What Lies Beneath: The Scope of Safety Investigations
Oilfield service company Baker-Hughes released a pair of safety videos in 2016 that tell the story of a safety incident. Together they illustrate an important point about safety investigations and how safety investigations ae interpreted (or sometimes misinterpreted). These short videos are meant to be watched in turn with reflection after each in order to get the full learning benefit.
The docudrama narrative approach allows viewers to be a fly-on the wall of an incident to see and hear what happened. That gives an insight that safety investigators almost never have. However, in this exercise the downside is that you can’t ask questions and follow-up leads as you might in a normal investigation. That however, is immaterial to the learning the videos provide.
Those not familiar with the working on a drilling floor might feel intimidated by the jargon and unfamiliar environment, but don’t let that put you off. Safety investigators not only need to be prepared to use their investigation expertise in unfamiliar circumstances but they need to avoid the hubris of thinking they are more expert at doing work than the workers involved.
What Lies Beneath: Video 1 (5:24 mins)
Watch the story unfold and think about what happened in the run-up to the incident and what the various people involved did or didn’t do. Feel free to replay again to crystallise your thoughts.
You probably have many questions your burning to ask some or all of the players in this story. Note down which of the characters you most want to talk to and why.
Only when you have done that, should you play the second video.
What Lies Beneath: Video 2 (10:07 mins)
A public inquiry chaired by Anthony Hidden QC investigated 1988 Clapham Junction rail accident. In the report of the investigation, known as the Hidden Report, he commented:
There is almost no human action or decision that cannot be made to look flawed and less sensible in the misleading light of hindsight. It is essential that the critic should keep himself constantly aware of that fact.
The Baker-Hughes videos show that narrowly focusing on the proximal means missing the full context.
Aerossurance’s Andy Evans was recently interviewed about safety investigations, the perils of WYLFIWYF (What-You-Look-For-Is-What-You-Find) and some other ‘stuff’ by with Sam Lee of Integra Aerospace:
You may also find these Aerossurance articles of interest:
- How To Develop Your Organisation’s Safety Culture
- James Reason’s 12 Principles of Error Management
- Airworthiness Matters: Next Generation Maintenance Human Factors
- Aircraft Maintenance: Going for Gold?
- B1900D Emergency Landing: Maintenance Standards & Practices
- Meeting Your Waterloo: Competence Assessment and Remembering the Lessons of Past Accidents
- Safety Performance Listening and Learning – AEROSPACE March 2017
- Learning from Adverse Events: Includes nine principles for incorporating human factors into learning investigations.
UPDATE 24 October 2022: The Royal Aeronautical Society (RAeS) has launched the Development of a Strategy to Enhance Human-Centred Design for Maintenance. Aerossurance‘s Andy Evans is pleased to have had the chance to participate in this initiative.