Posted on Tuesday, November 30th, 2010
This year’s Lectures were held on the evening of the 23rd November at the Holiday Inn, Taunton. Supplementing certain subjects being covered that week by Senior Members completing their IIAI Diploma in Industrial Accident Investigation and Analysis finals, the lectures were thought provoking and highly informative.
Phillip Martin opened the evening with a review of Heinrich’s Domino Theory and the models (e.g. Bird, Reason) that subsequently followed it. Drawing in part from the IIAI Ten Year Study and his work as a systems analyst, he identified the main problem with the subsequent ‘causation’ models as being an obsession with the notion that ‘management failures’ cause most accidents. Unfortunately, he said, “the notion is now the basis for most Root Cause Analysis software programs with effect that they default to a steady churning out of management failures as root causes…confirmation bias by design perhaps”. Summing things up in his own inimitable style, he said [quoting Sherlock Holmes] “It is of the highest importance in the art of detection to be able to recognise, out of a number of facts, which are incidental and which vital”.
Trevor Williams (IIAI Executive Committee Chairman) spoke next. His message, by way of some of the oldest and most modern cases, was simple. The HSE and CPS must, when industry’s investigators show it, accept the fact that there is such a thing as a ‘pure accident’. As tragic as it is, death can occur despite an appropriate system and all due care by management. If a management failure is the cause of a death or injury, we will find it. What we must not do, however, nor allow others to do unchallenged, is presume it and go looking for it despite clear evidence to the contrary.
RDC Director Director Difford, master of ceremonies for the evening, stepped in at short notice for an unavoidably delayed Doug Payne (IIAI Executive Committee Vice Chair). Referencing areas of the earlier talks by Pip and Trevor, Paul said that “In most of the UK, for example, it is regularly alluded to that ‘management failures’ cause around 70% of accidents. However, that figure is generated by the HSE and relates, in fact, to prosecution success rates. I have some difficulty with the word success given that over 95% of the 09/10 successes came by way of guilty pleas. I have even more difficultly comprehending the appalling failure rate (c.96%) of the HSE/LA/CPS in properly contested cases…a wake up call perhaps in the public interest if ever there was one”.
Paul then proceeded to touch upon a handful of the many findings from the IIAI Ten Year Study and will produce a summary of his talk in due course for the members area.
IIAI Memberships Committee Chairman, Alan Dell MBE presented a truly sobering talk entitled “In Context: London, July 7th 2005”. At the helm in CentreComm on that tragic day, Alan provided the audience with timings of the explosions on the underground and of the final explosion, at approximately 09:49 that morning, on board the Tavistock Square bus. But, everyone present already knew all this; all had clear cut and logical images of the events and circumstances of that terrible morning; it was obvious, or would have been, by 09:15 surely, that London was under attack…or was it? The orderly images that we all have were in fact constructed for us, well after the event by others…by the media. What was actually known by those in CentreComm up until 10:00 that morning was, in reality and in context, a million miles away from that which was only possible after the fact.
The message to the Diploma Finalists and prospective Fellows was clear and powerful. Professional investigators must remain constantly alert to the threat of hindsight bias and develop ways to guard against it and check for it. We do not judge, we analyse things in context.
The Institute extends its deepest sympathies to all who were affected by the events of 7/7/05.
Guardian of the late shift was Solicitor, HSLA Chair and long standing IIAI Member, Madeleine Abas. Guaranteed to grab and hold the attention of any audience, including Boardroom and Courtroom, Madeleine delivered a legal update packed full of must have information.
Left to right: Trevor, Alan, Paul, Pip, Madeleine.
The Institute is committed to the furtherance of Industrial Accident Investigation as a unique and distinct discipline supporting the International Risk Management process.
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