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Incident and Crash Investigation

Problem Solving Strategies For Incident / Accident / Crash Investigation

Incident and Accident Investigation is the single most important tool for improving OHS management performance in terms of risk and cost reduction. Murcotts provides training for those with risk management responsibilities as well as for Fleet Managers, OH&S and Human Resources representatives.

Murcotts can provide facilitators to assist your teams conduct investigations objectively to ensure a reduction in your exposure to OHS and other business risks, as well as ensure compliance with HSE legislative requirements.

Incident and crash investigations serve as useful training opportunities in hazard identification and risk management for those who participate.

Murcotts draws a strong distinction between internal investigations for OH&S purposes and external investigations conducted by various authorities such as the Coroner, Police or WorkCover. The latter may include forensic analysis which is not the domain of in-house investigations. Such external investigations are likely to result in legal actions and prosecutions. Internal investigations on the other hand, must establish effective corrective actions that will prevent recurrence of similar crash types.

The six stage group problem solving model systematically guides the investigators through a process that targets causal factors and avoids judgement, blame and emotional solutionism.

The stages are as follows:

  • identifying and describing the event
  • gathering the facts relevant to the event
  • isolating the contributory factors
  • establishing and checking corrective actions
  • carrying out the improvement
  • follow up

A key philosophical issue is the removal of blame and fault in favour of establishing the objective contributory factors or root causes of incidents/crashes. Assisting in-house investigation team members to overcome attitude biases that may have been influenced by public debate about road safety that focuses on blame through references such as “careless driving” and by insurers that refer to “fault”, is a crucial learning outcome in Murcotts’ training.

This investigation system can provide accurate information in the case of legal actions and compensation claims. Comprehensive training in workshop format supports this system and during training participants work on recent cases that have occurred in their workplaces.

Learning Objectives

At the completion of the program, participants should be able to:

  • Describe the stages of the incident investigation process and its role in effective OHS and Fleet Management;
  • Understand the issues of risk behaviour, risk perception and risk taking as contributors to incidents;
  • Identify and accurately describe problems, incidents, crashes and accidents;
  • Recognise when these events require a structured problem solving strategy;
  • Use the method of collaborative problem solving to analyse and resolve these events;
  • Participate in and lead a brainstorming session to gather incident data;
  • Use Cause and Effect Diagrams and Five Whys tools to assist in analysing root causes;
  • Describe the systematic link between Accident Investigation, Hazard Management and Job Risk Analysis;
  • Use the organisation’s documentation to assist in the incident investigation process;
  • Know where to source additional materials and systems information to assist in implementing the above systems.

Workshop Structure

A two-day program comprising a practical workshop that addresses the theoretical concepts of incident investigation using practical exercises and case studies. Participants are set an assignment that involves a practical on-the-job investigation using the model. This is followed by a half-day assignment review approximately three to six weeks later to assess the effectiveness of the application of the theory in the field.

Methodology

Murcotts’ program is based on the principles of prevention, using risk management and hazard management theory and practice and OH&S legislative requirements, particularly the requirement to provide safe systems of work.

This directs our investigation process to focus, in the first instance, on the systems that have influenced the driver behaviour or contributed to any driver error. For example, the systems of recruitment, induction, safety management, vehicle selection, maintenance, performance management, training, work scheduling, etc. In particular the investigation should focus on the lack of systems or weaknesses in their implementation which are likely to manifest themselves in inappropriate driver behaviour.

The process of Murcotts’ investigations involves teamwork and group analysis where the synergy arising from participants’ contributions is helpful in teasing out possible contributory factors. Employees involved in the incident (drivers) as well as those familiar with the work activity are included in the process where possible. A ‘value add’ from this process is the education of those employees in crash causation and problem solving methodology.

Problem solving is an active skill therefore the workshop is conducted using high levels of involvement and interaction between participants and facilitator. Participants are encouraged to think analytically and laterally. Healthy debate is encouraged and is essential for skills transfer to occur. Common myths are confronted such as blaming careless workers/drivers in favour of determining systems failures that underpin those behaviours.

A key component of the training requires each participant to complete a practical workplace assignment in which an incident is investigated using Murcotts’ six step problem solving model. To be assessed as competent the participant must demonstrate and provide evidence that all steps have been implemented and that their findings will deliver an improvement in safety outcomes. A presentation to the training group is required.

Murcotts’ program is primarily focused on the problem analysis process as opposed to accident reporting. The statistical and reporting data required by insurers and WorkCover authorities is secondary to establishing the root causes and treating them. Murcotts’ experience is that some clients discover a reversal of this priority where the bureaucratic reporting of incidents takes precedent over true causal analysis. In addition, the process often involves only one or two key persons rather than many, thus missing the opportunity to impact on organisational safety culture.

Content

Perceptual Bias in Investigations – an unfreezing exercise that engages the individual and small groups in interactions that highlight their perceptions and attitudes that may bias the outcomes of investigations – Highlights the need for objectivity and non-blame strategies.

Understanding the Reasons for Investigations – OHS Law – Hazard and Risk Management improvement – Team engagement and learning about OHS.

Collaborative Problem Solving – introduction to the six-stage model and root cause analysis. Includes common linkage between problems, incidents, crashes and accidents.

BAAMS® Driver Profile – understanding the human factors in incidents, accidents and crashes and their effect on risk behaviour, risk perception and risk taking as contributors to incidents.

Practical Techniques of Inquiry – Problem identification and naming, Brainstorming, Cause and Effect Diagram, Five Whys tools to assist in analysing root causes.

Case Studies – small group exercises using vehicle incidents and crashes then actual cases to apply the techniques.

Objective Analysis - isolating essential causal factors without bias, determining corrective actions, avoiding simple fixes.

Resources – OHS policies, sourcing additional materials and systems information to assist in implementing the above processes.

Assignment Setting – establishing requirements for practical application in the field in preparation for half day review.

Day 2 – Half day Review

  • Presentation of investigations into actual incidents in the workplace conducted since Day 1
  • Review of theory
  • Recommendations arising from the course (e.g. policy modification, systems upgrade etc.)
  • Presentation of Certificates ( Evidence of practical work required for accreditation)