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Providing industrial accident investigation and causal analysis to industry
KINASTON ASSOCIATES CONSULTANCY SERVICES
OVERVIEW
Overview
Historically industry has repeatedly tried to emulate the prosecution authorities in the way that they investigate accidents. Indeed in some organisations there is a defensive approach to investigation where the organisation must never be considered to have failed in some way. At the same time many organisations subscribe to the mantra that incidents are investigated in order to identify underlying causation, learn lessons and prevent repeat events. Evolution within an organisation should be considered a prime business function, thus knowing what worked and what failed is essential. Prosecutions take place on the basis of failing to achieve a minimal standard; however many business operate, and expect to operate above these minimal standards. Once the organisation has developed in such a way that it is beyond interest to the prosecution authorities it should keep investigating events in order to evolve into market leaders.
Failure does not always mean that a breach of standards has taken place. Indeed what should investigators do if there are no loss events at all. The simple answer is raise the bar and start investigating events that the authorities would not be concerned with. Many organisations are already at his stage. The modern day accident investigative system within high reliability organisations goes beyond the simple counting of events and the production of the pie chart. Indeed we recognise ‘pie chart culture’ as a stage in the evolution of organisational awareness. The modern system should be integrated with the corporate governance of values, attitudes, expectations and attributes as well as process. This requires a deeper qualitative system that eclipses the old fashioned tree style and linear approaches. We need to embrace peoples comments and perceptions as it is these that cause compliance with processes and innovation.
DEVELOPMENT OF ACCIDENT INVESTIGATION AND CAUSAL ANALYSIS SYSTEMS
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Kinaston Associates can provide assistance with developing accident investigation and causal analysis processes. All too often we are asked to develop investigation processes that are driven by a desire to disapprove civil claims. Although this is one element of an investigation, the key term of reference should be the identification of underlying causation.
The concept of underlying causation has changed considerably. Initially it was simply the identification of whatever it was that led an errant employee to ‘get themselves injured’. There is no room in a modern organisation for this stance. The easiest way of looking at the concept of underlying causation is to ask what it is that lets a parent allow their child to go to a sweet shop unaccompanied. The child has been many times before with the parent and knows the process, they know what they should do in order to successfully buy sweets. The controlling mechanism are the values and resultant attitudes instilled by the parent into the child that means that they will follow normal sweet buying practices. It is the same in industry. Those that set the values and attitudes of the workforce are responsible for rules being followed or otherwise. The values and attitudes and the governance of them are closely linked to underlying causation. This is particularly the case where ‘high reliability’ organisations have everything in place but still events occur. Managers often say that, ‘everything is in place so why did they not follow the system’. The answer, values and attitudes’.
Modern day accident investigation processes need to be able to examine the displayed values and attitudes of staff against the desired ones extolled by the organisation. The system should be able to, at least on a quarterly basis, provide the data required for such an analysis. This is so even in an organisation that is not experiencing any loss events.
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Kinaston Associates can provide assistance in developing a modern system.
FACILITATED DISCUSSIONS
The board room is where the character of the organisation is based. This has nothing to do with balance sheets, its about reputation and how the public, clients and staff perceive the organisation. You can have the best profit margin in the sector, but if your ethics are despised by clients and the public your reputation will suffer.
The role of the board room is often misunderstood. The very character of the organisation is driven from this group of people. The boardroom often supplies directions on what the values and attitudes of the organisation are felt to be. We see posters and displays and the broadcast 'value standards’ are fed to the employees. In a modern day accident investigation the investigator will develop a picture of what the values and attitudes really are. This information is highly subjective until it is amalgamated with similar information from a number of incidents investigated by a number of investigators. When this takes place there will be a set of ‘critical themes’ that appear that could be used to describe the actual values and attitudes of employees. This gap between actual and desired values and attitudes should be explored at least once a quarter in order for the board to develop strategies that will nurture the workforce. The discussion at board level requires facilitation from outside as without it the members will want to discuss specific events rather than holistic change.
Kinaston Associates can provide the service of facilitator for meetings with the senior management team / board to assist them in looking at their role in the causation process and how to evolve. An essential element of this process is to facilitate discussion not direct it. The organisation’s character is that of the team not the facilitator.
There is often some reticence among safety professionals within an organisation to facilitate such a discussion. The obvious cause for this is that they are simply part of the company.
RETROSPECTIVE CAUSAL ANALYSIS AND INVESTIGATION
Kinaston Associates are able to provide sessions with HSE professionals where they re-examine previous events within their organisation with the intention of identifying additional information and secondary coding information.
It has to be pointed out that it is fully understood that investigators are in a very difficult position in that it is always easier to criticise an investigation than carry out an excellent one. Criticism is not the intention here.
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By examining a number of events we are able to assist in the identification of critical themes in both process management and culture.
ASSISTANCE WITH PACE ISSUES
The Police and Criminal Evidence Act 1984 is a complicated set of legislation that effectively provides the rules for investigations by the authorities and others. Kinaston Associates are able to assist in examining the processes within these investigations to ensure that the issues surrounding PACE are understood.
STATEMENT TAKING / INTERVIEWING - FILE PREPARATION
Kinaston Associates are able to assist with statement taking and file preparation; however we have a basic rule in that we prefer to assist with the interview process rather than take it over from in-house investigators.
ASSISTANCE WITH ANALYSIS OF DATA
Kinaston Associates are able to assist in the analysis of statements and other data gathered during investigation as well as being able to help with the primary and secondary coding and trending of patterns.
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We are able to help with the assimilation of the vast quantity of data that is gathered during major enquiries. Using this we can assist in identifying patterns within organisational failure areas and underlying causation.
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