Safety culture incident investigation

With regard to evaluating these factors, it is recommended that structured checklists be used, such as those provided by the HFAM method described in Chapter 2. These checklists provide an explicit link between the direct causal factors and management policies. Figure 2.12 shows how these checklists could be used to investigate possible procedures deficiencies, and the policies that led to the deficiencies, as part of the incident investigation. Similar checklists can be used to investigate possible culture problems (e.g., inappropriate trade-offs between safety and production) that could have been implicated in an accident. 

Smith, K. and Franklyn, C. Conquering Cultural Change in Incident Investigation. International Conference and Workshop on Process Industry Incidents, Center for Chemical Process Safety (CCPS)/AIChE, Orlando, EL, October 2000. 

In the event that a serious incident was to occur and the system put in the frame, investigators will quickly turn to the safety case. An out of date safety case is a prime target for criticism and failing to maintain such an important report brings into question an organisation s entire safety culture. Organisations need to develop trigger points which automatically and habitually prompt a review of the safety case and elicit a possible revision. 

Because of the variances in safety cultures and the resources available, it is folly to suggest that an incident investigation system could be crafted that would universally apply in all organizations. Guidance is given for a safety professional to assess that which is attainable and to draft an incident investigation system that relates realistically to organizational culture and sophistication. 

Thorough incident investigation and follow through with remedial actions support a culture that gives importance to safety. Poorly done incident investigations give employees reasons to doubt management s sincerity with respect to safety. 

Discussions of achievements with safety professionals whose oiganiza-tions had top scores did not produce any surprises. Incident investigation for hazard identification and analysis gets done best where the organization s culture includes accountability for superior performance. Here is an aggregate Mst of the conoments made in discussions with safety professionals in those entities with the best incident investigation systems ... 

Since that seemed a bit much in relation to what is done elsewhere, I asked a safety director how the activity was supported in these times of lean staffs. His answer went like this We know that the time expended may seem excessive, but the procedure gets a lot of people involved and that reinforces their belief that in our company safety is truly important. Thorough incident investigation is a part of our culture. ... 

While this study cannot be considered conclusive, it is probable that a further and more scientific study would establish that effective incident investigation reaps many benefits — as a productive means of eliminating or controlling hazards and achieving fewer injuries and illnesses, as an augmenting factor in attaining reduced workers compensation costs, and as a supporting element within a sound safety culture. 

Darren M. Ashcroft is a pharmacist and Professor of Pharmacoepidemiology at the University of Manchester, UK. He is the research theme lead for medication safety in the NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre and has led work investigating incident reporting, medication error and safety culture in a range of healtheare settings. 

Reference is made several times in this book to an organization s safety culture and how it impacts on the injury experience attained, favorable or unfavorable. Since causal factors for incidents resulting in serious injury are largely systemic and their accumulation is a reflection of the organization s safety culture, that subject must be explored. Comments made on organizational culture in the August 2003 Report of the Columbia Accident Investigation Board on the Columbia space ship disaster are pertinent here. They follow. 

After the session, a woman approached me and said, Mr. Manuele, I think at my location, I have the kind of a culture problem you discussed because I believe that our risks are overlooked and a lot of risk taking is accepted. I say that because all of the incident investigation reports that hit my desk put the responsibility for what happened on the worker. The reports always say things like they reinstructed the worker or discussions about safety were held with the workers or the safe practice rules are being reinforced. They don t ever really analyze the situation. ... 

Although it is suggested that, in the study proposed, the reality of the design and engineering, operational systems, and cultural causal factors be identified and analyzed, safety professionals should not be surprised if the incident investigation reports are inadequate for in-depth causal factor determination. Mention was made previously of my studies of over 1200 incident investigation reports and that I found, in many instances, that causal factor determination was dismal. 

Be considered as a prime source for selecting leading indicators for safety management system improvement. Because—If incident investigation is done well, the reality of the technical, organizational, methods of operation, and cultural causal factors in the work system will be revealed. 

Deserves a much higher place within all the elements of a safety management system. Because—The quality of incident investigation emerges as one of the primary markers in evaluating an organization s safety culture. 

Comment on the cultural difficulties facing safety professionals who try to have incident investigations improved if an organization has condoned a low quality of incident investigation. 

Provide materials and resources to assist a safety professional in crafting an incident investigation procedure suitable to an organization s culture. 

Assume that the safety culture does not require effective incident investigation. Consider the following examples, limited to seven, of statements that could be made legitimately in investigation reports, but may be perceived as self-incriminating or accusatory of management levels above the first-line supervisor ... 

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