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Investigating accidents – who needs to learn?

May 6, 2024

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In this podcast, Greg and Nippin discuss how can we learn from accidents. Greg asks Nippin a range of questions including who needs to learn, why we need to learn, and whether or not learning is even an issue of importance within organisations. You will discover some uncomfortable truths and deep-seated beliefs about how investigations are conducted and why we are so far away from learning from accidents.

Further information

 

SPEAKERS

Nippin, Greg Smith

 

Nippin  00:01

Welcome to another episode of embracing differences with me Nippin Anand, a podcast aimed at understanding and promoting transdisciplinary ways of living and thinking, meaning, assimilating different viewpoints, different subjects, different disciplines, but focused on a very simple question. How do we human beings learn, unlearn, relearn, and make decisions? And how can we tackle risks in an uncertain world? Today, I’m joined by a very close friend and a mentor. I believe he is my mentor in many ways. He’s taught me a lot of things, and so proud to have him on with me on this podcast, Greg, would you do a very little or very light introduction about yourself, and then we can start off, not that you need to, but maybe as a ritual

 

Greg Smith  01:00

as original Thanks, Nippin. I think anybody who follows along on any of your podcasts probably have heard me speak before, but I’m an Australian based lawyer. I specialise in workplace health and safety law. And I have a real interest in the whole. The whole world of safety management and its rituals and the philosophies that underpin it and how it applies in practice, or, or doesn’t work in practice, which is what I see. And it’s a pleasure to chat with you again, you’ve been it’s been a while since you were here at our property. Last time you hear was quite warm, I think. And I don’t know if you can hear in the background. But we’ve got thunder and rain, we’ve got the first rain here since October last year. So everything is just dry. But thankfully, now everything’s freshening up. And if you hear any panicking, it’s because I’ve got my little dog, my Jack Russell in the room with me because she doesn’t like she doesn’t like the thunder, she’s just sitting at my feet panting. But as I say, it’s been a while since you’ve been here, you’re coming back for a couple of days in at the end of May 27 28th. May. We’re very lucky, you’re coming to run your learning from investigations programme. You know, this will be an opportunity for me to share this with my network a bit more broadly in Perth. So I’d really appreciate if you could just talk us through. Yeah, what, what the programme is about, but more importantly, I guess, what are the philosophies for underpinning it? Why and why do we need? Why do we need this programme?

 

Nippin  02:40

Great question, Greg, and thank you for the invite. I think Greg, we we are very good at? Well, we started off in this area by focusing on people involved in the accidents. And we have done fairly well in the last few years in that space to understand the behaviour of people and the frontline, if you like for the lack of a better term, we then moved into something more intense, which is looking at the work context, and trying to understand how we can improve the context of the work or where the where the shortcomings are, and see how we can improve that. And there’s been a lot of work in that space. Some call it safety differently, or others call it human and organisational performance. But it’s essentially trying to understand the the broader organisation, rather than just focusing on the people. And I think what I find interesting, Greg is that earlier on, it used to be the, the focus was the hero, if you like the successful one or the right one was always the organisation, I was the worker who was bad one, are in this new way of thinking we have somehow created the the worker as as the hero. And in some ways we have pushed the attribution upwards in the organisation. Yeah, and so what I find interesting is that when you do an investigation, whether you are processing the data, or you’re talking to people or you’re writing a report, how can you escape from your subjectivity? And, in my view, a lot of learning opportunity lies in understanding and focusing on how investigations are actually done. And by whom? What are the past experiences of these people? What are their motivations? What are their aspirations, how do they see the world? And I think, if we don’t understand that, we are so far away from Purdue Using any sort of meaningful learning, because to me, organisations don’t learn, people learn and people move. And if we, if we think that investigators have don’t have to learn that I think there’s a serious gap here. And much of my work is actually starting with the individual who is actually involved in the process. How are these people learning? And by that it’s a very simple question, Greg, that, tell me, what have you learned about yourself? After completing that investigation, the last investigation you did, and I think that’s something that drives my, my philosophy of investigations.

 

Greg Smith  05:45

And you’ve captured a lot of that in your new new book as well, haven’t you? I mean, that was my reading of the draft that you were kind enough to send me to have a look at.

