Are there Answers?
Accident investigations all lead to some form of an answer when it comes to someone dieing on the
job, right. AN answer is required and is considered as the root cause but in reality, how can the root cause be verified. How would one know when the person most impacted is no longer around?
There is a very interesting case which was posted by Dr. Rob Long of Human Dymensions which provides some very interesting and salient input on this 'process.'
Bottomline, we have a process of which we believe provides the proper answers to an accident investigation. But, in that process, how in depth is that investigation, really? The courts practically scoff at some of the conclusions which business present at the close of such an investigation because such investigations aren't 'real world' investigations.
As Dr. Long posited in the above article...."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."
As Dr. Long states, " When one has a narrow STEM (Science, Technology, Engineering and Math) methodology one will assume that incidents and decision-making ar mechanistic. Since there are over 200 social influences which shape human decision making, why aren't these discussed reviewed in accident investigations? As seen in the SEEK donut pictured below, there are 20 critical social psychological factors which are missing from classical safety approaches.
Don't we owe it to the descedants to provide the best possible answer to why a deadly accident happened? Of course we do....but it might hurt a business to find the real answer.
If you or your business needs andy help or just wants a healthy discussion, give us a call or send an email. We would love to discuss.