Do construction investigations take broader systems perspectives of accident causation, or stuck in the mud focused on local factors, people and behaviour?
Further, do investigations help organisations navigate complex, often entangled sociotechnical matters, or hinder progress in safety capacities?
Today’s paper is from Woolley, M. J., Goode, N., Read, G. J., & Salmon, P. M. (2019). Have we reached the organisational ceiling? a review of applied accident causation models, methods and contributing factors in construction. Theoretical issues in ergonomics science, 20(5), 533-555.
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Transcript:
Is it possible that our conventional approach to investigate incidents and construct reality will help to reinforce a blame focus on people? But if we always do what we’ve always done, are we truly surprised when we always get what we’ve always got? Namely, accidents that keep reoccurring and systemic problems that remain unaddressed.
G’day everyone, I’m Ben Hutchison, and this is Safe As, a podcast dedicated to the thrifty analysis of safety, risk, and performance research. Visit safetyinsights.org for more research.
Today’s paper is from Woollie et al. titled “Moving Beyond the Organizational Sealing to Construction Accent Investigations Aligned with System Sinking,” published 2018 in Human Factors and Ergonomics in Manufacturing and Service Industries. This study analyzed 100 serious or high-potential construction ICAM investigation reports from five Australian construction companies to see the extent to which they aligned with systems thinking principles.
It’s argued that construction can be described as being a complex socio-technical system, influenced by a fast pace of technological change, and the impact of economic and political pressures. Thus, accident and other models used within construction should reflect the various vertical and horizontal actors and hierarchies involved in decisions across the whole socio-technical system. In contrast, it’s argued that existing construction accident models and, I guess, existing worldviews may be dominated by linear thinking, with proximal factors like individual errors being the main focus of investigations. Rasmussen’s risk management framework and associated axiomaps were used to evaluate the comparison between ICAM investigations and the systems thinking tenets. I don’t have space to describe Rasmussen’s framework, so I recommend checking out some of his work, and you can find it by searching his name on my site.
So what did they find? Overall, analyzing the ICAM reports revealed that, quoting the paper, “construction has not moved beyond a human error focus and and does not presently identify multiple actors and contributing factors or the interactions between them.” These investigation reports from the participating construction companies revealed that, for the causal analysis, actors involved in the government, regulatory, client, or company levels of the framework were either not identified or not examined. Despite this, 100% of the reports identified the contribution of actors at the operational, management, and staff levels of construction.
Regarding causal links in the accidents, at the management level of analysis, supervisors were identified in just over 20% of the reports, and leading hands identified in about 9% of the reports. For the staff level of analysis, plant operators were, expectedly, the most frequently identified causal link in investigations, at 70%. Laborers were identified in about 23% of reports. Indeed, staff-related factors were identified pretty much in 86% of reports, with most of these instances being attributed to human error, like 83%. And of these, often it was reporting that workers had failed to follow procedure or the direction of a supervisor.
And in my view, regarding procedures and investigations, these have to be among the most intellectually lazy and insubstantive findings, unless matched with a nuanced understanding of how and why. How did it make sense to them not to follow the procedure? Did they even know the procedure? How was the task done last time? How was the task done usually? What were they instructed on when they started the company? What have they learned over time? What have leaders chosen to ignore? These are all things that need to be unpacked.
Regarding the interrelations of identified contributing factors, the investigation showed no relationships between any identified factors beyond the company level, as we would expect if a systems thinking approach had been used. Also, it was observed that in the few reports that did identify relationships between factors at the company level, just relinkages between safety management systems and project management were identified.
Next, the authors moved on to the corrective actions. Most actions were pitched at the staff level of the framework. The most commonly identified areas for corrective action and resolution were 46% of improving safe work method statements, 39% were delivering toolbox talks, conducting risk assessments were identified 33% of the time, there was further training in 14% of instances and then hazard awareness at 28%, and a few more findings that I’ve skipped.
Another interesting finding was that where corrective actions directed attention towards raising awareness of issues, they were typically framed as broad statements that appeared to shift responsibility to the workers. For instance, statements like “know your limits,” “stay safe,” “keep eyes on path,” “fatigue causes accidents,” as opposed to concise countermeasures capable of being implemented and measured. Also interestingly, they noted that when toolbox talks were identified as an action, they are often included as a corrective action without further explanation of required content, or the intended audience, or what the toolbox was to achieve or how its effectiveness could actually be measured. One of my audit studies found something similar. Toolboxes are used as corrective actions in a sort of Swiss Army knife merged with WD-40 way, tackling everything without really addressing anything.
A number of findings were covered for whom corrective actions were assigned to. For instance, 100% of the reports allocated at least one or more of the corrective actions to the safety advisor, but critically, only 36% of the reports allocated a corrective action to the project manager, a person who usually has far more clout and control of project resources. So corrective actions appear to excessively focus on lower-level aspects, not aligned with operational company-level contributing factors, the latent factors, the upstream factors. Corrective actions that were aligned to company and management level factors were consistently allocated to safety advisors, who, quoting the paper, “may be unable to influence the implementation of the required actions.”
Also, the investigations omitted quite a lot of other stuff. They didn’t examine the relationships between management inaction, cultures, and developing robust safety management systems on management or staff level practices.
So what can we make of the findings? The paper does a pretty good job. It says existing accident investigation processes are not identifying the range of contributing factors involved in construction accidents. So they’re missing out on a whole lot of useful intel. Also, they aren’t adequately considering the system-wide interactions that influence construction safety. Therefore, from the paper, “the ability for companies to substantially disrupt the existing rate of construction fatalities is diminished if we continue to overlook the influence of system-wide interactions.” And implementation of the countermeasures and the corrective actions of improvements that might actually help us improve are overwhelmingly allocated to people lower in the hierarchy with the least power or resources to effectively change things.
So limitations, there were a few. But importantly, investigation reports only provide a limited view of investigation practices. They’re less entirely objective captures of reality and more socially constructed abstractions. The data was limited to five Australian construction companies also. So it’s unknown how well we can generalize the findings. That’s it on Safe As. I’m Ben Hutchinson and hope you found this useful.
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