How To Get The Most Value Out Of Critical Risk Investigations

Thorough investigation of an accident or other high potential or “near miss” incident can provide a great deal of information about how and why it occurred – and what can be done to more reliably reduce risk in the future, according to Kym Bills, Chair of the College of Fellows and Board Member at Australian Institute of Health and Safety.

“Of course, it is better to learn from incidents that aren’t accidents that can involve fatalities, injuries and economic loss,” he said.

When a serious (non-fatal) incident occurs involving critical risks or safety critical elements, Bills said it must be reported to the relevant regulator such as WorkSafe Victoria or NOPSEMA, and in the case of aviation, rail and marine transport also to the independent investigation body, the Australian Transport Safety Bureau – which may choose to conduct an external investigation.

Bills was speaking ahead of the 2019 Victorian Safety Symposium, which will be held in Melbourne on Thursday 5 September, and said he will be using a fatal aviation accident from his time at the ATSB as an example of better practice.

“I will also show how UNSW Emeritus Professor Michael Quinlan’s ‘Ten Disaster Pathways’ might be applied to a focus on mission critical elements of this accident,” he said.

When organisations investigate their own critical risk occurrences, Bills observed that the quality of the investigation outcomes is very much dependent on their culture, maturity and resources.

“There are many good and bad examples,” he said.

“Managers and workers who fear being blamed and disciplined may not report or seek thorough investigations that could pose difficulties for them or the company.

“Or they may just be blinded by the surprise of the occurrence and unable to dispassionately see the key factors leading to it.”
Bills said that using lawyers to investigate under privilege is often done in larger organisations fearful of legal penalties, but this can make promulgation of safety lessons more difficult – both within and to others who could usefully know.

Furthermore, small organisations often don’t have the expertise or wherewithal to investigate, but if another serious event occurs it could be catastrophic for their future viability, said Bills, who explained that organisational failure or difficulty in learning lessons from past accidents and incidents is a theme repeated in many of books by ANU Emeritus Professor Andrew Hopkins AO.

Another important theme is the need for structures, processes and incentives to identify, report and address safety critical risks.

“This is a challenge for many organisations regardless of size,” he said.

“While nothing can replace careful design and review of hazards and controls from the outset, some help can be provided through technology and algorithms such as those being refined by my successor as AIHS WA Branch Chair, Dr Marcus Cattani at ECU.”

Bills predicted that augmented reality tools (based on a past accident, for example) could also assist in deeper learning of mission-critical risks.

Bills has worked in the oil and gas sector since 2009, and demonstrates many examples of better practice because of the high-risk nature of a business involving hydrocarbons under pressure and dangerous chemicals.

The ‘Stand Together for Safety’ publication by APPEA in 2016 may be helpful and the September 2017 OHS Professional article by Peter Wilkinson ‘Safety critical elements: overcoming human and organisational challenges’ is well worth re-reading.

Bills also said chapters in the OHS Body of Knowledge that most directly deal with controls for critical risks are by College of Fellows Executive, Dr Leo Ruschena (34.1) and by Trisk Kerin of ICHEME (12.3).

“OHS leaders can assist organisations to learn from critical risk incidents and avoid them in the future by seeking appropriately objective and capable investigation expertise if this is not available in-house,” he said.

“External review of in-house investigation can also be insightful.”

Article originally published by the Australian Institute of Health and Safety.