Employee prosecuted for workplace fall

In a recent Western Australian prosecution, the operations manager of a roofing company was prosecuted and fined $7,500.00 after a worker fell about 5 metres, through a skylight.

The worker suffered serious injuries, and was lucky not to be killed.

The operations manager, Charles Farmer, was prosecuted under section 20(1)(b) of the Occupational safety and Health Act, as an employee who “failed to take reasonable care to avoid adversely affecting the safety or health of any other person through any act or omission at work, and by that failure caused serious harm to a person“.

According to the prosecution summary, although Mr Farmer had identified the skylights on the existing portal frame roof, he did not ensure that a safe working procedure was in place that required the workers to use a fall injury prevention system.

You can access the prosecution summary HERE.

If you would like information about employee obligations for safety and health, I have developed an online training program, and you can find out the details at the link below:

Online training programs

 

 

What we say matters: Zero and other Aspirations

It seems hardly a day goes by without social media raising a new discussion about the merits or otherwise of “Zero Harm”.

As I understand the various arguments “for” and “against”, there seemed to be three broad categories of argument (although I do not discount further or additional arguments).

One argument says that Zero Harm is not a target, or a goal, rather it is an aspiration – something to pursue.  If I may be so bold as to paraphrase Prof Andrew Hopkins, it is like a state of grace – something to be striven for, but never truly achieved.

Another argument, more of a middle ground, articulates that Zero Harm is “okay”, but may have an unintended consequence of driving adverse behaviour.  In particular, it is argued that Zero Harm causes individuals and organisations to hide incidents or manipulate injury data in support of an organisation’s “zero” targets.

Yet another argument says that the language of zero is totally corrosive and destructive.  It argues  the language of zero  – amongst other things – primes a discourse that is anti-learning and anti-community (See, For the Love of Zero by Dr Robert Long).

I would like to use this article to discuss two matters.  First, the Safety Paradox in the context of aspirational statements, only using “zero” as a starting example.  Second, to demonstrate how aspirational statements can be used against organisations.  Both these points are closely related but ultimately, I want to argue whatever your “aspirations” you need to have “assurance” about the effect they have on your business.

The Safety Paradox is a concept I have been exploring for some time now.  The Safety Paradox supposes that our safety initiatives have within them the potential to improve safety and cause harm.

In my view, the single biggest weakness in modern safety management is the assumption that safety management initiatives are “good“.  I have no doubt that the proponents of Zero Harm suffer from this assumption.

The question of whether Zero Harm is good or bad is, on one view, totally irrelevant.  If you are a Zero Harm organisation the only thing that really matters is the impact Zero Harm has in your workplace.

  • What is the purpose of Zero Harm in your organisation?
  • How do you demonstrate that Zero Harm achieves this purpose?
  • How do you evidence that Zero Harm does not undermine safety in the way that many commentators suggest?

My personal experience with Zero Harm means that I remain unconvinced of its benefits, but I do not feel I am closed to being persuaded otherwise, it is just that I have never worked with an organisation that has been able to address the three questions proposed above.  Moreover, in my experience, there is usually a significant disconnect between corporate intentions and operational reality: What management think is going on is often very different from what the workforce believes.

Considering all the published criticism of Zero Harm as a concept, I do not think it is unfair that the onus should be on Zero Harm organisations – including government regulators – to demonstrate that Zero Harm achieves its intended purpose and does not have a negative impact on safety.

Now, this is more than a matter of semantics.  Aspirational statements can, and are used against individuals and organisations.

On 21 August 2009 and uncontrolled release of hydrocarbons occurred on the West Atlas drilling rig operating off the North-West coast of Australia.  The incident reawakened the Australian Public to the dangers of offshore oil and gas production, leading to a Commission of Inquiry into the event.

During the Commission the aspirational statements of one organisation was used against an individual.  The criticism was that a contractor had removed a piece of safety critical hardware, but not replaced it, and had not been directed by the relevant individual to replace it.

There was some discussion about a presentation provided by the organisation, and that resulted in the following exchange.

Montara slide

Q: All right. If the operator could go to page 0004 of this document, that overhead, which is part of the induction training of drilling supervisors, is entitled “Standards”. Do you see that?

A: Yes.

Q: If you could read what is said there, you would agree it captures, if you like, a profound truth?

A: Yes.

Q: Do you agree that that is a truth not simply applicable to drilling supervisors but also applicable to PTT management onshore?

