How Could It Have Happened Again?
You would think that having a significant incident resulting in a fatality would result in a thorough investigation, with robust recommendations implemented to ensure that it could never happen again… You would think…
However, on a few occasions I’ve been called back to a site after an initial fatality because they have had a repeat event. As an Accident Investigator, whose primary aim is always prevention of recurrence and reduction of risk, it’s like a kick in the guts to hear that the initial investigation has not prevented a repeat incident. What makes it worse is finding out that the reasons for this were so simple to overcome, but were not recognised.
So how it could happen? Well, in my experience, these are the top reasons why investigations fail to meet the desired outcome of prevention of recurrence.
Recommendations / Actions on paper were not actually implemented as there was no accountability – the actions were not allocated to specific personnel / roles and effectively “floated” in the system.
No clear deadlines were set to complete actions, resulting in them remaining on someone’s “To Do” list (in one case I saw actions following a fatality had been on a “To Do” list for a three year period).
Easy, quick actions were focused on (ie. issuing Safety Alerts, amending Procedures or giving people a bit more training), however, higher level actions were put in the “too hard basket” as there was a focus back on operations / production.
Corrective actions that had been initially implemented, were not maintained. The focus and activity following a fatality seems to result in dedicated resources and effort, but as time goes on the system / controls appear to sometimes gradually erode back to the state it was in at the time of the initial significant event.
Loss of corporate history and high personnel turnover results in a loss of reasons why system changes were made and they gradually revert back to the way things were operating at the time.
A conflict exists in that from a business perspective legal counsel advocate organisations keep information restricted pending possible prosecution / litigation – which therefore means information is not communicated to the workforce as safety learning's.
Learning From Incidents
In the 1980’s I read an article published by the Flight Safety Foundation and saw a short quote about learning from incidents that resonated with me to such an extent that I got one of the typing pool ladies (yes, showing my age there…) to type it out for me and I’ve had this quote up on every office wall I’ve ever worked at. The quote read:
“To have an accident is unfortunate, to have an accident and learn nothing from it is unforgivable.”
To me, this quote reflects the true essence of what an investigation is all about. Learning from adverse events is the raison d'être - the most important purpose of an Accident Investigation.
Any incident is unfortunate, whether it result in equipment damage, environmental impact, interruption to normal operations or, in the worst possible case, injury or death. Our goal as an Accident Investigator is to ensure the organisation learns from these unfortunate events.
It’s not enough to produce a high quality investigation incident report into what happened, why it happened and how an incident could be prevented in the future. I see many organisations tick the boxes that the investigation is complete after the approving officer signs off on it.
It has to be recognised that the incident investigation is not truly over until we can verify that:
a) the recommendations were implemented; and
b) the recommendations were effective. Only when the actions are in place operationally, can we assess if they met the intent we had.
To see that Recommendations, on paper, appeared to be effective, robust controls that addressed all the contributing factors identified in the investigation and could have prevented a repeat incident…but were never actually implemented, leaving the door open for a repeat significant incident…is tragic and truly unforgivable.
Interested in Knowing More?
Further information on Safety Wise’s Incident Cause Analysis (ICAM) Training is available from our website: http://www.safetywise.com/
Additional ICAM Related Services
Safety Wise also offers the following additional services for sites that adopt the ICAM investigation analysis method:
Quality review of incident investigations using ICAM
Trend analysis of organisational factors contributing to serious incidents
Participation in investigations as an external / independent party
ABOUT THE AUTHOR- Jo De Landre (Executive General Manager)
After 15 years with the Bureau of Air Safety Investigation (BASI),which became part of the multi-modal Australian Transport Safety Bureau (ATSB), Jo started co-facilitating ICAM training with Safety Wise in 2001 as the Principal Human Factors Consultant.
In 2005, Jo was promoted to the position of Executive General Manager of Safety Wise and beyond providing human factors specialist services and ICAM training and Investigations, she is now involved in strategic activities such as project management and developing safety management programs.
Jo has been the Safety Wise Lead Investigator for many high profile accidents, including multiple fatality investigations. She has a Bachelor’s Degree in Applied Psychology and a Graduate Diploma of Psychology, and has published papers in aviation, mining and police journals and publications.
Joanne has also been Secretary of the Australian Aviation Psychology Association (AAvPA) for close to a decade.