Over the years, as fatalities and incidents in construction have continued to rise, numerous initiatives have been implemented and plans drawn up to try to sort out what remains the most dangerous industry in which to work. Here, John Anderson argues that competent, independent incident investigation could be the answer.
In the world of occupational health and safety within the UK construction industry, where there can be tens of thousands of accidents and incidents a year, occurring in myriad circumstances, it is reasonable to assume that there would be an established and well-defined set of approaches as to how to conduct investigations, but this is not the case. One reason for this might be the fact that there is no requirement in UK law to investigate a reportable, or any other accident. The literature on this subject is not extensive,1-9 particularly in respect of the complex circumstances of the construction industry, but in my experience it can be the case that:
Construction accident/incident investigations are hurried, shallow, and can fail to determine the range of underlying causes;
There can be ‘investigation bias’ depending on the viewpoint of the person/entity leading the investigation, and investigations may be undertaken in a fragmented manner;
Investigations can suffer from a lack of planning and resourcing for this very specific work activity;
Investigations often do not consider human factors in enough detail, possibly owing to a lack of expertise;
Understanding of the “mishap environments”, which, in the construction industry, can be many and varied, may not be clear;
The diversity of situations in which mishaps occur in construction raises practical difficulties of investigation and description, and such difficulties are not easily overcome; and
The outcomes of mishap investigations are rarely efficiently shared within the organisation involved, while sharing information across the whole industry is even less likely.
Hurried investigations
Senior management often demands that those charged with the investigation come up with an “investigation outcome” as soon after the event as possible, and this pressure may be difficult to resist. It can be combined with other pressures to “get the facts” and to hand these over to senior management, who are waiting for answers. However, it may be the case that the “facts” are disputed or unclear, and any uncertainties must be resolved before the “facts” can be handed over to others who are remote from the detailed investigation process itself.
There may also be a conflict between the need to conduct a swift but effective investigation while also minimising the disruption to normal work activities, either on site or in the design office. In addition, there may be more general management resistance — whether expressed openly or not — to the diversion of key resources to this investigation work, which could be seen by some as non-productive.
Shallow investigations
There may be unreasonable time constraints imposed on investigators that could hamper the planning, discovery, thinking and analysis involved in the investigative process and its outcomes. There could be pressure to focus on pinpointing some person or persons, or some factor, as the primary or significant ’cause’ of the mishap. Indeed, the scope of the investigation may even be deliberately curtailed by senior management, who may pose questions, or have reservations, about the merit of any investigation that seeks, in their view, to go beyond what they might regard as the obvious causes of the mishap.
Those chosen to undertake the investigation may also lack the necessary investigative skills or knowledge, and this may or may not be recognised. There may be a lack of organisational specification as to how far any mishap investigation should go, and there may even be a desire by management to actually avoid any truly in-depth investigation process.
Investigation bias
Depending on the nature of the mishap, there are four parties that could mount an investigation: the company safety specialist; the local manager in charge of the specific work activity involved; an external enforcement authority person; and the insurance company representative. Mishaps are invariably failures (to some extent) of the health and safety system in place at the time, and it is within the author’s experience that a safety specialist might be inclined to minimise criticism of the safety management system that he or she was primarily involved in devising.
Senior management retains the responsibility for resourcing and implementing the safety systems, and any local management may be inclined to avoid open criticism of management’s role (or lack thereof) in the mishap. The enforcement authority will be primarily concerned with determining whether any rule or regulation has been broken. The insurance company investigator will also have his or her own agenda, which could be focused on the nature of the contract between the parties, rather than individuals’ actions at, or near the time of the mishap.
Other common investigation problems, as identified by Ferry,1 include:
Investigations are usually conducted by untrained people;
Management does not recognise its real stake in investigations, and thus has superficial interest;
The company or organisation, in general terms, does not feel supportive of good but time-consuming investigations;
The benefits of good investigation are not recognised;
The government is only mildly interested in detailed investigation of mishaps; and
Few organisations incorporate outcomes of mishap investigations into subsequent planned prevention programmes.
The big one
Reason4 describes large-scale events as “organisational accidents”, which he defines as “comparatively rare, but often catastrophic events that occur within complex modern technologies, and which are likely to have multiple causes, involving many people operating at different levels within their respective organisations. They can have devastating effects on uninvolved populations, assets and the environment.”
A structured investigation into such an event will require a closer look at a number of other factors, such as:
Competence of the individuals in key positions;
Procurement practices (design and construction) and the detail of the civil contracts between the parties;
The extent to which cooperation and coordination of effort were encouraged between the parties, and the extent to which they were achieved;
The extent to which there was or was not a person (or small group of people) charged with an overview of the effectiveness of the whole system;
The extent to which possible ‘big event’ mishaps had been anticipated, and to what extent preventative measures had actually been put in place; and
The extent to which emergency plans had been prepared and implemented, when they proved necessary.
