Legal Standpoint: Investigation objectives and evidence priorities RISSB Major Rail Occurrence Forum Michael Tooma Partner – Head of Occupational Health, Safety and Security (Asia Pacific) 28 April 2015
Aug 06, 2015
Legal Standpoint: Investigation objectives
and evidence priorities RISSB Major Rail Occurrence Forum
Michael Tooma
Partner – Head of Occupational Health, Safety and Security (Asia Pacific)
28 April 2015
2
1
How you frame the investigation will determine its outcome
2 Being transparent is deceptively dangerous
3
Look on the bright side, it might save some lives
Rethinking our approach to incident investigations
Identify
•People
•Premises
•Plant
•Substances
•Processes
Arrange
•Organisational structure
•Contractual Chain
•Chronology
Benchmark
•Policies
•Laws
•Codes
•Standards
Causation
• Identify event
• Identify High Potential
•Event causal analysis
•Trace cause to source
i A B C
Investigation
team
• conflict of
interest
• Expertise
Investigation
process
• Root cause
• What went
wrong?
• What went
right?
Set
up
Analysis
Avoiding investigation bias
Threat of litigation
Judging people for what should’ve been done
Hindsight bias
And… The full story rarely
emerges…..
Cherry-picking to fit narrative
Self-preservation
Protectionism
Subconsciously
Distorted truthStrategically
Distorted truth
Can be improved
through Just
culture
Requires
rethinking of
investigation
approach
Why don’t we learn the lessons from
disasters?
Rational decision-making
Model for existing analysis
Perfect Information
Infinite time
Information asymmetry
Time pressure
Ambiguity
Safe behavior based on rational
decision-making
Real World
Conflict of interest when gathering evidence
6
Factors weighing against full investigation Factors weighing for a full investigation
Incident No injury
outcome
What went right?
What went right?
What went right?
What went right?
What went right?
What went right?
Near Miss
Environment What if?
Plant What if?
Process What if?Operator What if?
Consequences What if?
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