Root cause: going beyond ‘human error’
In the first article I wrote, based on the media’s quest to find a cause for the Croydon tram crash, I proposed health and safety coaching for the media to include: incident causation, incident investigation and root causes, as well as health and safety law with a focus on directors’ and managers’ responsibilities.
Incident investigation and root-cause analysis build on the principles of Reason’s Swiss Cheese model and strike at the heart of what a journalist is always looking for: answers.
Journalists are trained in the art and science of asking questions: who, what why, where when – and often at what cost? Many of them go into journalism because they are naturally curious and are strong writers and communicators (as my first editor told me – ‘we are the nosey village gossips and we get paid for it’).
They are extremely skilled at winkling out information and getting normally balanced, discrete professionals to speculate on incident causes, and will even help you on your speculative way with closed questions.
But few reporters seem to have a grip on some of the excellent methodology used by incident investigators – and the benefits it could bring to robust reporting of incidents and their aftermath. After all, asking ‘why’ five times should come naturally to a journalist.
Sole cause and human error
As one HSE document investigating accidents and incidents puts it: “Investigations that conclude that operator error was the sole cause are rarely acceptable. Underpinning the ‘human error’ there will be a number of underlying causes that created the environment in which human errors were inevitable.
“For example inadequate training and supervision, poor equipment design, lack of management commitment, poor attitude to health and safety.
“The objective is to establish not only how the adverse event happened, but more importantly, what allowed it to happen.”
As we know, systemic failures will be a feature of what contributed to an accident, so journalists who have a grounding in incident investigation could focus in on these areas earlier in their reporting of an incident.
Businesses may not be in a position to answer the questions – or may be unwilling to do so, but it doesn’t stop the media asking them.
Tone from the top, company culture and previous track-record are key sources of evidence for the incident investigator and can also be for the journalist.
Piper Alpha: extensive recommendations
The Cullen Report into Piper Alpha is a good example of an incident investigation that shows the breadth and depth of contributory factors that result in an accident. The report certainly had improvement recommendations for the workers and managers on the platform, but its recommendations covered all levels of the offshore oil and gas sector from to the rig operators, right up to regulators and government.
Cullen’s 106 improvement recommendations were shared between procedures for operating equipment, information of platform personnel, covering the design of platforms and those related to the emergency services.
In the case of the Piper Alpha investigation – a structural mismatch of governance at regulator level resulted in the oversight of safety in an entire industrial sector passing from the Department of Energy to the HSE.
This was intended to separate the potential conflict of interest between promoting production and safety. From a journalist’s perspective, this government involvement makes it a meatier story.
Understanding the key elements of an investigation also helps journalists who attend the hearings to be more in touch with proceedings. Their knowledge of law when it applies to court cases helps them report on these cases in a professional way, but some coaching in the anatomy and terms of reference of a typical inquiry, including air accident and marine accident investigations, public inquiries and commissions would also make their job easier.
Sleep and Fatigue: Director’s Briefing
Fatigue is common amongst the population, but particularly among those working abnormal hours, and can arise from excessive working time or poorly designed shift patterns. It is also related to workload, in that workers are more easily fatigued if their work is machine-paced, complex or monotonous.
This free director’s briefing contains:
- Key points;
- Recommendations for employers;
- Case law;
- Legal duties.