E16: Systems thinking and investigations

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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Episode Transcript

(00:07):
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

(00:28):
remain unaddressed? Good day everyone.
I'm Ben Hutchinson 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 Woolley ETal titled Moving Beyond the
Organisational Ceiling to Construction Acts and

(00:49):
Investigations aligned with Systems Thinking, published 2018
in Human Factors and Ergonomics in Manufacturing and Service
Industries. This study analysed 100 serious
or high potential construction ICAM investigation reports from
5 Australian construction companies to see the extent to
which they aligned with systems thinking principles.

(01:12):
It's argued that construction can be described as being a
complex sociotechnical system influenced by 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 evolved in decisions

(01:33):
across the whole sociotechnical 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 AXI

(01:54):
maps were used to evaluate the comparison between ICAM
investigations and the system's 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, analysing the ICAM reports revealed that quoting

(02:15):
the paper, construction has not moved beyond a human error focus
and does not presently identify multiple actors and contributing
factors or the interactions between them.
These investigation reports fromthe participating construction
companies revealed that for the causal analysis, actors involved

(02:36):
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

(02:58):
analysis, supervisors were identified in just over 20% of
the reports and leaving hands identified in about 9% of the
reports. With a staff level of analysis.
Plant operators were expectedly the most frequently identified
causal Lincoln investigations at70%.
Labourers were identified in about 23% of reports.

(03:20):
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 a procedure or
the direction of a supervisor. And in my view, regarding
procedures and investigations, this have to be among the most

(03:43):
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?

(04:04):
What have they learnt over time?What have leaders chosen to
ignore? Are the procedures usable and
effective? Is it clear when and how the
procedure should be used? How the procedures impact the
efficiency of the task they evendeveloped and configured to be
effective in practise through our assumptions about the

(04:24):
procedures match reality. 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

(04:47):
factors at the company level, just three linkages 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,

(05:12):
conducting risk assessments wereidentified 33% of the time.
There was further training 14% of instances and then hazard
awareness 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 that
were typically framed as broad statements that appeared to

(05:33):
shift responsibility to the workers.
For instance, statements like know your limits, stay safe,
keep eyes on path T causes accidents, as opposed to concise
countermeasures capable of beingimplemented and measured.
Also interestingly, they noted that when toolbox talks were
identified as an action, they'reoften included as a corrective

(05:55):
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 tool boxes use
as corrective actions in a sort of Swiss Army knife merge with
WD40 way, addressing everything without really addressing

(06:17):
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 allocate A corrective
action to the project manager, aperson who usually has far more

(06:39):
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 thatwere aligned to company
management level factors were consistently allocated to safety
Advisors who quoted in the papermay be unable to influence the

(07:02):
implementation of the required actions.
Also, the investigations omittedquite a lot of other stuff.
They didn't examine the relationships between management
in action cultures and developing robust safety
management systems on managementor staff level practises.
So what can we make of the findings?
The paper does a pretty good job.

(07:23):
It says existing Accident Investigation processes and 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 performance.Therefore, from the paper, the

(07:45):
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.
The corrective actions improvements that might actually
help us improve are overwhelmingly allocated to
people lower in the hierarchy with the least power or

(08:07):
resources to effectively change things.
So, limitations. There's a few, but importantly,
investigation reports only provide a limited view of
investigation practises. They're less entirely objective
captures of reality and more socially constructed
abstractions. The data was limited to 5

(08:27):
Australian construction companies also, so it's unknown
how well we can generalise the findings.
That's it on Safe. As I'm Ben Hutchinson, please
help share, rate and review and checkoutsafetyinsights.org for
more research. Finally, feel free to support
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