 

Nippin  05:55

Absolutely, Greg, that was the focus of the book. And it took about it was a it was a journey. Yeah.

 

Greg Smith  06:01

It’s interesting. We’re chatting. Before we started the, the idea of learning from incidents, I mean, I. Yeah, at one level, you really, I really get it. I think I get it at a theoretical and intellectual level, I understand what it is. But it’s fascinating when you operate for me in a legal paradigm, where very often, the purpose of doing an investigation is not to learn for the purposes of improving it is to learn for the purposes of looking after the interests of your client, which may be very different from the interests of a lot of the people affected by the thing that is being investigated. And then, what I find even more fascinating is when I find it both fascinating and hypocritical in the context of health and safety, is that the pinnacle solution, or that’s probably putting it too high. But the sort of last solution of improving health and safety at work is a prosecution. That’s, that’s what we say, you know, if you’re bad enough, and you really need to be taught how to improve. There’s this legislation and we’re gonna prosecute you. And the one thing you do not do in a prosecution is learn. And it’s because nobody is there, nobody is there to share a common understanding to reach common ground to transparently divulge more than they have to divulge. And I remember, I think I’ve told this story to you before, but I remember acting for, and there’s a fatality event a few years ago, and the business owner ended up going to jail, and he was my client. And the magistrate in the prosecution said, Neither the defendant nor the prosecutor could explain why the work was performed the way it was done on the day. Which, from if I look at your perspective, from a learn genuine wanting to learn from that type of horrible event, that would be the one of the primary concerns. What Why was the why were things done this way? Not not to say it’s your fault. They were done that way or, or anything like that, just say genuinely, what made sense to the people at the time? What was their context? Why did they think it was okay to do this? None of that. And none of that comes up in a prosecution? Because it’s not in anybody’s interests to have that conversation?

 

Nippin  08:41

No, no,

 

Greg Smith  08:42

I find it really disappointing.

 

Nippin  08:46

It is at one level, but you got to think really hard about this thing that the question is that there are there is a difference between what we are learning and what we are realising and how much of it we really want to admit and share with the world. So yeah, so you see the the Costa Concordia accident, for example, or many accidents. There’s one person in the jail, let’s start with him. He has been in jail for the last seven years now. And he writes to me, he’s changed as a person. He is that person. Yeah, question. He writes, and he’s so he’s so articulate about what he writes. Even when he was under house arrest, and I met him, he actually produced the world’s lightest canoe. He prototyped it and he produced it. And he did it for his daughter. So people are known to bring the best out of their shadow of their dark side of personality when they’re going through this kind of this kind of things. There’s a lot of creativity in people when you push them to the limits. And there is this is one of the things why I find it so difficult to end brace the idea of positive psychology that, you know, we want to learn from things going well, all good. But sometimes, and a lot of times accidents are an opportunity to bring an entire organisation to the fringes of dissonance to say, You shattered their worldview completely. What have we been thinking? Yes, that’s one level drag. At an another level, you talk to people within the organisation, there is a realisation. The trouble is that a lot of it is not admitted in the open. And it’s not admitted, because people don’t want to be seen as as bad as vulnerable as weak, which is, you know, the way the society works. So, the trouble is that there’s a lot of implicit knowledge, but it never becomes explicit in many ways. And I think that’s something I talked about in the, in the, in the penultimate chapter of the book that you cannot escape blame, and you cannot escape scapegoating. It’s been around for 3000 years, the same, since you know, it started off in Israel, and you just can’t get rid of it, what you can do is admit that the human nature is violent, we are violent by nature. And in order to satisfy the needs of the society when a ship collapses, or capsizes, somebody will be blamed. So So that’s, that’s really the important thing that stop talking about not blaming people, about the idealist world that we have created, because there will always be somebody who will be scapegoated. The idea is that how can we get smarter to put our time and resources in other places where we can we can make improvements, rather than?