A: Yes.

Q: I want to suggest to you, sir, that your decision not to instruct Mr O’Shea or Mr Wishart to reinstall the 9-5/8″ PCC represents a very significant departure from what is described on that screen.

A: Yes, I can concede that.

Q: Without wishing to labour the point, your decision not to insist upon the reinstallation of the 9-5/8″ PCC was a failure in both leadership and management on your part?

A: Yes, that’s what it seems now.

Q: With respect, sir, I’m suggesting to you that, faced with the circumstances you were, your deference, as it were, to not treading on the toes of the rig personnel and insisting on the reinstallation was, at that point in time, a failure in leadership and management on your part.

A: I will accept that.

How many of these untested platitudes infect organisations, waiting for the opportunity to expose the business to ridicule and criticism?

Or consider if you will, the following scenario. An employee is dismissed for breaching mobile phone requirements when his mobile phone was found in the cabin of the truck he had been operating.

The employee bought an unfair dismissal claim and the presiding tribunal found that there was a valid reason to terminate his employment.  However, the tribunal also found that the termination was unfair for several procedural reasons. In part, the tribunal relied on the level of training and information that the employee had been provided about the relevant procedure.

The training documentation provided did not clearly demonstrate that employees were trained in this new procedure and signed accordingly, or that it was given a significant roll-out to employees commensurate with their ‘zero tolerance’ attitude to incidents of breaches, given how this case has been pursued (my emphasis added).

If you are going to have a “Zero” aspiration, that has to be reflected in your business practices. It seldom is.

What I think these examples illustrate is an inherent weakness in the way health and safety is managed.  We, as an industry, are overwhelmingly concerned with “how” we manage health and safety risks without paying anything like enough attention to whether the “how” works.

Do all of our aspirations and activities actually manage health and safety risks, or are we just keep keeping people busy or worse, wasting their time?  As importantly, how do we know our initiatives are not part of the problem?

BP’s corporate management mandated numerous initiatives that applied to the U.S. refineries and that, while well-intentioned, have Baker panel reviewoverloaded personnel at BP’s U.S. refineries. This “initiative overload” may have undermined process safety performance at the U.S. refineries (The Report of the BP US Refineries Independent Safety Review Panel (Baker Panel Review), page xii).

There is no doubt that safety is not the only management discipline that suffers from these deficiencies: “style over substance” and “window dressing”.  But if we claim the high moral ground of protecting human health and life, then perhaps the onus on us to show what we do works, is also higher.

Self incrimination in internal investigations: Is this really a thing?

If you have followed my thoughts over the past few years, you will know that one of my concerns about the increasing emphasis on legal sanctions and penalties for health and safety breaches is the likely increase in legal risk management strategies at the expense of health and safety management. (See for example: $450,000: Is this what we want from prosecutions?; Is this really what due diligence was designed for?; Rethinking safety prosecutions part 2)

This concern has poked its head up again in the recent Federal Court decision, Grant v BHP Coal Pty Ltd (No 2) [2015] FCA 1374. The case dealt with important issues about the rights of an employer to insist employees undertake a medical assessment with a doctor of the employer’s choice, a topic that has pervaded the management of injured workers for many years.

This topic is important and serious, and it has implications for both employees and employers. But the case also touched on another, far less well understood issue – the rights of employees to claim to self incrimination and refuse to answer questions in a company’s internal safety investigation.

Does an employee have a legal right refuse to participate in your internal incident investigations on the basis that in doing so, they may expose themselves to the threat of prosecution?

The protection against self incrimination has long been recognised in health and safety legislation. Legislation recognises the difference between “voluntary” interviews and “compelled” interviews. In the latter case, information provided to a regulator during a compelled interview cannot be used against the person providing the information, except in very limited circumstances, such as perjury.

In the Grant case, the employee had been terminated following a long running dispute over his capacity to return to work. As part of that process, Mr Grant attended an interview about his refusal to attend a medical appointment with a company nominated doctor.  During that interview, Mr Grant refused to answer questions unless they were put to him in writing.

During the various appeal stages of his case, Mr Grant asserted that he has refused to cooperate in the investigation on the basis of his privilege against self incrimination.

The Federal Court noted at [106]:

Privilege against self-incrimination means that a witness cannot be compelled to answer questions that may show the witness has committed a crime with which the witness may be charged if the answers may place the witness in real and appreciable danger of conviction:  Sorby v The Commonwealth (1983) 152 CLR 281 at 294.

