Simplicity in Safety Investigations by Ian Long

Author:Ian Long
Language: eng
Format: epub
Publisher: Taylor & Francis

Sustainable

One thing that often happens is investigation teams create actions that have no life beyond the immediate. Having a sustainable action means having one that will still exist in a year’s time or longer. They are generally systems-based. They are not necessarily an addition to a procedure but embedded somehow in the way that we do work. It could be changing some training or induction material or process. An example of an action that is not sustainable is “send a message at the next round of safety talks to remind the workers to be more careful”.

A word or two of caution for the newbie to incident investigations: watch out for actions that seem simple and common, but are actually wholly ineffective. Examples that come to mind include statements like: “Retrain those involved in the incident”, “Retrain the work force in risk management” or “Reinforce the importance of safety to the workforce”.

With respect to the first two examples, it has become commonplace over the years to use ‘training’ as a corrective action. Although it appears easy, there are a couple of reasons why it is usually useless. One is that the person at the centre of the investigation is by now fully aware of their ‘failing’ and certainly does not need to sit through another training session on the topic. The second is that training everybody else will just annoy them and cause frustration in the workplace. If the training was not effective the first time, why should it be any different this time? Keeping this in mind, the only time training should rate a mention in a list of corrective actions is if the investigation has identified problems with the training itself. The action would then be about fixing the training, not automatically repeating it and expecting a different outcome. The third example of an ineffective action is also, sadly, very common. I often see actions that are motherhood statements and not actions at all. These sorts of corrective actions should get picked up when exploring whether the action is measurable, as part of the SMARTS stage, but they often slip through.

The fundamental rules for assigning corrective actions – which must be followed in every case – are to make sure the person is aware of the action, agrees that they are the best person accountable for its completion and understands the context and purpose of the corrective action. We too often see actions fail because they are assigned to the wrong person – someone who is not interested in the action and has no context of why the action needs doing in the first place.

One more thing: avoid human resources actions in a safety incident investigation. Most organizations have models for ‘Just Culture’ or ‘Fair Play’ and processes designed to apportion blame – ranging from culpable individual action to organizational fault. Generally, these processes are neither just nor fair. They are inconsistently applied across departments and used to justify written warnings and sackings. They are not about accountability at all.

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