 

Greg Smith  11:46

I was just gonna ask, though, Nippin is, in your view, is there at least an imperative to go into an investigative process? Not seeking to blame? I mean, I accept I accept the social. I accept the social role that blame plays. And, you know, trust me, I’m on the other side. Yeah. When you’re a lawyer, you know, the social role that blame plays. That’s how everything hangs together. But then surely there must be, I suppose, I suppose it depends a bit if, if you’re talking about a catastrophic failure in shipping or construction, dozens of people have died. Nobody is going into that exercise. Under the illusion, that’s there’s going to be winners and losers, right. But when we’re dealing with individuals in the workplace, and the events are not so catastrophic, if they’re catastrophic at all, they’re just near misses where they are genuine opportunities to learn. Do you think there is a value of sort of accepting people’s failure, which there will inevitably be because we’re fallible human beings, somebody will fail or make an error or a mistake, but not turning that into a blame worthy, punishable? Error, fallibility or mistake?

 

Nippin  13:34

I love the first time I hear somebody using the word fallibility. Very, very rarely I see that. The answer to your question, my view is that, of course, it is possible. The trouble is that we don’t have a philosophy and accident investigations, that actually embraces the imperfection of being a human being, what we have to accept that. Yeah, we have, we have a philosophy called Managing error. And we have a philosophy called denying error that there is no such thing like error. But we do not have anything close to embracing vulnerability. So you know, what’s interesting is, the first question you ask, the person involved in an accident already tells me how you’re thinking about it. Yep, this first question. If the first question is, tell me about the work. Tell me about the word context. Tell me about why did you do that? Or you didn’t do that already tells me your approach. But if you start off with making a connection with the person, and just stepping this, keeping your agenda on the one side and just asking an open question, what would you like to share with me? Where would you like to begin? Walk me through the steps involved in this work. What have you learned from it? What have I learned from it? I think that’s a very different way of looking at it and I think and everything else, start still make sense from that position? So to answer your question, I think, yes, there is a methodology and there is a method. But I think most of the times, we fall into the trap of trying to manage a control error.

 

Greg Smith  15:15

Yeah, I find it fascinating. Having looked at this stuff for so long now, you know, you mentioned safety differently before and some of the new view type views. And I’m not, I’m not convinced at a macro level that much of what we see is genuinely new. But I think what we see is, I do believe we are seeing genuine attempts to put a different approach or different philosophical bent to the same processes. And what I think what you’ve described, actually illustrates that so it doesn’t matter what you you call it, you can call it an investigation or a learning team or whatever, it doesn’t matter. What you are in quite what you are doing is you are inquiring into work. Either something’s gone wrong, something hasn’t gone wrong, but you are inquiring into work. And there are probably countless ways that you can inquire into work. And when whatever personal biases or approaches you bring to that inquiry is probably going to very much dictate the outcome, I would have thought.

 

Nippin  16:42

And this goes back to what I said earlier, that if you don’t know, as an investigator, where you stand, what’s your position? what’s your what’s your bias? What’s your assumptions? Yeah, it’s going to, you know, doesn’t matter what you what you investigate it. I’ll give you an example. I was doing an investigation a few days ago, on somebody who has a certain faith. And I asked him some questions about himself. And I said, so what have you learned from this investigation? And his answer was, what’s there to learn? It’s, it’s God’s Well, yeah. And then he kept repeating that it’s God’s will. And he said that at least three or four times, even during the course of the interview, my point is this, you can have the best investigation systems in the world, you can have the most trained and competent people doing it. But if they’re not aware of their own belief system, and they’re not aware of these cultural differences, how on earth are you going to make any changes through processes and systems, you can push this guy beat him to the limits and say, you need to follow this process, because it comes from another faith, which is find a root cause and put a corrective action. But in his world, there is no such thing in his world, all that exists is he has no control over the situation is God’s will. What how are you going to make him learn anything at all? Tell it.

 

Greg Smith  18:10

That’s interesting. Yeah. And sorry, and you do hear what I have heard sorry, over the years, similar sorts of observations around around that sort of thing.