The Federal Court went on to confirm the privilege against self incrimination :

  • Can apply to questions asked by an employer [108]; and
  • Can apply to questions asked during a workplace interview that have implications for a persons liability under health and safety legislation [108].

Unfortunately the Federal Court said that they could not decide the issue on the facts of the case. Or more eloquently, they said they could not decide it in “such a vacuum of facts” [110].

The Court did not need to decide the question of self incrimination to decide the case, but clearly reinforced its relevance in workplaces.

Of course, the next question that follows, is what is an employers rights in relation to an employee who refuses to participate in an investigation on the basis of self incrimination? Can they discipline them? Can they terminate their employment?

I do not want to try and give a definitive answer here, but it is at least arguable that any “adverse action” taken against an employee because they were exercising a legal right could amount to a breach of the General Protection provisions of the Fair Work Act, and leave the employer liable to penalties.

If the purpose of health and safety legislation is to help ensure safer workplaces, in my view, there is a need for constant vigilance to understand when the legislation undermines, as opposed to promotes, better safety management. If the legal risks have become so acute that employees no longer need to cooperate with safety investigations, it may at least be time for a discussion on the merits of penalties and prosecutions.

 

 

 

 

Safety leadership: enabler, excuse or doing harm?

I do not think that there is any serious view suggesting that “leadership” is not an important, if not the most important driver of safety performance.  One of the main findings from a 2002 review of Safety Culture was:

…  management was the key influence of an organisation’s safety culture. A review of the safety climate literature revealed that employees’ perceptions of management’s attitudes and behaviours towards safety, production and issues such as planning, discipline etc. was the most useful measurement of an organisation’s safety climate. The research indicated that different levels of management may influence health and safety in different ways, for example managers through communication and supervisors by how fairly they interact with workers (Thompson, 1998). Thus, the key area for any intervention of an organisation’s health and safety policy should be management’s commitment and actions towards safety (Safety Culture: A review of the literature).

In the wake of findings like these, and numerous others, it is unsurprising that safety leadership often dominates discussions about safety management.

But are there conversations about safety leadership that we are not having and should be?

To my mind, the hard work in health and safety management is understanding if, or the extent to which, health and safety risks in our business are being controlled.  All too often, however, in my experience “leadership” is an excuse to avoid the hard work of health and safety management.

The “psychology” (and I use that term as a complete layperson) of safety leadership seems to be that if I can convince my workforce that I genuinely care for them and that safety is genuinely important, then safety will take care of itself.

If I “care“, if I am a “safety leader” I do not need to do the hard work to critically challenge incident investigations, I do not need to analyse, understand and challenge audits.  If I am a “safety leader” then I can accept declining personal injury rates and green traffic lights on my corporate scorecard as evidence that my safety management system is working, without ever having to challenge the assumptions that underpinned that information.  Assumptions that have been shown time and again to be wrong.

This is the same discourse that threaded its way through safety culture: It doesn’t matter how bad our management systems are because we have a good “culture“.   It is also the same discourse that is starting to creep into the next wave of safety thinking, concepts like “safety differently” and “appreciative enquiry“.

I make no comment on the efficacy of leadership, culture, safety differently, appreciative enquiry or whatever the next trend will be but I do question where, in any of these concepts, we do the hard work of confirming that our risks are being controlled.

I recall many years ago reviewing a matter where a worker sent a hazardous substance through the internal mail using a yellow into office envelope (back when they existed).  The worker broke every one of the organisations procedures and protocols for managing hazardous substances, yet the organisation viewed this dangerous  event as a triumph of their “culture“, because the worker “cared“.

The twisted logic where organisations use leadership or culture to wallpaper over the cracks of ineffective safety management systems, and actively avoid the hard work of understanding if their risks are being controlled,  is very often bought into stark relief following a disaster.

The next time you are in a meeting discussing safety management  listen to see if leadership or culture is being used as an avoidance strategy.  Are the difficult topics such as improving the quality of incident investigation or clarifying complex and bureaucratic safety management systems  or improving risk assessments bypassed with comments like:

we just need to get out and be seen more

or

we just need to spend more time in the field talking to the blokes

 Is this leadership or an excuse to avoid the hard work?

Over and above  avoiding what really needs to be done, is it possible that the things we do in the name of “leadership” have the potential to actively undermine safety in our organisations?

