Workplace accident — who can I blame?

As many of us in south-east Queensland watch (and re-watch) the videos and media stories on the recent helicopter accident at Sea World, we want to know how an accident like this is possible. Social media speculation often seeks simplistic answers, someone to blame, but the truth is there is rarely ever a single cause for any one accident. This is why accident investigations require time, patience and sensitivity.

In a former role I worked as a Senior Transport Safety Investigator, trying to determine why some of our fatal and non-fatal aviation, rail and marine accidents / incidents occurred.  As part of my training, I learnt one valuable lesson – the unlikely is always possible, no matter how much you think you have safeguarded against it - because accidents / incidents are, by definition, unintentional.

However, once an investigation has run its course, and the findings have been made public, lessons can and should be learnt. Take the 2005 Sea-King Helicopter accident in Indonesia (Nias Island Sea King Accident Coronial Inquiry Report). The coronial inquest following the accident indicated that it was a chain of factors that lead to the accident. And this holds true for most workplace accidents. Rarely, if ever, is there a single cause for an accident. Instead, there are multiple contributory factors that, on that particular day, at that particular time, in that particular location, all coincided and resulted in the unwanted outcome. This idea is often in stark contrast to our legal system (or the voracious demands of social media), which wants to find a single causal factor or a single entity liable for the accident.

James Reason's 'Swiss Cheese Model of Organisational Accidents' (Reason, 1990) is a model of accident analysis that has survived over 30 years of scrutiny. It provides a framework for the investigation of organisational accidents that aids in identifying what factors contributed to the accident, so that re-occurrence can be prevented. It uses a Swiss cheese analogy to represent that at each level of the organisation - systems, environment, task, team and individual - there are various 'holes' (deficiencies) that may or may not align. The organisation and individuals in it do as much as they can to fill these holes, but the holes are always there in some shape or form. From poor organisational policies, procedures, and practices (such as boring mandatory online training), through to task conditions (too much workload to thoroughly check every detail), to personal, individual conditions (coming to work when you aren’t feeling 100%), down to unsafe acts (accidentally leaving trip hazards at the top of the stairwell). The holes in the Swiss cheese occur at any of these levels, and if they align on any particular day then the result might be falling down a flight of stairs and breaking your leg.

What becomes apparent is that there are a range of factors that need to align for a particular outcome to eventuate. This is why it is important to report and investigate the near misses – those situations where you almost had a bad outcome. Only then can an organisation learn where deficiencies lie in its processes, and to pose questions to rectify the deficiencies. Does a staff member need more training (or more engaging training)? Are more stringent organisational policies required (no mobile phone use while driving)? Or are more staff needed to undertake the workload required? Does the equipment need to be re-designed?

Take for example the humble hot/cold filtered taps that you find in most corporate buildings. Many years ago, a new tap had been installed in the kitchen that I frequented at work. I went to fill up my water bottle with chilled water from the tap. I pressed the cold tap down and was almost instantly burnt by hot water coming out of the spout. I managed to work out that the tap was designed in a way that it was possible for both levers to remain in the up (permanently on) position and if this happened, when one lever was returned to the centre (off) position, whichever lever remained up would then be activated. I reported my burn through the WHS register, only to receive an email from the building maintenance organisation with the remedy, “Select the cold lever next time”. This manager’s 'investigation' of the situation was entirely person and blame focused. It didn’t even look at the facts as reported (I did select the cold lever). They not only didn’t really investigate, they didn’t understand what actions had occurred, and their response allowed the situation to arise again. There were no lessons learned, no identifying of holes in the Swiss cheese, nor attempting to fill them. My response to their report clearly identified not only the error in their investigation methodology, but explained that they were opening themselves up to reoccurrence, which if repeated time and time again, may be deemed negligent. I am happy to say that the taps were redesigned so that they don't dispense water until both levers have been returned to the off position.

Investigating these types of accidents often forms part of the responsibility of managers and supervisors, sometimes as a delegation through WHS legislation. For these individuals, it is important to understand the reality of investigating accidents in the workplace. Don’t allow your personal biases to cloud your speculation of what happened or minimise your curiosity as to why the accident occurred– this is how the truth does NOT get out there and people continue to be injured at work. And while one specific incident may seem minor remember that often there’s a range of factors that need to co-exist (many holes in the Swiss cheese aligning) for a negative outcome. Learn from the situations where the not-so-bad happens, so that you can hopefully avoid that worst case scenario where everything aligns.

Learning from incidents / accidents is an organisation’s chance to stop, reflect and adapt, so it stays safe. This is what investigations should have as their underlying premise.

As for the Sea World accident, let’s wait until the investigators have identifed all the holes in the Swiss cheese that aligned on that particular day, at that particular location. Many will continue to speculate on the limited evidence they see on social media, but they don’t have the full picture to identify, let alone plug all of the holes, any one of which may contribute to future accidents. A safety proactive organisation will be reacting to, not just reading, the safety investigation report into this tragic accident to work out whether any of the same holes exist in their own operations. An investigation report that hasn’t happened in your organisation is a free safety audit worth paying attention to.

Dr Christine Boag-Hodgson is the Head of Discipline, Aviation. Her career incorporates over 15 years applied aviation industry experience working in senior safety and human factors roles. Christine also has extensive tertiary education experience, having held academic appointments for over 20 years.  Her research interests centre around enhancing operational safety and improving performance efficiency, including accident analysis, cognitive complexity, psychometrics, safety attitudes, virtual reality training, and human factors in unmanned aerial vehicles. She is an Organisational Psychologist and member of the Human Factors and Ergonomics Society (US), as well as the Australian and International Societies of Air Safety Investigators.