Post Incident Investigations – Why do some employees have repeat safety incidents?

This is the second of two articles written by Dr Stephen Fletcher, Director and Occupational Psychologist at the Occupational Psychology Centre (OPC), around Post Incident Investigations that share some observations and insights that managers may find useful when working with employees who have had safety incidents.

As a rail industry, safety is the number one priority and at the OPC, we are constantly trying to understand what we can do to improve safety performance. As an organisation the OPC has a special interest in why rail employees make errors and have safety incidents. At an individual level this is focused on helping to understand the ‘human factors’ piece of the jigsaw in a safety incident. More importantly the OPC wants to learn from incidents and put solutions in place at an individual, team or organisational level to help improve safety performance.

Are some individuals’ incident prone? Are some employees just unlucky to have lots of incidents, whilst others are lucky to have none? Chance can have a role to play, however, there is an Ernest Hemingway quote that says ‘You make your own luck’.

The OPC has been working in the rail industry for over 25 years, and during that time they’ve undertaken hundreds of post incident investigations, assessments, interviews and development reviews. They have met with some individuals who have been in a rail professional job for thirty years and not had a single incident but then worked with others who have been in a role for a couple of years and had numerous incidents. Is this luck or could the individual have a part to play in the cause? What stops an employee from learning from one incident to avoid another?

During the OPC’s post incident work, a question that the psychologists often ask an employee is “What stopped you learning from the incident”?

These are some observations drawn directly from rail employees’ interviews that could go some way to answering that question:

• The employee focuses on the symptoms: Sometimes an employee e.g., a track worker might say “I didn’t know that I had put the possession boards in the wrong place on the track. In future I will check it.” The insight here is that the employee might only be focused on this particular incident, and the Non-Technical Skill (NTS) shortfall of checking as the main cause for this event. However, it’s possible they might also neglect to check other aspects of their work too – potentially leading to another safety incident and then another. Having highlighted the NTS shortfall through an incident, we need to help them apply the NTS of checking across all their work routines. In the OPC’s experience, post incident development plans for some employees can focus on fixing the symptoms and may not address the underlying NTS causes.

• Denial or displacement: “It was a one-off” or “Yes but, it wasn’t really my fault… it was my work colleague…..or the process…. or the organisation’s” or anything else other than the individual. The answer to the mistake was somebody else’s responsibility! Whilst that might possibly be the case sometimes, the employee still has to attribute the part they played in the incident and the contribution that was influenced by them. If an employee can’t accept responsibility for their mistake or their part in an incident it can be more difficult for them to learn from it – with the possibility that there may be another incident in the future.

• The incident was painful: For some employees, the incident may have been a bit more serious and resulted in some psychological distress. An employee in this situation may feel unable to face the incident head on and learn from the mistake. Alternatively, the employee may be so hurt themselves by their sub-standard safety performance, that they feel unable to face the learning. In both these examples it’s as if the shutters come down and the learning stops.

• All safe now. Job done: In some cases, an individual may have had a number of incidents, after which they may have received additional development plan areas to focus on. Sometimes these can be a fixed point of attention for some time, and then there is a lapse. What they may feel is that the learning has been done already, and there is no longer the need to continue with their plan. In fact, they believe they can stop doing what they were doing to be safe. Job done! I’m safe now! What psychologists at the OPC might say is ‘No – it’s your plan and it has to be continued, keep on taking the tablets!’

• Ignoring the opportunity for continuous improvement: There are some employees who are outstanding in their role, and one of the personal attributes of these individuals is they often focus on continuous development. Other individuals may be happy to deliver an acceptable, satisfactory level of ‘safe’ performance and may not strive for any further improvement. As human beings we can, over time, choose the path of least resistance when undertaking development plans post incident. So gradually we erode our performance, slowly, consistently and accumulatively.  We might now skip through check ‘X’, we might leave procedure Y’ out all together and/or we now fail to focus on ‘Z’ at all!  Without robust attention to continuous learning and development plans it’s possible that an employee may have another or repeat incidents

As a final reflection Dr Stephen Fletcher said: “Learning from our mistakes is an important skill that we all need to learn. Mistakes or incidents have the power to make us better than we were before… if we choose to learn from them. We should view them positively as ‘ongoing on-the-job training’ to help us all benefit from better safety performance on the railway – which is what we all strive for as a priority.”

Want to know more?

Join our complimentary webinar exploring Post Incident Investigations, and how they can help to improve safety performance.  Tuesday 05^th October 2021. 9.30am – 10.15am or contact us if you would like to hear more about our work around Post Incident Investigations. For more information, visit: www.theopc.co.uk email: admin@theopc.co.uk or call: 01923 234646.

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