Whatever your “leadership” objective might be, whether it is to demonstrate commitment, to understand the work being performed in your organisation, to appreciate what might be preventing people from complying with safety procedures or any other objective, how do you know that your actions in the name of leadership are achieving those objectives?   Because for all your good intentions there is a real risk that your presence in the field talking about safety might have the opposite effect.  It might promote cynicism amongst your workforce, it might disengage them from your safety message.

You may be seen as a leader whose only concern is to cover their own backside and who obsesses over safety issues important to you, without really listening to the concerns of the workforce.

How do you know if your safety leadership works?

I think that much of what is done in the name of safety and health has, consciously or unconsciously, devolved into “window dressing“.   Much of what we do is held up to the public or to our workforce as evidence of our commitment to safety, yet the substantive hard work necessary to understand if our health and safety risks are being managed remains undone – the façade of health and safety management is attractive but the building is crumbling.

Safety leadership and related concepts of care and culture have a place.  More than that, they are critically important.  But they are not buzzwords to be lightly tossed around and as a critical process, leadership deserves the same level of scrutiny and analysis as any of your other critical processes.

Demonstrating compliance: The SD Tillett case

I recently posted an article about the way health and safety is measured and reported in organisations.  In the article, I argued that many of the indicators that we used to understand how well health and safety risks are managed in our business are measures of activity and provide no real assurance that health and safety risks are being managed.  I suggested that the assumptions that are drawn from these indicators create a dangerous illusion of safety – because all our indicators are green”, we assume our risks are managed.

The article prompted a lot of discussion and several questions about how health and safety are measured and how organisations might better understand if their health and safety risks are being managed.

I thought it would be helpful to further the debate by looking at a few cases where organisations have met their legal obligations, even though there was an accident to try and understand the sorts of factors that are considered.

In this article, I want to look at the decision of Moore v SD Tillett Memorials Pty Ltd [2002] SAIRC 47, a decision of the South Australian Industrial Relations Court.

On 21 December 1999, an employee, Mr Bacon was helping another employee, Graham Muscat, move an “A” frame loaded with approximately seven granite sheets.  The men were moving the granite sheets using a forklift.

Mr Bacon died when the granite sheets loaded on the ‘A’ frame fell, trapping him between the granite sheets and a metal table.

The defendant company, SD Tillett Memorials Pty Ltd was charged as follows:

On the 21st day of December 1999 at Hindmarsh in the said State, being an employer, failed to ensure so far as was reasonably practicable that its employee, namely Craig Anthony Bacon, was, whilst at work, safe from injury and risk to health and, in particular:

(a)     failed to provide and maintain so far as was reasonably practicable a safe system of work; and

(b)     failed to provide such information instruction training and supervision as were reasonably necessary to ensure that the employee was safe from injury and risks to health.

The particulars of the charge, that is the precise allegations were that SD Tillett failed to:

·         Provide and maintain a safe system for the movement of ‘A’ frames loaded with granite sheets.

·         Provide and maintain a safe system for the loading and storage of granite sheets on ‘A’ frames.

·         Provide adequate information instruction and training to Graham Muscat will about the safe movement of “A” frames loaded with granite sheets.

·         Provide adequate supervision for the employee and Graham Muscat.

·         Provide adequate information instruction and training to the Operations Manager, Stephen Tanner about the loading and storage of granite sheets on ‘A’ frames.

The process for moving the granite sheets required them to be secured using a strapping.  When Mr Bacon died, the slabs had not been strapped in accordance with what was described as a “standard operating procedure”.  While there was some discussion about a memorandum setting out this standard operating procedure, it was not produced in the trial period

Earlier in the day, there had been an incident where slabs had not been strapped, and disciplinary action was taken against the work involved.

There is no discussion in the case about SD Tillett’s injury rates or any other lead or lag indicators used to measure health and safety.

The evidence at the hearing came from the workers.  In all but one case, that evidence was consistent.  The evidence confirmed that all the workers understood the requirements to strap the granite, and this was a requirement that was continually reinforced by the operations manager Mr Tanner.  The Court said:

… there is a common thread through the evidence of those witnesses that there was a continuous verbal reinforcement of the requirement to strap loaded “A” frames.

