Business profile
Peter Abbott of AbsTracked Solutions outlines some of the common pitfalls in accident and near miss investigations O
n a wall of the offices of Finland’s now defunct Accident Investigation Board, there hung a notice bearing
the aphorism: ‘If you think safety is too costly, try having an accident.’ That simple message has been reproduced in similar guises all around the world. It strikes a chord with the companies and individuals involved in almost every industry sector, as the costs of accidents are much wider than financial. AbsTracked Solutions managing director
Peter Abbott said: ‘We are all aware that robust accident investigation processes delivered by competent investigators, consistently and accurately identify both immediate and underlying causes. Yet, despite the wealth of standards and guidance available to us in the railway industry, we can still encounter investigation reports that fail to accurately establish causation or develop well-targeted actions and recommendations to prevent recurrence.’
Understanding the scale of investigation According to Abbott, investigation is an ‘inherently reactive response'. He continued: 'Clearly, the scale of the investigation should be proportionate to the level of risk posed by the event. This essential aspect of planning an investigation is often overlooked as it requires the consideration of the potential consequences of the event, rather than the actual consequences. Effective investigation processes require potentially high-consequence near misses to be investigated using the same rigour and application as for high-consequence accidents. We should ensure that investigation remits fully consider this factor.’
Addressing causation The objective of an investigation is to establish how the event happened and, as importantly, how it was allowed to happen. Abbott said: ‘This latter aspect requires the examination of risk control failures, human factors and organisational factors. We are therefore steered to underlying causes. There are many tools and models that can be used to establish causation, but whichever model is used, the integration of human factors is essential to ensure effective investigative practice.’
Two of the causation models most
commonly referred to in the railway industry are Heinrich’s Domino Theory and Reason’s Swiss Cheese Model. The latter features in RSSB guidance and illustrates the fact that accidents usually have a number of contributory factors, some of which are latently present in the routine working environment. However, said Abbott: ‘Investigation
reports do not always identify organisational factors and they frequently omit actions and recommendations to effectively address them. Investigation time pressures can contribute to this weakness, which can raise the temptation for investigators to draw conclusions from previous, and apparently similar events, even though the evidence may suggest different factors are involved.’
As a result, a review of investigation
reports can reveal examples that simply identify and address the immediate cause or causes. Abbott stressed. ‘Tackling immediate causation can provide a short-term solution, but the underlying causes will remain as latent conditions that are likely to act as precursors for future adverse events, possibly with more serious consequences. ‘We must ensure that investigators
understand this concept and receive effective
training in simple techniques to derive a wider view of causation.’
Improving performance and investigator competence In order to minimise the level of subjectivity inherent in an investigation, Abbot believes it is important to provide investigators with the skills and knowledge to review the risk controls and processes that were implemented leading up to an event, and to compare these with minimum requirements and good practice. He said: ‘Investigators’ training should include investigation techniques, tools to derive causation, interviewing skills, the development of targeted action plans and drafting recommendations. These skills should be kept fresh, ideally through a competence management system that includes refresher training, exercises, scenario assessments and output reviews. Adoption of such an approach will help us to ensure that investigators retain the ability to tackle investigations, even if they have not delivered one for some time.’
Improving company performance ‘Through the identification of event causation,’ said Abbott, ‘effective investigations provide a deeper understanding of risks associated with our undertakings and our organisations. Without this additional focus, we lose important data that supports our efforts to continuously improve our risk management systems.’
Require Support? Clearly, improved investigations will lead to the delivery of effective actions, improved risk control and fewer accidents. AbsTracked Solutions, founded by Abbott,
a former Principal Inspector with HM Railway Inspectorate, provides investigation training and investigation services to several of its rail clients. The training, which is tailored to meet clients’ specific needs, is highly interactive and delivered by trainers with vast experience of a wide range of accidents within the railway industry.
For more information on accident investigation and training, contact Peter Abbott, AbsTracked Solutions on 07872 609619. Visit:
www.AbsTracked.co.uk
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October 2013 Page 89
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