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September 13, 2019

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Accident investigation

‘Without something being different, incidents don’t occur’

‘The Times They Are a Changin’ wrote Bob Dylan in his famous song of 1964. This is certainly true today. People all around the world are experiencing or being exposed to more political and environmental change than has probably existed for at least a generation.

David Ramsay, Group Managing Director, Kelvin TOP-SET, tells SHP that, “WDavid Ramsayhen we consider accidents and their causes, the first question has to be, “What has changed?” Because without something being different, incidents don’t occur. Amazingly, this isn’t always understood. We were engaged to conduct an investigation where a massive oil storage tank on a refinery site imploded. Amazingly, the site Chief Engineer denied that anything had changed. Clearly, complete nonsense.

“We had a broadly similar experience of a fire onboard a ship. A large major electrical module was burned out. Nobody had touched it, it was not supplied with power, but it still burned out; a total mystery. The investigation, which took days, concentrated on what had changed; something is always different.

“When we look at safety, and risk assessment in particular, there are many excellent tools and programmes available. We particularly like bow ties because they are a visual representation of risks and barriers. However, their use requires a high degree of imagination. You may think this strange, but risk assessment is essentially an exercise in ‘What if?’. Of course, much of risk assessment is based on experience and expertise, but it is the ability to consider all of the possible changes that may occur that is particularly difficult. Quoting Donald Rumsfeld in 2002 ‘The unknown unknowns’. Very challenging.

“When we look back over all major disasters, the information about the triggers and causes is always there, but has been missed. Aberfan, Chernobyl, Deepwater Horizon, Boeing’s 737 Max, and any others that you care to think about, are full of examples of missed signals or indicators. What makes it worse, is that there is never a single cause. Also there has often been creeping change or what we call ‘Organisational Rust’, small unseen systems degradations, unrecognised, or unseen over time.

“From all incidents, it should be obvious that human factors are at the core of the problems. You might question this, but everything is designed, maintained and operated by people. Also obvious to all of us, is that we live in an increasingly complex world. So how can we help to see the risks?

“Crazy as it may seem, small children are best at unconstrained thinking. When we teach people from around the world how to investigate, we do emphasise the importance of being undefended and being open to thinking like a child. This is probably harder to do the older and more qualified we become. We can become fixed in ‘what we know’, whereas it is important to also concentrate on what we don’t know. An example of this was in another investigation that we conducted, this time in a very remote location. A 250-tonne load had been dropped. Full risk assessments had been done by professional engineers, and yet the potential failure had been missed. After the event, non-technical people were saying that it was obvious that this lift could go wrong. Our recommendation was to have mixed discipline and mixed gender risk assessment teams to widen the thinking, and to even ask apparently ‘daft’ questions, to be challenging and ensure that all possibilities were explored.

“Edward de Bono who in 1967 coined the term ‘Lateral Thinking’, suggested that one of the problems is that while we teach people various disciplines, we don’t actually teach them to think. His system works on the basis of indirect and creative problem solving that doesn’t rely only on step by step logic. Perhaps there is a solution here in that we should, as a first step, teach risk assessors and safety specialists to think differently, to use more lateral thinking. To avoid incidents we need to be better at spotting was has changed or might change. It always comes back to people and how we think.”

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