There’s a Hole in Your Investigation.
Any fatality is sad news for family and loved ones of those who have died. It is even more sad when there are no definitive answers for cause. Many who die working alone cannot be interviewed, one can never know the root cause. Root cause is the concoction that imagines that all incidents must have a known and singular cause. Root cause flies in the face of all we know about ‘wicked problems’ (https://vimeo.com/167228715).
The mythology of root cause fosters mis-attribution and sheer fiction in the search for a cause. The courts however don’t believe in the notion of root cause because of a curriculum and anthropology that is far more professional and sophisticated than what one observes in safety discourse and training. A great example of this is the investigation into the Danny Cheney fatality (https://safetyrisk.net/the-convenience-of-complacency/). The gap between the analysis of the company into the fatality (that was proudly broadcast across the internet) and that of the coronial inquiry illustrate how simplistic safety methodology concocts pure fiction manufactured from the assumptions of mis-educated safety.
EXTRACT FROM THE LESSONS REPORT (See Full Report: Danny Cheney Fatality Learnings )
In the company investigation the conclusion of a root cause was that Danny wanted to suicide that day (see slide 10). This is repeated in the court transcripts. This comes from the assumption that safety is a choice you make’. Therefore, ‘un-safety is a choice someone makes’. Therefore in the company inquiry it states that Danny “made a conscious decision not to comply with well established rules and procedures to undertake this job safely.” What a remarkable conclusion. Did they interview Danny to get this information? Was there a suicide note??? Of course not, this is what one gets in incident investigations founded on the simplistic beliefs of safety. The Coroner is equally scathing of the company’s simplistic safety investigation methodology (p30ff). The Coroner made no such finding of choice to be unsafe as did the company investigation.
Many safety incident investigations are more a display of positivistic and binary assumptions than open enquiry. Many say much more about the anthropological assumptions of the investigator than much else. It is usually from a mechanistic framework (and training) that most safety investigations are undertaken. Most investigations on the market in safety are mechanistic. It doesn’t matter whether the investigation is appreciative or punitive, if it’s undertaken under the rubric of STEM (Science, Technology, Engineering and Maths) one knows that not much social psychology is included.
When we undertake SEEK (https://cllr.com.au/product/seek-the-social-psyvhology-of-event-investigations-unit-2/ ) or Due Diligence (https://cllr.com.au/product/due-diligence-workshop-unit-13/ ) training we explore all the key elements that are missing from classic orthodox safety investigations. We use the metaphor of a donut to demonstrate all that is missing in STEM-only methodology of investigations.
Of course, a whole donut is not a hole donut.
In the SEEK Donut we demonstrate 20 critical social psychological factors that are missing from classic safety approaches to investigations. These are illustrated below.
Most of the popular safety investigations models on the market simply do not consider any social psychological factors that play a part in human decision making. There are over 200 social influences that shape human decision making (https://safetyrisk.net/mapping-social-influence-strategies/ ) and none of these are discussed as part of classic safety investigations.
When one has a narrow STEM methodology one will assume that incidents and decision-making are mechanistic. I often get called into an investigation towards the end of a process and am astounded by all that is omitted from the typical safety investigations process. In the Danny Cheney Coronial Enquiry the court was highly critical of the methodology as if the company had already decided the outcome before the investigation had started (p.31). When one assumes under mis-education that human choice is simple, binary and behaviourist one will get an inquiry that proves ‘safety is a choice you make’.
Of course such belief flies in the face of all the evidence but just like the nonsense of zero, Safety still believes it. Belief against the evidence is called ‘faith’ and this is why safety drifts constantly into religious discourse.