We need to make sure this can never happen again
Can you picture this scenario?
Manager: So Ben, I’ve just read through the incident report and I see you injured your back when you ran the forklift into the bollard. I need to ask you a few questions as we need to make sure this type of incident never happens again. It’s not acceptable that any of our team is hurt at work. So lets start by looking at your forklift license?
Ben: Sure here it is, I renewed it only two months ago. Hey boss, you know that it’s not the first time the bollards have been hit, don’t you?
Manager: That’s great, your license is current. Let’s not worry about any other incidents now Ben, it will just distract us from reviewing this incident. One of the things that makes a good investigation is focus. Now lets look at your training records, when was the last time you did a forklift re-induction?
Ben: We did one of those ‘Toolboxy things’ a couple of weeks ago, it’s all good I signed the form. Do you think it matters that sometimes I have trouble seeing that bollard, it’s kind of in an awkward spot?
Manager: This is great, looks like we are compliant with your license and training records and that’s important. I’ll need to take copies for our file. Like I said, we can look at the bollard later. Right now, we need to focus on this investigation.
Manager: OK, last thing we need to do is complete the section of the form that asks what we are going to do to make sure this type of incident never happens again. It’s important that we consult with our employees Ben, so do you have any ideas?
Ben: Sure boss, I think I just need to take a bit more care when driving, I’m a good driver and I will be more careful next time. Although that bollard does seem to be a problem, oh and there are some times when the brakes seem a bit spongy, maybe we can look at them too?
Manager: That sounds great Ben, we know you’re a good bloke and you didn’t mean to do this, it was an accident and yes you just need to be more careful mate, these forklifts can be dangerous machines.
So let’s wrap this up now that we have got to the bottom of things. We know you have a license, and that you have been trained and re-inducted, and we now have an improvement idea to make sure this type of incident never happens again. Thanks for mentioning the brakes, that’s a good one. I’ll make sure that the last maintenance report for the forklift is on the file, that will prove that the brakes were checked according to the schedule. I think we are all done now, the form is complete, that’s great.
Oh by the way Ben, if your back keeps playing up let me know, but I’m sure you’ll be ok. You know we have a Physio who can help and I can arrange everything so you can stay here at work being a productive and valued member of our team.
Ben: Thanks boss, I’m sure it will be all-good, I don’t want to cause any trouble.
Manager: Well done Ben, thanks for being honest and involved in this important process. I’m confident that you will be more careful from now on. That is all I really need from you now Ben, thanks.
What did Ben’s manager learn from this investigation?
Have you ever been involved in an incident investigation that was really just a checklist of organisational processes? Have there been times when you might have missed something because you became too focused on one aspect and weren’t open to exploring?
I’ve been in these situations. I’ve written reports that were focused on checking off on corporate procedures rather than on understanding what really went on. I’ve prepared reports that were ‘protected’ by legal professional privilege so that what we learnt could not be shared with others. I’ve written reports where I know that there were a range of other factors at play, but I had neither the time nor resources to explore them, so I ‘parked them’ for later (they are still parked!). Is this normal in risk and safety, or is this just my experience?
If this is our approach, what chance do we really have of learning anything?
Alternatively, does an investigation ever have to be considered ‘complete’, or is it just the starting point for thinking and reflecting? If we accept that most of our decisions and judgments are made in our non-conscious, are we ever really able to ‘get to the bottom of things’? What does it really mean when we propose to ‘make sure this type of incident never happens again’?
If we are left with more questions than answers, could this be a ‘good’ investigation?
I was reminded of how clinical the ‘incident investigation’ processes can be when I received an e-mail from a friend this week asking for my thoughts on an investigation that they are involved in. The help they were seeking was about how to raise the issue of a less clinical incident investigation process with a team of managers whose focus is on compliance.
One way to explore things differently is by considering Dr Robert Long’s ‘Workspace’, ‘Headspace’ and ‘Groupspace’ way of exploring which he recently wrote about HERE. I’ve used this approach myself to follow up on an event that also involved a forklift and I thought it might be useful to share my experience.
To understand the context, I prepared the report for an organisation I was working for (and not under legal privilege!) and we actually shared it with the health and safety Regulator (WorkCover NSW). The report followed a serious incident where someone at work had their foot run over by a forklift. The person subsequently spent the following six months receiving specialist medical treatment. Some exerts from the report I prepared are outlined below:
This Event (the name this company gives to ‘incidents’) highlighted that there were few formal controls in place to protect against the risk of mobile equipment (e.g. forklift) and pedestrians colliding. The forklift operates in tight spaces on some occasions and there are peak times when the forklift is required to be used.
The team at the site identified that the time clock was located in an area that required people to walk into the path of the forklift. The team also identified the number of times that people walked through the share space could be limited. They implemented a gate that is now used when the forklift is in operation and also changed the location of some of the racking that was commonly used so that it was in an area where pedestrians don’t go. All of these ideas came from people working at the site.
There are many factors that impact on the way people make decisions and judgments, a lot of these occur in the non-conscious, a-rational mind (as opposed to rational, logical and analytical decisions). Some ‘headspace’ factors that may have contributed to this Event include the operator of the forklift being distracted; Mary (injured worker) not being aware that the forklift was about to move on and (non-conscious) decision making and complacency and over confidence by the forklift operator.
This should not be confused with deliberate intent or neglect, rather acknowledgement that the decision to drive in the direction of Mary was not likely a conscious ‘choice’ but rather based on the physical ‘cue’ that Mary was walking. These factors can be difficult to predict and control. The key way to deal with ‘headspace’ factors is to encourage a culture of open questions and ‘entertaining doubt’ that assists in dealing with the possibility of complacency.
Groupspace factors are those where the different departments on site work together. One of the key recommendations agreed to by both departments (operations and sales) was to regularly catch up with each other (in Weick terms ‘updating’) which will help to develop a culture and environment where relevant information is shared and learning is maximized.
We also considered some aspects of culture at the site. For example, we explored the words and phrases that are commonly used and discovered that ‘we just get things done’ was a common phrase people use on site. Another was ‘everything we do is about the customer’. We sat and thought for a while about what these phrases could actually mean and do to us. We’ve agreed that they probably do impact on how go about things and decided to think about this for a while longer and come back in a month and talk through again.
Ah, the power of reflection!
What is your approach to investigating incidents?
Do you extend your line of thinking beyond the typical approaches to incident investigation and ‘explore’, ‘imagine’ and ‘listen’?
Is understanding and coping with ambiguity and equivocality one of the key skills we need to learn if we are going to do an effective investigation? In fact, should we use the word ‘investigation’ at all? What is the discourse usually associated with the word ‘investigation’. What other words do you think we could use that would better describe a process that is focused on exploring and learning?
Do we ‘satisfice’ when we make decisions and judgments? Can we ever really ‘prevent this from ever happening again’? What are the trade-offs and by-products of this approach? There are so many questions.
Do we need to find answers to all questions, or are we comfortable with ambiguity?
As usual, I’d love to hear your thoughts, experiences and comments.
Author: Robert Sams
Phone: 0424 037 112
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