“RED HERRINGS” IN WORKPLACE INCIDENT INVESTIGATIONS
“Red herrings” – the bane of any incident investigator’s life. The evidence that misleads or distracts us from the relevant facts and issues. All Investigators need to be wary that they are not led towards a false conclusion by these common, but potentially very damaging fallacies.
The term “red herrings” in itself is actually a misnomer. Did you know that in a literal sense, there is actually no such fish as a “red herring”? The herring itself is a small, oily fish that is commonly cured in brine and heavily smoked. This process makes the fish particularly pungent smelling. With strong enough brine, the flesh of the fish turns a dull reddish colour. So where did the term “red herring” originate from? Well, just like an incident investigation, the answer is not so simple and there are various theories behind the origins of the saying.
Some credit a news story in 1807 by an English journalist William Cobbett, who claimed that as a young boy he used red herrings (cured and salted) to train hunting hounds. Puppies were apparently initially trained to follow the scent of the pungent red herrings. Later, when the dog was being trained to follow the faint odour of a fox or badger, the trainer would drag a red herring perpendicular to the animal’s trail to confuse the dog. With enough training, apparently the hunting hound eventually learned to follow the original scent rather than the stronger scent of the red herring, thereby making it a very good hunting hound that wouldn’t get distracted during a hunt.
However, an alternate theory as to the origin of the term “red herring” was traced to an article on horsemanship in 1697 by Gerland Langbaine. The article recommended a method of training horses (not hounds) by dragging the carcass of a cat or fox so that the horse would be accustomed to following the chaos and smells of a hunting party. Langbaine stated in the article, “if a fresh, dead animal such as a cat or fox is not available, a red herring will do as a substitute”.
Whether the term referred to the training of hounds or horses, one thing that is clear is that the use of the red herring is a seemingly plausible, though ultimately irrelevant diversion that can mislead. It’s important to note that in incident investigations, the so called “red herrings” do not have to be intentional (ie. a conscious intent to mislead). They can also be unintentional due to flawed perceptions and incorrect information processing, which can result in erroneous information being conveyed and invalid conclusions being reached. This is why it is critical for Investigators to ensure that as far as possible, conclusions are based on evidence and information is not simply accepted at face value as demonstrated in the case study that follows.
INITIAL ON-SCENE INSPECTIONS
At Safety Wise, apart from providing training to our clients in the Incident Cause Analysis Method (ICAM), we also provide assistance with investigation facilitation. Usually, we get called in by our clients when they have had a significant event take place and they need assurance that the investigation is being conducted to a high standard.
When we arrive at a client’s site, the first thing that occurs (after we validate that the Emergency Management Plan has been activated and any hazards are totally controlled) is we get a briefing by site representatives on what they know about the incident so far. We then go out to look at the incident scene and conduct an initial inspection to establish what the incident scene looked like at the time, before things start to move and change too much.
So what do we focus on and look for when we first arrive at the incident scene? Valuable evidence can be gained from observations made at the scene of the incident, particularly if equipment remains in position. It’s also important to note that we don’t just focus in on the end incident site, but also look further afield for any conditions in the immediate area which could have contributed to the incident. Just some of the issues we may consider and examine during the initial on scene inspection include:
Position/s of injured workers
Positions of witnesses
Position and condition of equipment
Position of valves, switches and controls
State of guards and safety barriers
Illuminations, visibility, noise levels, trip hazards etc.
Any marks, artefacts on the ground or equipment etc.
DETECTING THE “RED HERRINGS”
Seeing the incident scene – conducting a site inspection is critical. It helps us really understand the what happened and put things in context. We know that witnesses during interviews are undoubtedly going to talk about specific equipment and landmarks for instance which we need to have seen beforehand to understand references and context.
Where ever possible, we try to validate information which is critical in detecting “red herrings” and ensuring the validity of findings. Remember – if we get distracted by erroneous information then our analysis may be incorrect, which will subsequently lead to recommendations that don’t achieve our goal of prevention of recurrence and reduction of risk.
Here’s an applied example. Imagine you’re called to an incident involving an interaction between a light vehicle and heavy vehicle on a mine site. As soon as you arrive, you validate that all personnel are accounted for, medical treatment has been initiated, all hazards are contained, relevant notifications have been made and that an adequate exclusion zone around the wreckage has been established. The Site Manager informs you that the initial response has been first rate and he personally has overseen the emergency response.
You are so used to having to request and wait for documentation and data when you turn up to an incident site, however, on this occasion you’re quite impressed when the Site Manager hands over documentation / evidence he has compiled in the time taken for you to travel to the site. You flick through the pile of information and see a Safe Working Procedure for driving operations on the site, a copy of the roster for the light vehicle and heavy vehicle drivers for the last six weeks, photographs of the incident scene during the emergency response and extraction of the two drivers, a list of names of those who responded and participated in the emergency response, a transcript of radio calls for access on to the road involved, maintenance / service records of the two vehicles, drug and alcohol initial testing results and a copy of the employment / service history of the two operators.
