Detailed Root Cause Analysis Leads to Industrial Manslaughter Charge

Following a recent fatality at a residential construction site, the WorkOver Authority commissioned me to undertake an independent, unbiased root cause investigation to help them confirm what they already knew and to justify further action against those even remotely involved.

As a result of my findings, industrial manslaughter charges will be laid against the Farmer for intentionally engaging in conduct that is in breach of their health and safety duty and which caused the death of an individual (to whom the duty is owed), and for being reckless or negligent about the conduct and causing the death – obviously! Jack, as the Director of the construction company and Principal Contractor, knows people so he will receive appropriate compensation.

I am very proud of my work here and WorkOver said it was exactly the outcome they were hoping for. Process and tenacity are key and most safety professionals are reluctant to go past 5 whys but if I just stopped there it would have looked really bad for the dog. They had mentioned something about a scapegoat but they must have had the wrong farm.

I have now made a video of my findings for Youtube and this is exactly how your next TapRoot or ICAM investigation will probably look if you were to do the same.

I will be presenting the simplified version at the next virtual World Congress for Zero Safety Vision:

Full transcript of the investigation:

1. This is the house that Jack built.
   
2. This is the malt
   That lay in the house that Jack built.
   
3. This is the rat,
   That ate the malt
   That lay in the house that Jack built.
   
4. This is the cat,
   That kill’d the rat,
   That ate the malt
   That lay in the house that Jack built.
   
5. This is the dog,
   That worried the cat,
   That kill’d the rat,
   That ate the malt
   That lay in the house that Jack built.
   
6. This is the cow with the crumpled horn,
   That toss’d the dog,
   That worried the cat,
   That kill’d the rat,
   That ate the malt
   That lay in the house that Jack built.
   
7. This is the maiden all forlorn,
   That milk’d the cow with the crumpled horn,
   That tossed the dog,
   That worried the cat,
   That kill’d the rat,
   That ate the malt
   That lay in the house that Jack built.
   
8. This is the man all tatter’d and torn,
   That kissed the maiden all forlorn,
   That milk’d the cow with the crumpled horn,
   That tossed the dog,
   That worried the cat,
   That kill’d the rat,
   That ate the malt
   That lay in the house that Jack built.
   
9. This is the priest all shaven and shorn,
   That married the man all tatter’d and torn,
   That kissed the maiden all forlorn,
   That milked the cow with the crumpled horn,
   That tossed the dog,
   That worried the cat,
   That kill’d the rat,
   That ate the malt
   That lay in the house that Jack built.
   
10. This is the cock that crow’d in the morn,
    That waked the priest all shaven and shorn,
    That married the man all tatter’d and torn,
    That kissed the maiden all forlorn,
    That milk’d the cow with the crumpled horn,
    That tossed the dog,
    That worried the cat,
    That kill’d the rat,
    That ate the malt
    That lay in the house that Jack built.
    
11. This is the farmer sowing his corn,
    That kept the cock that crow’d in the morn,
    That waked the priest all shaven and shorn,
    That married the man all tatter’d and torn,
    That kissed the maiden all forlorn,
    That milk’d the cow with the crumpled horn,
    That tossed the dog,
    That worried the cat,
    That killed the rat,
    That ate the malt
    That lay in the house that Jack built.

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Barry Spud

Safety Crusader, Zero Harm Zealot, Compliance Controller and Global Pandemic Expert at Everything Safety

Latest posts by Barry Spud (see all)

• Detailed Root Cause Analysis Leads to Industrial Manslaughter Charge - June 9, 2020
• Real Zero Harm - May 19, 2020
• Working From Home Health and Safety Tips – Covid-19 - April 5, 2020
• Dumb Ways to Improve Rail Safety - August 13, 2019
• Even Safety Is Fallible - August 11, 2019

What is a Safety Spud? Lets look at a few more spud head activities in risk and safety: 1. Coming on to site saying there is a safety issue when in fact there’s no such thing, it’s a political issue. 2. ‘Falling apart’ when people make choices that we think are stupid because they won’t do as we ‘tell’ them. Then we put on the angry face and think that overpowering others creates ownership. 3. Putting on the zero harm face, presenting statistics, knowing it has nothing to do with culture, risk or safety. 4. Putting on the superman (hazardman) suit and pretending to be the saviour of everything, this is good spud head cynic stuff. 5. Thinking that everyone else is a spud head except me. 6. Thinking there’s such a thing as ‘common’ sense and using such mythology to blame and label others. 7. Accepting safety policies and processes that dehumanize others. 8. Blaming, ego-seeking, grandstanding and territory protecting behind the mask of safety. 9. Thinking that risk and safety is simple when in fact it is a wicked problem. Denying complexity and putting your spud head in the sand. 10. Continually repeating the nonsense language and discourse of risk aversion that misdirect people about risk, safety, learning and imagination.