The only person who said he was not aware of the prohibition against moving the granite without strapping was the driver of the forklift, Mr Muscat.  In relation to his evidence, the Court said:

It is my view that Muscat has tried to cover up the system of work that he adopted at the time of the incident. His denial of any rule about strapping loaded “A” frames is contrary to the evidence of all the other witnesses who were either former employees or current employees of the defendant.

With respect to the written standard operating procedure or memorandum, although the document was not produced at the trial, the Court formed the view that the procedures had been committed in writing, because all the witnesses gave evidence that they had seen a written procedure or memorandum.  The prosecution then argued that a written record should have been made of who had received the document.  In response to this, the Court said:

This is of course desirable but what would it have achieved against a background of constant verbal reinforcement? Recording who received the document had not been carried out in the past although there was a universal awareness of the document by the employees and former employees save and except for Muscat. As I have indicated I find that the evidence of Muscat is unreliable.

This proposition is in quite stark contrast to what we normally see.  Here we have witnesses who clearly understand the safe procedures are doing the work, even though a documented procedure could not be produced.  Normally, we are faced with a position with a documented procedure can be produced, but nobody understands it or complies with it.

The preponderance of evidence in the case was that the employees were aware of the requirement to strap the granite before moving it using a forklift, there was constant verbal reinforcement of this requirement, and disciplinary action was taken against employees who did not comply with this requirement.  In the face of this evidence, the Court found:

I find on the totality of the evidence led by the prosecution that it has not discharged the onus of proving beyond reasonable doubt that there were one or more measures which the defendant may have reasonably practicably taken but did not take which would have eliminated or ameliorated the risk.

I find that there were constant verbal directions to strap loaded “A” frame pallets before any movement. The responsibility for the incident lies not with the defendant but elsewhere.

I therefore find the defendant not guilty.

This case reinforces that it is incumbent on an employer to be able to demonstrate that they have proper systems in place to manage the health and safety risks in their business and that those systems are implemented, understood, constantly applied and enforced.

 The inherent weakness in most health and safety reporting is it does not confirm any of these matters.

Injury rates do not give us this information.  The number of action items that have been closed out does not give us this information.  The number of management walk arounds or “interactions” does not give us this information.

Let me address the obvious objection at this point.  In my view, this is not just about legal compliance.  If an organisation does not have effective assurance that they have proper systems in place to manage the health and safety risks in their business and that those systems are implemented, understood, constantly applied and enforced how can they have any comfort that health and safety risks are being managed?

In my view, it is beyond argument that health and safety reporting needs to move beyond measures of injury rates and “activity” and start to provide positive assurance the critical health and safety risks are being managed.

 

 

 

Welcome to the intellectual vacuum that is political comment on WHS

Today (29 October 2016) the ABC had an article on the ongoing coverage of the tragic loss of lives at Dreamworld in Queensland.

I have commented before about the disconnect between the loss of life in this workplace accident and the near weekly loss of life in Australian workplaces that the coverage of this incident highlights. That disconnect was underscored by a picture of the Federal Opposition Leader, Bill Shorten, laying flowers outside Dreamworld. I do not begrudge Mr Shorten the opportunity to express his condolences (or advance his political position depending on your level of cynicism), but I cannot recall too many times political leaders have given similar public displays of solidarity when people die at our construction, mining, agricultural or any other workplaces.

But what has prompted this article is the simplistic, reactive, leaderless response that politicians trot out in the face of these types of events.

The ABC Article reports Queensland Premier Annastacia Palaszczuk as saying:

“It is simply not enough for us to be compliant with our current laws, we need to be sure our laws keep pace with international research and new technologies,”

“The audit will also consider whether existing penalties are sufficient to act as deterrents, and whether these should be strengthened to contain provisions relating to gross negligence causing death.

“Because we all know how important workplace safety is and how important it is to have strong deterrents.

“That’s why Queensland has the best record in Australia at prosecuting employers for negligence – and we are now examining current regulations to see if there are any further measures we can take to discourage unsafe practices.”

The idea that we “should not be compliant with our current laws” is both a nonsense and a failure of policy makers to properly accept the findings of the Robens Report published in the mid-1970’s. The reason our laws cannot keep pace with “international research and new technologies”, is because governments continue to insist on producing highly prescriptive suites of regulation which in most cases are adopted by organisations as the benchmark for “reasonably practicable”.

For most businesses, particularly small and medium-sized businesses, technical compliance with regulation is the high-water mark of safety management – an approach reinforced by the “checkbox” compliance mentality of many regulators.

