safety culture and investigations - microsoftbtckstorage.blob.core.windows.net/site987/2018...
TRANSCRIPT
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
[email protected] OCAID