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Venue: Holiday Inn, Taunton.

Date: 18th November 2015.


Alan Dell MBE Hon FIIAI:

IIAI Executive Committee Chairman; Network Liaison Manager, London Buses/Transport for London.


Phillip Martin MIIAI DipAI:

Head of eLearning, IT and Software Development with Neucom/RDC.

Paul Difford FIIAI:

Director of the Institute's Research & Development Centre; Principal Investigator with Neucom Ltd.

Cliff Jones FIIAI:

Head of Compliance and Behavioural Change, Balfour Beatty Power Transmission and Distribution.

John Birchmore FIIAI:

SHE Governance Lead, BAE Systems Surface Ships.


Alan's first piece of business for the evening was to confirm the addition of Cliff Jones and John Birchmore to the IIAI roll of Fellows.


Cliff, pictured right, receiving his certificate from Alan.



Cliff and John are highly experienced, highly regarded professionals in the risk and safety management fields. Respected by the accident investigation community, they are long standing members of the Institute of Industrial Accident Investigators and completed their IIAI Diploma studies in 2010.

As it happens, Cliff and John received their IIAI Diplomas together at a ceremony hosted by Morgan Cole Solicitors in January 2011 (see here, John is 3rd from left back row, Cliff is 6th from right back row).


John, pictured right, receiving his certificate from Alan.



Phillip Martin

Following the election ceremonies, Pip got things underway with a lecture entitled "Causal Enquiries and Common Sense". Pip has delivered this title before but no two are the same since each is designed with a specific aspect of the lecture it precedes in mind (here, the aspect in mind was causation and the Coroner).

Pip's goal was to explain the approaches to causation employed by Civil Enquiries, Criminal Enquiries and Central Causal Enquiries. As regards Civil enquiries, he relied upon a number of cases (including March v Stramare 1991) to put forward the Civil law's general view that...


...a person may be responsible for damage if his/her wrongful conduct is one of a number of conditions sufficient to produce that damage.


He then presented a number of examples to show how and why the Civil law's approach (the 'but for' test or 'but for' causation) was knowingly problematic (i.e. known to be problematic by the courts) and, on many occasions, contrary to common sense.



As regards Criminal enquiries, Pip again relied upon a number of cases and examples to remind us that the prosecution is not required to prove a causal connection between an alleged offence and its 'result'. In summary there, he offered the following from Lord Hoffman...

The answer to the question of what caused what depends not on common sense but upon law; on a careful assessment of the reach of the substantive rule on which liability is based.


By way of a succinct recap and some straight forward questions, Pip left us in no doubt that the Civil and Criminal Courts are fully aware of the 'commonsense approach to causation' but (and knowingly so), are generally unable to employ it. He then compared and contrasted the finer points of all three types of enquiry and asked...."who, then, employs the common sense approach and what is it"?



Paul Difford

Paul was up next with a lecture entitled "Drawing the line in the Central Causal Enquiry". Paul has previously delivered the essence of this lecture to the IIAI Executive Committee ahead of the release of 'Redressing the Balance - A Commonsense Approach to Causation' and to the Health and Safety Lawyers Association.

Mid way through the previous lecture, Pip had reminded us that we do not select, from amongst a set of conditions, the one that we treat as cause; the belief that all conditions, necessary or otherwise, have an equal right to be labelled as causes is wrong (citing Hart & Honore 2002).

Paul referred back to that comment...

...and then put forward the following...



(Note from Ed: Sir Anthony Mason was Chief Justice of the High Court of Australia from 1987 to 1995).


Earlier, Pip had noted that in-house investigators tend to be health and safety professionals and the causal philosophy employed (whether knowingly or not) by most is that of multiple causation theory. However, he demonstrated that a multi-causal approach produces the same result as a civil and criminal approach; i.e. ....

  • The investigator tends to see every factor associated with an accident as being causative of it; and
  • By default, their employer's strictly liable on numerous counts.


Paul picked up on this point and offered that some (he referred to them as 'safety extremists') are unable (or blankly refuse) to 'analyse' things in any other way. Unfortunately, they pursue aspects that stretch endlessly into the antecedent part of the causal chain and find nothing but fault and blame in their employers and clients.

The problem, he said, is straight-forward and relates to the difficulty that has always existed for some who must draw the line. In the health and safety context, the problem is usually an inherited one (i.e. programmed in and constantly reinforced) but, nonetheless, prevents the grasp of the science of causation which the preventionist needs.



More soon

Cliff Jones

(summary arriving shortly).

John Birchmore

The final presentation of the evening was entitled “Quality of Investigations”. Delivered by an engaging professional, this talk gave us real time insight into how important the quality of an investigation is with regard, in particular, to its outcomes.

From a Health and Safety perspective, John offered that the primary purpose of an investigation is to identify causes and suggest remedial actions to prevent recurrence. However, he said that accurate remedial intervention requires a thorough (and professional) analysis of cause/s and that means looking beyond the immediate to the underlying or root. Only when all of these are identified can we claim to have taken both appropriate and effective action. Consequently, a quality analysis of cause/s is necessary if we are to...

  • identify and remedy any associated system failure/s;
  • ensure that human factors are covered; and
  • where relevant, identify errors and violations and why they occurred.


By way of numerous real time examples, John’s went on to demonstrate that the quality of the investigation performed was critical for...

  • Full analysis of the accident/incident;
  • The effective identification of cause/s;
  • The design of effective control/prevention measures; and
  • The on-going improvement of the system.


In concluding the first part, John offered that it could be summarised by saying...

If we are to properly analyse and learn from accidents/incidents then the quality of the investigation performed is critical to the identification of appropriate remedial intervention strategies”...


“We must recognise that this is a Continuous Improvement Initiative”.


In the next part, John presented an overview of the journey his business had been involved in as part of its continual improvement initiative for the investigative process. He began by explaining why they investigate and the aims of, and reasons for, their investigations and theĀ  outcomes that are expected from them. He then described how a complete review of a selection of investigations was undertaken and how shortcomings/failings within them were identified. He then explained how an action plan had been produced and a review tool developed for use by trained personnel. In essence, the tool facilitated a review of the quality of a conducted investigation and enabled the identification of lessons learnt/shared and best practice. In addition, John described how an investigator’s workshop (tasked to meet regularly) had been enabled with the remit of maintaining skills and understanding, sharing of outcomes and lessons learnt and the sharing of knowledge and practice.

Finally, John demonstrated the tool by using several anonymous examples from his business. Not surprisingly, he made his points in a way which ensured both humour and debate.






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