KINASTON ASSOCIATES LIMITED

1. Advanced industrial accident investigation and causal analysis

Industry has always been controlled by two fundamental domains.  The first is its ‘core process’ and the second its ‘ethical positionality’.  How these are governed by the corporate entity will be reflected in consumer and public confidence in brand.  When failure takes place, it is arguably a weakness in  governance that results in the loss.  Loss can occur within five main streams, however due to the links with litigation and prosecution, personal injury apart from ill health, appears to have received a disproportionate amount of attention.  The other four areas (environmental loss, asset damage, security issues and reputation / brand damage) are equally important and as with personal injury are linked to the corporate governance process.


Modern day industry has often been so successful in reducing loss that it lies on what can be termed a ‘event flat line’ where successive applications of tried and tested controls do not appear to provide any additional reduction in loss statistics.  These organisations can be termed ‘high reliability’.  In some cases using predictive analytics it could be possible to factor in loss statistics and state how many loss events would be expected over time by a high reliability organisation.  This position is obviously not a good place to rest comfortably as we are talking about numbers of loss events and not their outcomes.  Different organisations will demonstrate different flat lines.  Often the operational processes that the organisation carries out are fully understood.  The operators know how systems work, have the appropriate resources, but still there are instances where individuals deviate from the expected behaviour.  Why do people decide to deviate?  If one thinks of a traditional family, then the parents eventually will allow their child to leave the home unsupervised and go to a shop.  The parents expect a certain behaviour from that child.  They would be disappointed if the child stole from the shop.  If that were to happen then most parents would not only remonstrate with the child but they would also ask themselves what they had done that caused the deviation from the expected behaviour.  Back to our event flat line;  what is it that exists in the culture of an organisation that makes deviation acceptable and who is responsible for deviations from the expected norms.

Modern day industrial accident investigation has one key aim; to provide those with the responsibility of corporate governance with evidence with which to understand loss and through that prevent future events.  It would be a nonsense for those in corporate control to be appraised of every event, indeed individual events may represent an anomaly ands caution should be exercised before considering them to be representative of normal circumstances.  However key critical themes that have been found to be present in a number of loss events should be subject of examination and discussion.  It is for those individuals to use this information to strategically direct the organisation in a way where evolution takes place and such loss is ultimately controlled.  The process of investigation and providing sound management information falls into the two fundamental domains (core process and ethical positionality) and has moved considerably forward from the old fashioned tree style maps, layers of cheese and tumbling domino’s.  

The first step in a modern approach is for the organisation to self examine its ethical positionality (The parents).  It maybe that despite public and consumer moral positions, the organisation is happy to stagnate and accept a degree of loss.  This is particularly the case in sectors where loss can be offset by insurance, contractual requirements or social / political policy.  However many large organisations now wish to be seen as global ethical leaders in their sectors and thus are willing to examine change more deeply.  The key question now is; ‘what did we do that created this loss environment’.  Brand confidence and reputation amongst entities within supply chains as well as the public, require a visible socially acceptable ethical position.

If an organisation wishes to embrace change then it will need to adopt a loss management system that provides information in such a way that it is trusted and understood by those who have executive control.  This is far more straight forward than it seems, but requires some fundamental repositioning of cognisance in relation to causation, including the acceptance that individual loss events are simply just symptoms of an organisation failing to corporately govern and strategically manage process.

The investigative process

A modern day investigative process has two core components.  Data collection and data processing.  It is an obvious fact of life that where an event may be of interest to the authorities, that the data collection system should not conflict with their processes.  It is extremely important that organisations understand the terms of reference (TOR) associated with prosecutor’s investigations and that these will be different from those of the organisational investigators. In simple terms the organisation should be collecting data so that it can understand underlying causation.  Very rarely are these two different sets of TOR the same, industrial investigators are not prosecutors and have completely different roles.  

The data collection process will have to have some form of written material.  In some countries (UK) this has to be completed on specific government forms, elsewhere it will depend on the purpose that the information is to used for, and in many places the choice of recording is left to the organisation involved.   The recording and storage systems must also be compliant with data control legislation where this is relevant and incorporated into this are the issues surrounding sharing of data.  Best practice is to use the same process that is used when interviewing subjects for a grounded theoretical investigation.  This is a recognised academic process used in doctorate level research, is not open to subjective direction and  because of the rigorous procedure can often be used by lawyers at a later date to defend an organisation.  The process allows data to be gathered, ordered and cross referenced for later processing.  All too often the data collecting process is understated.  Many investigators have been trained to use methods employed by prosecutors, this is very old fashioned and simply not acceptable for the purposes of causal analysis in the current climate.  