WHS legislation is a leading example of this failure of policy, in so far as it increased the number of regulations in most of the jurisdictions where it has been implemented.

Flexible, innovative safety management requires a regulatory framework that promotes it, not limits or discourages it.  How can a regulator have any credibility when it calls on industry to keep pace with “international research”, when it continues to define safety performance through the publication of lost time and other lag injury rates?

Ms Palaszczuk then adopts the standard “tough on safety” call to arms, without taking the time to recognise inherent contradictions in what she is saying. She boasts that “Queensland has the best record in Australia at prosecuting employers for negligence”, but hints at tougher penalties still.

If the considerable penalties under the WHS Legislation and the “best record” of prosecuting employers are not a sufficient deterrent, why would “tougher” and “better” be any different?

I have written about these types of matters before, and would just ask that before policymakers go charging off in pursuit of higher penalties and more prosecutions, we stop and take the time to see if this tragedy can provide the opportunity lost during harmonisation and introduction of WHS legislation.

That lost opportunity was a chance to stop and consider the way that we regulate and manage health and safety in this country.

And can we start with the question of whether criminalising health and safety breaches and managing safety through a culture of fear driven by high fines and penalties is the best way to achieve the safety outcomes we want?

What is the evidence proving high penalties and prosecutions improve safety outcomes?

Are there ways that we can regulate safety to provide significant deterrents and consequences for people who disregard health and safety in the workplace, but at the same time foster a culture of openness, sharing and a willingness to learn and improve?

Can we redirect the time, money, expertise and resources that are poured into enforcement, prosecution and defending legal proceedings in a way that adds genuine value as opposed to headline value?

This is a chance to stop and think. This is a chance for the health and safety industry to stand up, intervene and take a leadership role in health and safety.

If we do not, the intellectual vacuum will continue to be filled by the historical approaches that have brought us to where we are today.

Work as it is actually performed: investigating when nothing happens

There has been some discussions and commentary in various online forums recently looking at the issue of “positive” incident investigations.  Although there seems to be a variety of nuances in the description of positive investigations they focus on “what went right“.

Some of these investigation models have also incorporated a broader management technique of “appreciative enquiry“, which, as I understand it, came to prominence in the late 1980’s (see HERE for examples and information about appreciative enquiry).

The discussion about these frameworks describes the “what went right” philosophy as a positive view of investigations. It is a philosophy that does not focus on blame, but promotes discussion:

The benefit of that approach is that the conversation with witnesses is an entirely positive one. It is not about what could have happened. Not about the doom and gloom narrowly averted. Rather, it is about their heroic act, well designed process or lucky event that allowed us to avoid the adverse outcome. People love talking about positive things particularly if they had something to do with them. (https://www.linkedin.com/pulse/investigate-your-serious-near-misses-positive-way-michael-tooma?trk=prof-post)

 In my view, when organisations are not mature enough to talk about issues in a non-judgmental way, without attribution of blame, the “what went right” enquiry may present a risk.  It may be seen as a contrivance, with the facilitator spending a lot of their time saying things like “remember this is not about blame“.

In “mature” organisations the need to construct a system of enquiry to focus on the positive and avoid discussion of blame is largely redundant because the participants are aligned with and support the goals of the organisation.  Their desire to support the goals of the organisation overrides any petty, personal concerns about individual praise or blame.

If you have ever been privileged enough to work with high-performance sporting teams or elite military forces, you will understand this idea.

A precondition of belonging to these groups is the willingness to say and hear things that support the group’s objectives without personal agendas or taking personal affront.  The newest member of the team has a license to speak frankly about the performance of the most senior, and the most senior is expected to accept that conversation, not in the context of them personally, but in the context of the overall objectives of the team.

The extent to which organisations have to contrive a system whereby participants are corralled by a “what went right” narrative says a lot about the culture of an organisation and the “buy in” that people have to team objectives.

That is not to say that appreciative enquiry or investigating “what went right” does not have a place in organisations, nor that it could be an important building block along the way to developing something like an elite performing team.  But as a word of caution, you should also understand some of the paradoxes involved.

The Safety Paradox supposes that any initiative done in the name of health and safety has the potential to both improve and damage health and safety in a workplace.

Having sat through appreciative enquiry “management brainstorming sessions” and incident investigations there is a strong sense of “flavour of the month” initiative as well as an even stronger sense of avoiding accountability.  An overriding impression of a process delivered without context or explanation – why this and why now?  The end product is a wall of butcher’s paper populated with sweeping motherhood statements and management speak, completely absent any meaningful desire to manage known problems.

