Safety Culture and Investigations - Microsoftbtckstorage.blob.core.windows.net/site987/2018...
Transcript of Safety Culture and Investigations - Microsoftbtckstorage.blob.core.windows.net/site987/2018...
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WOSHA
John Dillon
RyderMarsh OCAID
Safety Culture and Investigations
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Topic
• Safety Culture.
• The impact of poorly carried out investigations.
• Why poor quality investigations occur.
• The benefits of high quality investigations.
• The benefits of improving peoples perception of Safety Culture
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SAFETY CULTURE
It’s all about what NORMALLYgoes on around here
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What is Culture?
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RMOCAID Safety Culture Development Map
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The Culture of the Organisation
• Accidents get us into trouble– Keep quiet and cover it up
• Accidents are caused by people– Who can we blame for this?
• Accidents happen because the system failed
– Let’s review the paperwork
• We need to prevent accidents– Let’s fix this to stop it happening again
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100%
100%
0%
0%
SELF
ORGANISATION
XXX
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Mistakes
Routine
Situational
Exceptional
Optimising
Unsafe Act
Errors
Violations
Skill-based errors
Slips (of action)
Lapses (of memory)
Rule-based mistakes
Knowledge-based mistakes
Human Failure
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System 1, or Fast Thinking
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17 x 24System 2, or Slow Thinking
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System 1 or 2?
• A bat and a ball costs £1.10
• The bat costs exactly £1 more than the ball
• How much does the ball cost?
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Stages of The Incident Investigation Process:
Mobilise Incident Investigation
Team
Collect Information/evidence
Analyse/Review Findings
DevelopRecommendations
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Blame
V
Just Culture
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An Investigation is NOT about
• Apportioning blame• Covering up facts• Determining legal liability• Fending of investigation by an enforcing agency• Reducing the likelihood of a civil claim
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Do a bit of self analysis first
Yes you are!
I’m not trying to blame anyone,
but ...
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RMOCAID Safety Culture Development Map