We use the term statement to represent the recorded written data, yet often little is understood as to how to interview, structure or indeed record information.  Many even believe that a dictaphone is a suitable tool and get confused with interrogation and subject  / witness interviewing.  It is essential that investigators are trained in the the correct interviewing techniques, these are not the same as those required for prosecution or defence statement taking; however, historically this was considered to be an acceptable standard.  

Data processing

After data has been collected it is essential that there is reflection on its statistical relevance. One event maybe a statistical anomaly.  There are three coding processes that will lead to an understanding of causation.  Each event’s data should firstly be coded against a number of organisational failure areas (OFA’s) and subjectively recognised values, attitudes, expectations and attributes (VAAE).  This coding should be done against Groeneweg’s 11 BRF categories as these are the only academically peer reviewed OFA’s in existence.  Each OFA weakness will need to be scrutinised for compliance with expected standards, yet the potential of anomaly must not be forgotten.  The investigator should be considering data rich events rather than those that may just have severe outcomes.  Historically some organisations adopted this primary coding process but failed to take the next steps.  The outcome of this was the development of what is termed ‘pie chart culture’, where directors are provided with charts demonstrating how the organisation is managing in each OFA area.  In these cultures each event is dealt with as being an individual failure rather than symptoms of a wider issue.  Obviously any weaknesses found during the primary coding need to be examined and addressed, but simply coding the data does not explain the existence of such weaknesses. The next two coding stages are essential if this failure is not to be repeated.

After each event has been coded against the OFA’s and VAAE the data will then be held by the organisation and collated with other data from other loss streams / events.  This secondary coding will provide a number of patterns that disclose critical themes of failure.  At this point the qualitative subjective comments in a subject’s statement take on a better statistical significance as they are linked to similar comments from other witnesses from other events.  If one person states that a process is arduous then that individuals comment will trigger examination, but it is one person’s opinion.  If ten others say the same, then the opinion carries more weight but it is still ten opinions.  However from examining such weight of opinion, we are able to develop theories of failure and thus we have a theory grounded in our data.

Once critical themes have been identified, usually in three month batches, the organisation will then need to look at two distinct sets of information.  The first are the critical themes associated with the identified VAAE, the second the critical themes associated with the OFA’s.  The organisation should then carry out tertiary coding and ask itself the key question, ‘What was it that operated that caused us to be in the position where these areas of weakness existed?  This usually takes the form of a facilitated discussion with the board as it is their job as the ‘parental entity’ to develop the environment where both core process and ethical positionality are acceptable to the society within which they operate.  Facilitated discussions should not last more than an hour per quarter.  The result are rationalist changes to the workplace culture.  Usually after such tertiary coding events there area some moments of realisation amongst the participants.  These moments of realisation; ‘Ah-Ha’ moments, may take place immediately or indeed after sometime, or never, but they are where innovation is based, the penny drops is a very good metaphor.  The results are subtle changes of the values and attitudes of the supply chain and brand image.  Notice that the question is not, ‘what are we going to do?  In order for the corporate governance to move on it has to be able to understand how it was failing in the past.  Once this is understood then it can develop action plans aimed at developing more positive VAAE.  Effectively it is developing a better loss control culture (Safety Culture).


A word of warning

All too often there is a desire to examine base data by those who do not understand either how it was collected nor how it is to be analysed.  This can cause an organisation to stifle its development as individuals who are untrained in the correct process are likely to examine the data with subjective hypothesis and thus direct the investigation away from causation.


The benefits for the executive board

Good data that is legally and academically sound
An academically recognised analysis process
A set of primary categories that are academically recognised
A coding system that is academically recognised
Acceptance of failure as being symptomatic of organisational weakness
Continuous examination of Core Ethical process (VAAE)
Examination of the link between weakness in the communication and education of VAAE and events
Continuous examination of corporate understanding of process
Probable legal protection from allegations of corporate negligence (UK)
Probable increase in brand confidence in client / investor / public arenas
Accident investigation leading to continuous improvement of standards and more positively balanced cultural dichotomy

This précis does not go into sufficient depth to describe the whole process, there simply isn’t room here.   

Kinaston Associates Ltd.

We are able to provide training and facilitate sessions in relation to the whole of this process.  We believe that organisations should strive to become self sufficient in this process.