WOSHA

John Dillon

RyderMarsh OCAID

Safety Culture and Investigations

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

SAFETY CULTURE

It’s all about what NORMALLYgoes on around here

What is Culture?

RMOCAID Safety Culture Development Map

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

100%

100%

0%

0%

SELF

ORGANISATION

XXX

XX

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

13

System 1, or Fast Thinking

14

17 x 24System 2, or Slow Thinking

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?

Stages of The Incident Investigation Process:

Mobilise Incident Investigation

Team

Collect Information/evidence

Analyse/Review Findings

DevelopRecommendations

Blame

V

Just Culture

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

Do a bit of self analysis first

Yes you are!

I’m not trying to blame anyone,

but ...

RMOCAID Safety Culture Development Map

Thank You

john.dillon@rmocaid.comRyderMarsh OCAID