actively encouraged to report errors and safety failures? Can they be confident that they will be valued for doing so? Do health and safety performance targets, for example, tend to act as a disincentive to reporting accidents and incidents?)
3. Scaling and terms of reference
Are there adequate and suitable processes and criteria (e.g. risk/consequence or learning potential) in place to enable the organisation to decide on the scale and depth of investigation and to draw up initial terms of reference? (Does the organisation simply scale its investigation response according to the severity of injury or does it consider the safety significance of the each accident or incident and its potential for improving safety in the future?)
4. Team-based approaches
To what extent does the organisation adopt an open, team based approach to investigation, with effective involvement of operative level employees, safety representatives, and supervisors, drawing on their practical knowledge and providing opportunities for them to learn more about safety and become champions for necessary safety change? (Is the team led by a manager with appropriate seniority?)
5. Training, guidance and support
Have all team members received necessary training and guidance to enable them to play their part effectively in the investigation process, for example, training in interview techniques? Is practical guidance and technical support available to the team from qualified H&S professionals?
6. Information gathering
How adequate are existing procedures in enabling investigators to gather necessary data following accidents and incidents - including for example: securing the scene, gathering essential physical and documentary evidence, taking photographs (for example, using digital cameras), interviewing witnesses etc?
7. Use of structured methods
Does the organisation make use, as appropriate, of structured methods to enable it to identify the circumstances of which the accident or incident is the outcome? Does it use such methods to help it integrate evidence, generate and test hypotheses and reach conclusions so it can make recommendations?
8. Immediate and underlying causes
Do investigations seek to identify and discriminate between immediate and underlying causes? Is there a clear link between the outcome of investigations and revision of risk assessments, for example, to establish if and why risk assessments for the activities concerned were inadequate, had not been properly implemented or had been allowed to degrade.
9. Communication and closure
Are there effective means in place to communicate conclusions back to stakeholders and to track closure? Is the implementation of recommendations managed to an agreed timetable with reporting back to the investigation team?
10. Reviewing investigation capability
Does the organisation undertake a periodic review of the adequacy of its approach to investigation with a view to improving its capability to learn lessons from accidents, incidents and OS&H problems and to embed these lessons in 'the corporate memory'?
Organisations that have difficulty in providing robust responses to these questions are strongly urged to review their current approach to learning from accidents.