The pendulum, it seemed, had swung too far the other way.

Again, that is not to say it is not an idea that should not be explored and applied.  But it needs context.  It needs explanation; it needs skilful facilitation, and it needs, perhaps most importantly, dedicated and meaningful follow-up with implementation.  Otherwise?  Well, we have all been in “those” types of sessions.

Another aspect of the “what went right” investigations is the requirement for something to have occurred.  There needs to be an incident or near miss to trigger the enquiry.

A risk in the “what went right” enquiry (without more) is that it can contribute to the illusion of safety.

The illusion of safety is the gap between safety management as we imagine it in our organisation and what happens in practice.  Incident investigations can be a powerful tool in exposing the illusion of safety because they have the potential to illustrate the disconnect between what we think happens and what is happening.  By just focusing on “what went right“, particularly in near miss incidents, we may fuel the illusion of safety and create a narrative that our systems are working to protect us from these incidents – effectively papering over the cracks in the edifice.

While avoiding blame and promoting open discussion is important, so too is avoiding sugar-coating the situation.  Again, balance, transparency and genuine enquiry ought to be the goal.

I would like to suggest something different – investigating work as it is performed; investigating when nothing happens.

An investigation framework that I find useful uses systems as opposed to causal analysis.

It supposes that organisations have systems and processes in place to prevent certain things from happening and tries to understand:

  1. What should have happened: how should these are systems and processes have been applied in a particular case to prevent the particular thing from happening; and
  2.  What happened: how was the work performed in the particular case.

From there, we identify and try to explain the “gap” between what should have happened and what did happen.

This framework is not concerned with “causation“.  All identified gaps are given equal attention and analysis, regardless of their potential causal relationship with the incident.  They are all important because they all represent a potential systemic weakness in safety management which, given a different factual matrix, could be causal.

The attractiveness of this framework is that it can help you identify systemic weakness when nothing has happened.

A few years ago I was involved in an incident leading to the prosecution of a client following a working at heights incident.  The incident and the various investigations that followed revealed the usual list of suspects:

  •  Training not followed;
  •  Procedures not followed;
  •  Risks not identified;
  •  Lack of supervision;
  •  Documentation not completed properly, and so on.

As part of working with that client, we applied the systems analysis framework to a range of other, similar high-risk work, including:

  •  Examples where the same task had been performed;
  •  Examples of different working at heights tasks; and
  •  Examples of other high-risk work tasks, including lifting operations and confined space entry.

In every case, the work had been performed “successfully“, without incident or near miss.

However, the analysis of the gap between how the work should have been performed and how it was performed demonstrated the same types of “failures” in the way that work was ordinarily performed as when the incident occurred.

In other words, even when work was “successful”, procedures were not followed, risks were not identified as well as they could have been, training was not complied with, documentation was not completed and so on.

The systemic weaknesses were not just present at the time of the incident.  They were characteristic of the way work was performed in the days and months previously.

The incident was not a one-off departure from an otherwise “good” system – it was simply evidence of otherwise broader, systemic failures.

Moreover, this system analysis approach highlighted weaknesses hidden by the traditional safety metrics – injury rates, action items closed out, hazards reported, management site visits, etc. – all of which were “green“.

I have applied this method of review from time to time over the years where I have been able to convince clients of its value.  On every occasion it brings to light the gap between the safety as imagined and safety in practice, lifting the veil on the illusion of safety.

In the Pike River Royal Commission, the Commission carefully examined Pike River’s system of incident investigation to understand if it “worked“.  They reviewed 1083 incident investigations and did a detailed examination of 436 of them.  Managers were subject to examination of their understanding of the investigation process, and ultimately the Commission found that “incidents were never properly investigated“.

You can see an example of the examination of management HERE.

Weakness in incident investigations, amongst other important systems elements, formed the basis of significant criticism of Pike River and its management:

 Ultimately, the worth of a system depends on whether health and safety is taken seriously by everyone throughout an organisation; that it is accorded the attention that the Health and Safety in Employment Act 1992 demands.  Problems in relation to risk assessment, incident investigation, information evaluation and reporting, among others, indicate to the commission that the health and safety management was not taken seriously enough at Pike.

 What do your philosophy and implementation of incident investigations say about you?