 

Nippin  18:25

Use You see, a lot of times in in the near miss reporting systems, somebody is detected a problem, let’s say a leak or an unsafe behaviour. An immediate responses are excellent job well done. You know, you commend the heat, you make a hero out of this person. But that’s a great method play. There’s the heroes and the anti heroes. Yeah. Yeah. And you have the quick response to say, why did you not follow the process, which is the Christian myth at play, which is, you know, so you have, we don’t understand that you’re actually working with belief systems underneath. And if you are not aware of your own assumptions and biases as an investigator, you’re not getting very far with whatever you want to learn this, you know, in terms of facts, evidence, as you can put a lot of stuff there. There’s a, you know, in this 175 page report on the Costa Concordia, there is no dearth of evidences and facts. But in the end, it’s an antihero narrative. That’s what it is. And people don’t get it. That is this industry is more religious than it thinks it is. And quite often, what you see is people say, I’m not religious. Well, of course you are. Some people worship money, and that’s their religion. So the we cannot run away from what we believe in. And to me, that’s the starting point, right.

 

Greg Smith  19:48

I think I think most people, listening to this, myself included, would find that level of introspect. Action and willingness to accept the the history that sits behind each of us as individuals and how much influence it has quite uncomfortable and quite disarming to actually bring that perspective to an investigation. But one of the I just want to pick up on something you said before, because I’ve I’ve observed this, and I’m interested in your thoughts. Because it’s interesting. So even if you if we adopt your approach, so you, you had the God’s Will roadblock, and what you described as a sort of the Christian background of just follow the process. And it’s interesting, because both of those, both of those positions to me, a very convenient points for organisations to stop looking. So if somebody says, Oh, it’s God’s will, so Well, it’s there’s nothing wrong with our systems. Our approaches are all fine. It’s this person’s belief value set. So we don’t need to inquire any further into what we’re doing. Which is just just another way of describing what we do when we say, Oh, they breach the policy and procedure, we don’t need to look any further. If they will just follow the process. They’d be okay. So it’s, yeah, they become very convenient, stepping off points, don’t they to say, Well, it’s obvious what’s going on here. We don’t need to do any further. And even I think, I think even. And this might not be the right language, I’ll be guided by you. But the idea that we use a belief that somebody else is unable to learn or change has a really convenient point to say, therefore, we don’t need to learn or change.

 

Nippin  22:10

Absolutely. Greg, and Greg actually did some word mapping yesterday and showed us to you. It’s maybe not because it’s doesn’t cover the whole thing. But let me just talk to you about. Yeah. You know, if you look at the the, the the Christian met, for example, it’s all about compliance and rule following. You know, this is one God, He created the world in seven days. And under seven days, he gave it to the human beings, and he told them not to eat that apple from the tree, and they did. So they are doomed. And that’s the original sin. That’s the human error that we are after. That’s when we say follow the process. And this is the God with a capital G. Right? One God, one rule, follow the rule. That’s the safety management system. Right? And then you have another Abrahamic faith, which says that, no, whatever happens, don’t question it. It’s God’s will. And that’s what comes out from it. Right? And then you go to the Greek myth, and it says that it’s not about compliance, it’s actually about defiance, which is solely at work, that there is an there is there is an unjust world, and we need more justice in this world. There is a lot of chaos in this world, and we need to create order out of chaos. And those who create or can create order out of chaos become the heroes, and hence Sully, you know, he flies a plane, the bird strike engine failure, and whatever happened, and we commend this hero, we create a hero out of it. That’s a great method play, and then come to the Indian myth, or the Hindu myth, which is it’s not about compliance. It’s not about defiance. Learning is all about self realisation. It’s the journey of life is all about learning more about yourself is connecting with yourself. And you know, Greg, it’s interesting that you asked me, what did you learn from this from this six, seven years, what I learned was that how religious I am deep inside, even though I never believed that I was a religious person. And the point is, you cannot run away from your belief. You just can’t. It’s there. And in the second chapter of the book, I you’ve read it, I actually show to the investigators how religious they are, even though they think that they are doing a scientific objective exercise. We are so belief driven. Craig, we are not even aware of that. And you know, the interesting thing is that when we do this workshop and we spend a couple of days with people start to help them meditate and reflect on their language. Everything floats up Everything, and people are mostly left shocked after that.

