30 Aug 2019
13:15 - 13:45
St George Room


This study provides a comparison of two events involving a run-away light vehicle which occurred for the same organisation, at the same location, 24 months apart.

The first event was investigated using a typical investigation technique designed to identify the root cause and implement corrective actions to prevent recurrence.  A review of the investigation highlighted how this methodology is linear, focused only on the event itself and is not designed to specifically identify how work is normally completed in an organisation.  Failure is not linear and encompasses the entire environment and circumstances in which the task is undertaken. (Conklin/Edwards/Baker/Howe)

Traditional investigation methods are focused on classifying the root cause, rather than identifying the multiple reasons the failure occurred. They provide limited direction for the collection of evidence. The investigation analysis was based on insufficient evidence, resulting in findings which did not provide corrective actions to prevent recurrence of an unwanted event. (The investigation summarised that the root cause of the event was primarily the driver’s fault.)

The second event (repeat) was investigated in a framework of Just Culture and focused on the broad collection of evidence as a primary objective. Interviews with a broad selection of the workers performing the task, provided understanding of how the work was normally completed.  Work as Intended was identified, not only by reviewing relevant procedures, but by also interviewing supervisors and management.

With the broad collection of evidence, investigators were able to determine the differences between work as normal (blue line), work as intended (black line) and work as done.  Identifying the basis of these differences was key to determining the causes of failure. The investigation determined that there were systemic issues with the understanding and application of basic change management principals by the management team.

The case study also explores how traditional investigation methods structure analysis using a time line or sequence of events.    This methodology does not account for variability and forces the investigator into structured, predetermined outcomes.  Using the broad range of evidence collected, investigators are able to use methodology that best fits such as inductive reasoning, conditional mapping, human factors or why-because analysis. This enables the investigation to identify and correct systemic organisational issues that will resonate through to the workplace.