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We will release a number of discussion papers and welcome any comments.  The idea is to take accident investigation away from the old fashioned tree style systems and forward into modern qualitative analysis aimed at identifying underlying causation.

Go for it and get involved - either email kinaston100@gamil.com or use the website to leave your comments.








A Change of Perspective - What is meant by ‘terms of reference’ in the world of accident investigation and their link to causation and loss control.


We come across the phrase ‘terms of reference’ (TOR) regularly within industry and depending on ones ontology it means different things to different people.  In the world of accident investigation TOR have been used for a variety of purposes.  These range from identifying those who are to ‘blame’ for loss through to the identification of weaknesses in organisational culture. 

Many TOR could be said to reflect the perceived organisational needs of the individuals who develop them. The weakness with this situation is that it requires those who identify the organisational needs to appreciate the full gambit of what options are available in order to make the best choice of TOR.  It is obvious that this is an impossible situation and we have to do the best we can, however those who are in this position should obviously have direct access to the boardroom decision making process.  In the past there was a drive to establish blame; then with the politically correct evolution of the blame free environment there was a re-positioning in order to establish responsibility.  None of this appeared to reduce the number of incidents and indeed neither did it have much effect on the development of organisational philosophy.  If one were to examine the number of accidents that occurred each year many organisations found that they were flat lining.  They were spending huge amounts of their resources on reducing accidents and loss, indeed they had been very successful until they hit what appeared to be a ‘wall’.  Little change occurred even with the most drastic direction from the top of the organisations.  In many organisations the concept of the no-blame culture faltered, it was replaced by fair-blame and other similarly named concepts; still apart from a few fluctuations the number of accidents remained constant.  Often discipline was seen as a key tool to control loss with the result that terms of reference sometimes even reflected a stated desire to identify information that could be used for this purpose.  The effect of this process was that the flat line persisted.

It is important to make the point here that it is the number of accidents that remained constant not necessarily the outcomes.  In general many of the organisations will say that they have experienced a reduction in the number of severe outcomes; however it is possible that this is achieved as a consequence of increased understanding of risk control.

The flat line has a different height for different organisations and possibly sectors within businesses that operate in a western organisational environment of profit and loss.  Each organisation has tried different patterns of similar strategies for controlling the flatline, each recognises the loss in turnover that the events are causing and each recognises the risk that is associated with failure to control loss events.

The obvious question that the flat line conjures is, ‘what does it represent and how do we control it’?  The answers lie in understanding modern day concepts surrounding causation.
What is meant by underlying causation?  There is much written on this subject, but in essence it means; what was it that initially triggered an event.  Modern day approaches tend to look at boardroom decision making as being the locus of causation.  The rational behind this is simple.  The board dictates workplace culture and the ‘goalposts’ within which the organisation operates.  These are different for every organisation.  The goalposts dictate rules; both explicit and implied; what’s allowed, what’s not and more importantly the degree of deviance that will be tolerated at different times.  This set of values and attitudes are transposed throughout the organisation and are reflected in the way that staff at the front end interpret them; in effect their actions are symptomatic of the culture that they find themselves within.  The development of this culture is linked heavily to four key groups of factors that effect boardroom decision making.  These are, education, organisational cultural issues, personal factors and information.  Through unrecognised weaknesses in these areas executive decision makers set up ‘organisational failures’  that then result in individuals committing substandard acts in the workplace which potentially may lead to events.  Whether an event occurs or not is often dictated by sets of prevention measures which in reality maybe as complicated as policies or as simple as the human recognition of danger.  When an event of sufficient impact occurs the organisation will usually investigate it and try to identify organisational failure, but it will often resist the need to look at decision making for fear of exposing the board to scrutiny.

Thus in the world of accident investigation the investigator needs to be able to work with a set of organisational TOR that will reflect the organisational desire to identify causation.  There is an obvious legal issue here in that the organisation will also have to satisfy its need to provide legal advisors with the information that they require in order to identify civil or criminal exposure.  There will obviously be legal conflict where an organisation wishes to try to place its investigation under legal privilege as on the one hand there is a desire to be open, whilst on the other, a desire to control the release of information.  Although there is a balance to be drawn an organisation should realise that if it does not deal with the problem of causation then the flat line will not reduce further.  If its competitors are looking at causation then obviously they will become more competitive as they reap the   the rewards of a positive reputation and the associated financial benefits.  If it is already looking at causation then it is likely that it will be able to justify its actions in relation to cultural control.

The TOR obviously need to be set by the boardroom as they will have to understand the strategic nature of the process.  This will likely require some CPD at that level which should also include a presentation on modern day causation.  There is a second issue linked to this; what about our contractors or even our clients.  Hopefully their culture will be able to co-exist with ours; but how far does there investigation process go and what are their TOR in relation to AI.  Too close a relationship with a poor culture can obviously have a negative effect on our own organisations.



Ian Langston - October 2015