Latest / Safe As Podcast / E16: Systems thinking and investigations

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E16: Systems thinking and investigations · Safe As Podcast

• 0:07
  Is it possible that our conventional approach to
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  investigate incidents and construct reality will help to
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  reinforce a blame focus on people?
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  But if we always do what we've always done, are we truly
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  surprised when we always get what we've always got, Namely
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  accidents that keep reoccurring and systemic problems that
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  remain unaddressed? Good day everyone.
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  I'm Ben Hutchinson and This is Safe as a podcast dedicated to
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  the thrifty analysis of safety, risk, and performance research.
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  Visit safetyinsights.org for more research.
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  Today's paper is from Woolley ET al titled Moving Beyond the
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  Organisational Ceiling to Construction Acts and
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  Investigations aligned with Systems Thinking, published 2018
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  in Human Factors and Ergonomics in Manufacturing and Service
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  Industries. This study analysed 100 serious
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  or high potential construction ICAM investigation reports from
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  5 Australian construction companies to see the extent to
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  which they aligned with systems thinking principles.
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  It's argued that construction can be described as being a
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  complex sociotechnical system influenced by fast pace of
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  technological change and the impact of economic and political
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  pressures. Thus, accident and other models
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  used within construction should reflect the various vertical and
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  horizontal actors and hierarchies evolved in decisions
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  across the whole sociotechnical system.
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  In contrast, it's argued that existing construction accident
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  models, and I guess existing worldviews, may be dominated by
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  linear thinking, with proximal factors like individual errors
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  being the main focus of investigations.
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  Rasmussen's risk management framework and associated AXI
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  maps were used to evaluate the comparison between ICAM
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  investigations and the system's thinking tenets.
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  I don't have space to describe Rasmussen's framework, so I
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  recommend checking out some of his work, and you can find it by
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  searching his name on my site. So what did they find?
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  Overall, analysing the ICAM reports revealed that quoting
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  the paper, construction has not moved beyond a human error focus
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  and does not presently identify multiple actors and contributing
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  factors or the interactions between them.
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  These investigation reports from the participating construction
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  companies revealed that for the causal analysis, actors involved
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  in the government, regulatory, client or company levels of the
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  framework were either not identified or not examined.
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  Despite this, 100% of the reports identified the
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  contribution of actors at the operational, management and
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  staff levels of construction regarding causal links in the
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  accidents. At the management level of
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  analysis, supervisors were identified in just over 20% of
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  the reports and leaving hands identified in about 9% of the
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  reports. With a staff level of analysis.
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  Plant operators were expectedly the most frequently identified
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  causal Lincoln investigations at 70%.
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  Labourers were identified in about 23% of reports.
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  Indeed, staff related factors were identified pretty much in
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  86% of reports, with most of these instances being attributed
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  to human error like 83%. And of these, often it was
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  reporting that workers had failed to follow a procedure or
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  the direction of a supervisor. And in my view, regarding
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  procedures and investigations, this have to be among the most
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  intellectually lazy and insubstantive findings unless
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  matched with a nuanced understanding of how and why.
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  How did it make sense to them not to follow the procedure?
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  Did they even know the procedure?
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  How was the task done last time? How was the task done usually?
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  What were they instructed on when they started the company?
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  What have they learnt over time? What have leaders chosen to
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  ignore? Are the procedures usable and
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  effective? Is it clear when and how the
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  procedure should be used? How the procedures impact the
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  efficiency of the task they even developed and configured to be
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  effective in practise through our assumptions about the
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  procedures match reality. These are all things that need
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  to be unpacked. Regarding the interrelations of
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  identified contributing factors, the investigation showed no
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  relationships between any identified factors beyond the
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  company level, as we would expect if a systems thinking
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  approach had been used. Also, it was observed that in
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  the few reports that did identify relationships between
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  factors at the company level, just three linkages between
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  safety management systems and project management were
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  identified. Next, the authors moved on to
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  the corrective actions. Most actions were pitched at the
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  staff level of the framework. The most commonly identified
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  areas for corrective action and resolution were 46% of improving
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  safe work method statements, 39% were delivering toolbox talks,
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  conducting risk assessments were identified 33% of the time.
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  There was further training 14% of instances and then hazard
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  awareness 28% and a few more findings that I've skipped.
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  Another interesting finding was that where corrective actions
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  directed attention towards raising awareness of issues that
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  were typically framed as broad statements that appeared to
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  shift responsibility to the workers.
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  For instance, statements like know your limits, stay safe,
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  keep eyes on path T causes accidents, as opposed to concise
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  countermeasures capable of being implemented and measured.
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  Also interestingly, they noted that when toolbox talks were
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  identified as an action, they're often included as a corrective
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  action without further explanation of required content
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  or the intended audience, or what the toolbox was to achieve
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  or how its effectiveness could actually be measured.
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  One of my audit studies found something similar tool boxes use
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  as corrective actions in a sort of Swiss Army knife merge with
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  WD40 way, addressing everything without really addressing
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  anything. A number of findings were
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  covered for whom corrective actions were assigned to.
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  For instance, 100% of the reports allocated at least one
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  or more of the corrective actions to the safety advisor.
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  But critically, only 36% of the reports allocate A corrective
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  action to the project manager, a person who usually has far more
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  clout and control of project resources.
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  So corrective actions appear to excessively focus on lower level
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  aspects not aligned with operational company level
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  contributing factors. The latent factors, the upstream
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  factors, corrective actions that were aligned to company
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  management level factors were consistently allocated to safety
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  Advisors who quoted in the paper may be unable to influence the
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  implementation of the required actions.
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  Also, the investigations omitted quite a lot of other stuff.
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  They didn't examine the relationships between management
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  in action cultures and developing robust safety
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  management systems on management or staff level practises.
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  So what can we make of the findings?
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  The paper does a pretty good job.
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  It says existing Accident Investigation processes and not
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  identifying the range of contributing factors involved in
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  construction accidents. So they're missing out on a
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  whole lot of useful Intel. Also, they aren't adequately
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  considering the system wide interactions that influence
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  construction safety performance. Therefore, from the paper, the
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  ability for companies to substantially disrupt the
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  existing rate of construction fatalities is diminished if we
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  continue to overlook the influence of system wide
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  interactions and implementation of the countermeasures.
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  The corrective actions improvements that might actually
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  help us improve are overwhelmingly allocated to
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  people lower in the hierarchy with the least power or
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  resources to effectively change things.
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  So, limitations. There's a few, but importantly,
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  investigation reports only provide a limited view of
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  investigation practises. They're less entirely objective
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  captures of reality and more socially constructed
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  abstractions. The data was limited to 5
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  Australian construction companies also, so it's unknown
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  how well we can generalise the findings.
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  That's it on Safe. As I'm Ben Hutchinson, please
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  help share, rate and review and checkoutsafetyinsights.org for
• 8:41
  more research. Finally, feel free to support
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  Safe As by shouting a coffee link in the show notes.