Before you can even start to thank him for this start to data collection, the Site Manager starts briefing you on some further background and what he knows so far about the sequence of events. He tells you that the two operators were on day four of their seven day swing, had clocked on to their shift at 0600 that day, had attended a pre-start briefing and then commenced operations as usual. He tells you that it was a crisp start to the morning, possibly about 5 degrees, but a fine, sunny day. He tells you both operators were quite experienced, having been with the company for over five years, and that neither had been involved in a previous incident.
The Site Manager proceeds to inform you that according to the radio logs, there was an emergency call at 0825 on Channel 1 by another heavy vehicle driver stating he had come across the accident near the access road to the processing plant. He tells you that the light vehicle driver was unconscious when found and later was assessed as being in a critical condition by the doctor on board the RACQ LifeFlight Rescue Helicopter which was called in. The heavy vehicle driver, although uninjured, was taken by road ambulance to the town hospital in a state of shock and had not yet spoken about what happened.
After giving a detailed account of the emergency response, the Site Manager then states “if you look at Photograph No. 5 that I took just near the heavy vehicle during the emergency response, you’ll see I came across a pool of reddish oil. So clearly, the heavy vehicle had a transmission leak which no doubt led to a transmission failure. He probably had trouble shifting and the transmission got stuck in a gear or shifted into the wrong gear”.
Before you can say “are you sure it was transmission fluid and are you sure that it came from the heavy vehicle?”, the Site Manager goes on to tell you about Photograph No. 6 which appeared to be skids marks in the dirt near the collision site. According to the Site Manager, “this is clear evidence that the light vehicle was exceeding the posted speed limit and when it came up behind the heavy vehicle, it swerved to the left and braked at speed to try and avoid a rear end collision with the heavy vehicle – which was obviously struggling to get into gear due to the transmission leak”.
The Site Manager thought he had it solved. He was confident and even quite proud that he had apparently worked it all out. He had seen the transmission fluid and immediately made a connection with the heavy vehicle. Which to give him some leeway, could be understandable. It’s a bit like that old saying that Dr Theodore Woodward from the University of Maryland coined in the late 1940’s “when you hear hoofbeats, think of horses, not zebras”. Or in other words, logic dictates that on most occasions, the most obvious conclusion can be confidently reached. However, in this case it was a zebra not a horse that our Site Manager should have focused on.
It turned out that the transmission leak and the skid marks were from the site ambulance that had responded to the incident. When I arrived at the Emergency Management Team building to interview the on-site paramedics who attended the incident with the site ambulance, I noticed immediately that there was cardboard on the parking bay floor where the ambulance was parked. The paramedic explained that they had noticed what they thought was a transmission leak two days prior but were waiting on the site mechanic to identify exactly where the leak was coming from. In the meantime, the cardboard was put down to avoid the leaking fluid staining the parking bay floor.
The paramedic stated that they had first detected a burning smell three days prior to the incident and the gears were grinding. He went on to tell me that handling of the ambulance had been a slight issue at low speed, but that morning when they responded to the incident they were travelling at high speed and as they approached the scene the gear appeared to stick and they actually skidded to a stop.
The “red herrings” of the skid marks and transmission fluid that distracted the Site Manager were easily explained when evidence was examined. I confirmed that the truck was not moved during the emergency response, looked at the location of the apparent transmission leak, then looked at other photographs of the rescue. I identified where emergency response vehicles had parked during the rescue operation. The images clearly showed the site ambulance parked over the location where the fluid was. A simple examination of the heavy vehicle by the on-site mechanic revealed no apparent visible leak of any fluid.
Always remember the stringent rule about validating evidence and not getting way laid by red herrings…. which the Site Manager undoubtedly wished he’d adhered to after it turned out his assumptions were completely wrong. To add insult to injury, he also suffered major embarrassment and possibly future credibility issues, as he had already briefed the CEO and Senior Management of the Company on his preliminary findings before I had arrived and then had to make some calls to retract what he had initially conveyed.
PUTTING IT INTO PRACTICE
In response to many requests, Safety Wise is pleased to announce that we are running a Public ICAM Practical Master Class (*) at the Singleton Mines Rescue Centre, NSW on 18th October 2018. The challenge of red herrings and the importance of initial on scene inspection and validating evidence will be a focus of this class.
The workshop has previously only been offered in-house to our clients, however, the majority of respondents in our latest survey indicated interest in attending a practical workshop to reinforce theoretical knowledge obtained from the ICAM Lead Training.
This one day workshop, which follows a Lead ICAM Public Course on 16 - 17 October at the same venue, provides attendees with hands-on experience at a simulated incident scene (… and be warned, there may be more than one red herring that we’ve set up for attendees…)
Practical Workshop Includes
Mobilising to site
Site Risk Assessment
Securing the Site
Initial Site Inspection
(*NOTE – pre-requisites for enrolment. Attendees must be enrolled to attend the ICAM Lead Course on 16th – 17th October 2018 preceding the practical workshop on 18th October 2018 - or have completed ICAM Lead Investigator or ICAM Refresher training in the last 2 years).
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 (Chief Operations Officer)
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.