 

Greg Smith  25:05

Yeah, I find, I find the work that you do them in the whole social psychology of risk approach is very. It’s powerful, and it’s helpful. And it has a role to play. And I think it’s interesting because everything that I see, and I’m talking from an Australian context, so much of the philosophy and approach and the ideas and the thinking, that I think could help us to create better workplaces for people in from my perspective, and again, I, I bring 30 years of legal bias to this. I’m often stymied because of the legal framework within which they operate. And it seems to me that, you know, in the same way that belief systems, the pendulum can swing too far. I mean, you might you can you take a belief system around any of the major faiths, and you get extreme isms, at all levels of it. But I see that at the moment in the legal framework, at least in Australia, we’ve got this extreme system of retributive justice, which I think really hampers genuine inquiry into understanding workplace safety, understanding work, how work is performed, why work fails, the fallibility of people. I mean, God forbid that we would ever call someone like yourself as an expert witness, in a court case to explain all these underlying philosophies because no one in the courtroom is interested in that it’s a very linear factual process. And so trying to blend these ideas together as a as an enormous, enormous challenge, but again, to learn from my own comments before, just because we bump up against something that seems immovable, the breaching procedures or faith in God. That ought not stop us from continuing to challenge and learn and question. What’s in front of us

 

Nippin  27:38

is, and you’re so right, Greg, because in the end, it all comes back to realising that my world is so limited. What I know is so yes, I’m constrained. And I’m, in a way, I’m a victim of my own experiences and values. So why not take this time and opportunity to listen to what other people have to say? And so creating different stories and comparing between them? And some good things come out from them? Some really nice things, some really powerful things.

 

Greg Smith  28:09

Yeah, I think I think it’s, I think us you talk to me, and I apologise if I’m, if I am, Miss attribute these but the idea of sort of changing workplaces one conversation at a time. And it may be that many of the macro structures that inhibit, ideally, what we’d like to see, I’m not going to change. But I think you’re right, I think there are daily opportunities for for learning and sharing and just gaining more insight.

 

Nippin  28:50

When, when I read your work on risky conversations with Rob and, and Craig, it was such a powerful exercise, trying to understand the power of risky conversations, as you say, because there is nothing more powerful than having a conversation with people. And part of it is helping them realise where they are stuck. But part of it is realising on your own where you are stuck. And yeah, absolutely. If you if you want to understand how a procedure works in practice, why wouldn’t you have that Converse open conversation? Because quite often, behind what we call work is done. There are belief systems that work. There are people who have been doing it for 2030 years, and they genuinely believe without even knowing that they do things and take our baggage when we get to work.

 

Greg Smith  29:46

And I think, you know, my lived experience with that and different would be a decade ago, I couldn’t imagine myself. Having this type of conversation, I was adamant that I understood the legal process. spent and how that worked and what we needed to do to manage excellence. I absolutely convinced about that. But the last decade of actually immersing myself in some of the research and some of the different ways of thinking and taking a deeper look at human psychology as much as anything else really, really demonstrates how much more complex the not even complex, that’s not the right word, how much more wicked The problem is, then, a purely legalistic perspective would have you believe.

 

Nippin  30:36

I was fascinated to hear when you when you said in your book in your recent book that take any sort of safety initiative as a research project, that’s precisely where it should start. You should keep an open mind a really open mind as to what might come next and, and we don’t see much of that, Greg, it’s a lot of it is preconceived ideas and an assumption they become part of everything. I

 

Greg Smith  31:04

can’t wait to get you over here on the 27th and 28th. And just looking forward to sharing ideas with you again, perhaps catching up for another meal, my turn to cook this time. And, and really getting a chance for you to share the wisdom with people over here in WA looking forward to it.

 

Nippin  31:21

Wonderful, great, wonderful and so nice to talk to you as always and yes, looking forward to seeing you have a lovely evening. Yes,

 

Greg Smith  31:29

you turn you can take it

 

Nippin  31:38

if you enjoyed listening to this podcast, many more podcasts are available on our website novellus dot solutions fourstroke knowledge space. Podcast. embracing differences is available on Spotify, pod bean, Apple podcasts and anchor. You can also subscribe to our YouTube channel team developers. That way. Every time we publish a new podcast, you will get to know you want to find out more about our work, visit us at novellus .solutions or simply write to us at support@novellus.solutions. Thank you for wanting to learn more than you knew yesterday. And until we meet again. Goodbye and have fun