We had an incident where a car came off a hoist. The independent IQP for the hoists clearly pointed out and proved that the fault was "operator error". The end result was a costly exercise for the company as the vehicle was written off from the damage sustained and the hoist had to be replaced due to damage resulting from the incident. The technician, whilst obviously embarrassed with his actions, was not persecuted by the company. We undertook a full enquiry which resulted in a new SWP for Hoists being written and we also made adjustments to the telescopic arms of the hoists.

Without reading the article yet... is it just semantics? Is it actually simply "you can learn or you can not learn". After all post-incident I can blame the worker for being an idiot and fire them, but still also learn from that and change how I go when I am hiring their replacement. This could be seen as blaming the worker, but also learning from one recruitment mistakes. Sometime we do end up with job-fit mismatches where the best outcome for all parties is the worker finds work more suited to their abilities and skills (best yet for the company to work with them to make that transition).

Really the situations where we are just blaming the workers for incidents are essentially just a justification to not have to learn. It isn't as simplistic as if you stop blaming you'll start learning, rather it is an active choice that must be made to want to change and improve systems. However this takes time and resources, which are usually in short supply especially after an incident, which goes to explaining why simply blaming the worker is often the choice of action. How can we change this...?

I agree. When a Manager blames "idiots" for an incident it is an indicator that there a is a problem with recruitment, supervision, training or a combination of both.

If we blame one person it can often be used as a way to hide other system or culture failures.

You may not agree with me but this is how I see it.
The Clive Lloyd @Peter Bateman refers to is not the West Indian cricketer. Clive F Lloyd is an Australian-based Psychologist specialising in Safety Leadership and Culture development. And he is particularly talented.

Looking at Clive's website here, there is an article "Reducing Incidents by Managing Unconscious Drift". I can relate to the methods Clive suggests will create a learning environment both before and after incidents.
However, if Safety 2 is not palatable, you may wish to skip the article but Clive makes the statement (in the middle of the article and in bold letters) We can blame or we can learn!.

Regarding blame, the best I have read and still use is by George Robotham here. In HSWA, there is an entire regulation that is devoted to penalties that looms over everything else. What a way to conduct an activity where trust and respect can generate improvements - in fear of making an error.

George wrote Guidance for the beginning OHS professional in 2013. I personally believe it should be compulsory reading for anyone who utters the words health and safety.

As I said at the being,
You may not agree with me but this is how I see it.
I would appreciate if you will trust this is what I believe and show respect for my beliefs.

But, how often is it just a 'recruiting mistake'?
True learning from incidents requires some level of introspection. e.g. was it a recruiting mistake, or were you not willing to pay for someone with the experience required (which is financially driven, and not a mistake, IMO). Or did you not provide adequate training?

There are competing objectives that very rarely sit nicely together with education vs. prosecution.

On a related note, I see that Worksafe are under the spotlight for this as a result of the White Island Accidents. One of the criticisms is that of the conflict between regulator (management and education) and prosecutor.

I know from first-hand experience how much more forth-coming you are when the entity doing the investigation has no prosecution ability, and their information is specifically protected. You are able to speak freely, without having to make sure that your words are not able to be mis-interpreted or used other than you intended.

Afternoon All,
The problem I find with statements like Clive Lloyd's, is there are now too many directors/managers etc., that, without a solid understanding of health and safety, use the statement to not hold people to account.

I believe we (the royal we) would be better of keeping these terms distinct from each other; learning - blaming - holding to account are not mutually exclusive. Rightly or wrongly, all three can happen at once. It is how we manage all three that counts.

Afternoon All

I find that the issue is than when investigating events, risks, incidents the focus needs to move away from human error and go a bit more in-depth into organizational issues such as process, training methodology, risk assessments, incident investigations, management reviews, etc

Secondly, the way we train is a big issue to as we need to build the capability of the employees by encouraging them to think and learn on the job, instead of telling them what to do.