In summary, the present arrangements for construction accident investigations:
do not ensure that sufficient valuable information revealed by quality investigations is passed effectively between companies and others for the benefit of the whole of the industry;
mean there is too much of a difference between the best techniques and strategies in this subject and poorer standards of approach elsewhere;
mean there is less circulation of the facts resulting from accident investigations because of concerns over confidentiality and subsequent legal actions of one kind or another; and
have become an urgent matter for consideration, given that investigations are now under way under the Corporate Manslaughter and Corporate Homicide Act 2007.
Branching out
The time is therefore appropriate to consider the merits of setting up a skilled and truly independent investigation branch to look into the fatal accidents happening in the construction industry.
Of course, this would require new legislation, which, for the sake of argument, we’ll call the Construction (Fatal Accident Investigations and Reporting) Regulations 200X. Three Investigation Branches already exist, and there is an official protocol for investigating workplace deaths,11 but it is only signed by some of the parties who could be involved, and the key phrase it uses — “sound investigation” — is neither defined nor explained.
This document is disappointingly unhelpful, as it is largely focused on the procedure for mounting criminal prosecutions, and has little to say about establishing the facts and the independent discovery of the causes of what happened. The issues of matching legislation and enforcement are important,12 but so is the business of independently establishing cause. (There is an interesting feature of the Air Accident Investigation Board, where the investigations are carried out by both an “experienced professional pilot” and an “experienced aeronautical engineer”.)
Borrowing words from the legislation relating to the existing Investigation Branches, and applying them to the context of fatal accidents in construction:
The minister would appoint independent inspectors to investigate fatal accidents in construction. These persons would be a combination of experienced construction professionals and qualified construction engineering professionals, with a wide technical background;
One of those inspectors would be the chief inspector;
The aim of this new investigating inspectorate could be threefold — namely, to (a) undertake the investigation of every construction industry fatal accident and to make recommendations; but also, more broadly, to (b) promote improvement in the safety of construction work and thereby help prevent fatal accidents in construction; and to (c) promote efforts to improve and disseminate techniques of accident investigation within the construction industry by means of publicly available training and education activities;
In investigating a fatal accident that has occurred during construction work, the inspectors’ duty would be to determine what caused it, and in undertaking this task, inspectors would not consider or determine blame or liability;
A report would be prepared for each fatal accident, and that report would address the question of what caused the accident, and contain recommendations;
Investigating inspectors would give an opportunity to persons interested in the investigation to comment on a draft of the report before publication.
Could all this be a practical proposition? Well, given that there were about 70 fatal accidents in construction last year, this does not seem an impossible workload for the right team of people. While companies and individuals (and their legal advisors) may continue to seek to establish ‘blame’, the important prize of having an independent report focused on ’cause’, and the wide use to which such valuable information could be put, in terms of future preventative measures, would be well worth having.
References
1 Ferry, T S (1988): Modern accident investigation and analysis, John Wiley & Sons, New York
2 Vincoli, J W (1994): Basic guide to accident investigation and loss control, John Wiley & Sons, New York
3 Dekker, S (2006): The field guide to understanding human error, Ashgate Publishing, Aldershot, Hampshire
4 Reason, J (1999): Managing the risks of organisational accidents, Ashgate Publishing
5 Health and Safety Executive (2004): Investigating accidents and incidents (HSG 245), HSE Books, Suffolk
6 Health and Safety Executive (1999): Reducing error and influencing behaviour (HSG48), HSE Books
7 Construction Safety Association of Ontario (1999): ‘Accident Investigation’ (57 pages)
8 Abdelhamid, T S, Everett, J G (2000): ‘Identifying root causes of
construction accidents’, in Proc. Journal of Construction Engineering and Management Jan/Feb, 126, No1, pp52-60
9 Haslam, R S et al (2005): ‘Contributing factors in construction accidents’, in Applied Ergonomics 36, pages 401-415
10 Oates, A (2008): Tolley’s corporate manslaughter and homicide, LexisNexis Tolley (see Chapter 10)
11 Health and Safety Executive (2003): Work-related deaths — a protocol for liaison, (Misc.491)
12 Anderson, J M (2007): ‘Health and safety — matching legislation and enforcement, in Proc. Inst. of Civil Engineers 160 1 ‘Management, Procurement and Law’, 11-15
John Anderson is a consulting civil engineer and regular contributor to SHP.
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