Investigation recommendations and the hierarchy of control

Have national focuses on the hierarchy of control and prevention through design influenced investigation findings over time? A 2014 paper from Michael Behm and Demetria Powell explored this question.

Comparing 249 investigation reports prior to 2006 and from 2008 to 2014:

1) Incident causes categorised as either latent or active failures have not statistically changed over the time periods

2) Risk reduction recommendations in investigations had slightly changed to include more higher-order controls, but this wasn’t statistically significant

3) Elimination was the only control where a statistically significant change was observed

4) For lower order controls, no significant difference between the time periods was observed. However, they found that administration controls were recommended in nearly 88% of all investigations.

Investigations “were focused largely on single causes and single solutions”.

This could be a limitation since a body of evidence suggests incidents having multiple factors and multiple learning opportunities.

Taken together, the authors wonder whether “safety professionals are stuck in an administrative control mind-set” and whether the “safety profession [is] stuck at the sharp end?”.

Another view is the ease of targeting training, updating procedures or worker behaviour, such that these facets are “likely within [safety professionals’] sphere of influence”.

Further, they question whether safety professionals are effectively working “with the people who can implement higher-order controls (e.g., engineers, architects, designers, senior-level executives, operations managers and planners)?”

The authors argue that the safety professional’s role “must evolve and be upgraded” and subsequently focus further upstream in the lifecycle and with higher-order controls (see image 2).