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  • John Kingston

Polite Self-Investigations

In the UK, there is no statutory duty to investigate occupational accidents. There is, however, a duty to have a valid risk assessment. Although an incident or accident is not proof that the relevant risk assessments are invalid, it is a reason to check. And that’s a good starting place for self-investigation. Are the risks what we thought they were? Do the precautions work, do they add up to a safe system? And, if they sometimes don’t, what is that telling us about how we manage our business. Like debriefs, investigation can be seen as three steps. First, get clear about what happened. Second, explain what it means in terms of precautions and management. Third, decide what needs to be done and make it happen. Gary Rolfe put it brilliantly: ‘What happened? So what? Now what?’

Fifty years ago, the Robens committee report said ‘we need a more self-regulating system’. That’s not a question of if; it’s a matter of how. Yet, how we do ‘safety things’, especially looking into accidents, seems drawn to a top-down fault-finding mode like a moth to a flame. Finding what went wrong seems to dominate, and what is right is not questioned enough. Instead of adults sharing their reasons, we fall into the roles of ‘critical parents’ and ‘rebellious children’. An accident is the time to regroup outside of our usual roles. For a short while, the status quo is something to unfreeze: to question and improve. Remarkably, the ceiling does not fall in. It’s possible to preserve the dignity of the organisation with polite openness to each other and to change. It is a cliché, but it’s true: everyone has something to learn. And that’s why, for actions after self-investigation, amongst its other meanings, the A in SMART needs to stand for agreed.

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