Lastly, holding people leaders accountable while focusing on soft skills training such as facilitation, how to manage poor performance, etc and building a toolkit for the managers to use and refer to

Here's an example of me getting it wrong:

Before I became a OH&S Professional, I worked in civil engineering. I was leading a piece of work, where I was supervising the construction of an experimental pavement structure (a road). The work was complicated and as it was a research project, required high levels of accuracy. I had hired in multiple pieces of plant and due to the nature of the work, had hired in very highly skilled operators at great expense. As with all construction projects, deadlines and budgets are a factor of stress and concern.

On this particular day, 'things' were happening and as usual for construction, we were treading a fine line on progress to the plan. I had done everything I could to plan and anticipate problems. One of those things is that I had expressly asked our Transport Manager to ensure we had a full diesel tank (it was a 30,000 litre tank and normally we only needed to fill it every now and again - it was his job to check it regularly and ensure it didn't drop below 1/4 full), so the plant could fill up as they needed to. Our excavator and dumper truck were running low on diesel, so went to the on-site pump (right next to where we were working) to fill up and found it was empty. Everything stopped! I lost my sense of humour and summoned the Transport Manager. He arrived and I let him have it; both barrels! After he had recovered from the 'telling off' (which to be honest is putting it very mildly) he contacted our supplier and ordered a tank re-fill - the earliest they could get to us was the next day. I'm now paying for plant and people to do nothing for the rest of the day, so when he broke that news he got a second dose of my wrath.

The tank got filled the following day and work continued. The project finished on time, to budget and the research project was a successful. All good, right?

Wrong! Here's what I didn't know:

-The Transport Manager was having issues (with his workload, his relationship with his boss, and his health).
-He had checked the tank, ordered fuel, but the order was lost by the supplier.
-My on-site team who witnessed the outburst made sure if anything similar happened in the future, I didn't know about it.
-I experienced a number of challenges in the future, that the Transport Manager could have helped me with, but he didn't because of the way I had treated him.
-I started to find it hard to get internal staff to work on my projects, because weirdly people don't like being shouted at when they make mistakes.

I acted appallingly. I thought that was the way front-line leadership was done in my industry - it had worked for me before. I didn't see any reason to change, as I was always rewarded for meeting deadlines, budgets, and other important project outcomes.

Fortunately, I had a few good mentors at that place. They helped me to understand the importance of good relationships. They showed me the value of receiving bad news and responding with questions, rather than actions. I did better; I became a better leader and immediately started to see the longer term benefits for me and the people I worked with.

In the words of Sydney Dekker, "Blame is like pissing in your pants; you get immediate relief, then you feel uncomfortable, and ultimately end up looking stupid".

(dedicate to Bob - a great guy who I apologised to then and do so now)

But, how often is it just a 'recruiting mistake'? — Aaron Marshall

Agree that the strawman I put up is an unlikely situation, but was just to illustrate the point the "blaming" (while the wrong word to describe it) may be valid in some situations and shouldn't prevent learning from occurring at the same time.

There are competing objectives that very rarely sit nicely together with education vs. prosecution... — Aaron Marshall

I agree, and a big part of the problem you highlight is when we (either a regulator or a business) try to do both at the same time.

I find that the issue is than when investigating events, risks, incidents the focus needs to move away from human error and go a bit more in-depth into organizational issues such as process, training methodology, risk assessments, incident investigations, management reviews, etc — TracyRichardson

I think it isn't exactly to move the focus away from human error, but to ensure that human error isn't the only focus. Otherwise we will still be missing a big piece of the puzzle when it comes to understanding the work and what went wrong (or right) - we need to understand why someone made the mistake they made to understand and assess how the rest of the system parts worked together to result in the outcome that eventuated.

Agree that the strawman I put up is an unlikely situation, but was just to illustrate the point the "blaming" (while the wrong word to describe it) may be valid in some situations and shouldn't prevent learning from occurring at the same time. — MattD2

And that's at the heart of a just culture.