Moving beyond the organizational ceiling: Do construction accident investigations align with systems thinking

This study analysed 100 serious or high potential construction ICAM accident investigation reports from five Australian construction organisations to see the extent to which they aligned with systems thinking principles.

It’s argued that construction can be described as being a complex sociotechnical system, influenced by fast pace of technological change and the impact of economic and political pressures. Thus, accident and other models used within construction should reflect the various vertical and horizontal actors involved in decisions and actions across the sociotechnical system. In contrast, it’s argued that existing construction accident models & worldviews may be dominated by linear thinking, with proximal factors like individual errors being the main focus of investigations.

Rasmussen’s risk management framework and the associated AcciMaps were used to evaluate the comparison between ICAM investigations and systems thinking tenets. As per this frameworks, the levels of system hierarchies, in vertical order, were:

·        government policy and budgeting,

·        regulatory bodies,

·        clients and external associations,

·        company management,

·        management,

·        staff,

·        work.

Results:

Overall, analysing the ICAM reports revealed that “construction has not moved beyond a human error focus and does not presently identify multiple actors and contributory factors or the interactions between them” (p7).

These investigation reports from the participating companies revealed that, for the causal analysis, actors involved at the government, regulatory, client or company levels of the framework were either not identified or not examined.

Despite this, 100% of the reports identified the contribution of actors at the operational management and staff levels of construction. Regarding causal links in accidents, at the management level of analysis supervisors were identified in 21% of reports and leading hands identified in 9% of reports. For the staff level of analysis, plant operators were expectedly the most frequently identified causal link in investigations, at 70%. Labourers were identified in 23% of reports.

Indeed, staff-related factors were identified in 86% of reports, with most of these instances being attributed to human error (83%) – many of these instances reporting that workers failed to follow a procedure or direction of a supervisor [And in my view regarding procedure use: perhaps one of the most intellectually lazy and insubstantive things regularly “found”].

Regarding the interrelation of identified contributing factors, the existing investigations showed no relationships between any identified factors beyond the company level [as would be expected had a systems approach be used]. Observed was that in the few reports that did identify relationships between factors at the company level (12% of cases), just three linkages between safety management systems and project management were identified.

Interestingly, it’s highlighted that even though 88% of reports identified factors at the lower levels of system hierarchy (management, staff and work level), just 50% linked the relationships that influenced the incident.

Next the authors moved on to the corrective actions. Most actions were pitched at the staff level of the framework. The most commonly identified areas for the corrective actions were:

·        Improving safe work method statements (46%)

·        Delivering toolbox talks (39%)

·        Conducting risk assessments (33%)

·        Developing construction procedures (29%)

·        Conduct further training (14%)

·        Hazard awareness (28%)

Another interesting finding that the authors observed is that where corrective actions directed attention towards raising awareness of issues, they were “typically framed as broad statements that appeared to shift responsibility to workers (e.g., “know your limits,” “stay safe,” “keep eyes on path,” and “fatigue causes accidents”), as opposed to concise countermeasures, capable of implementation and measurement” (p6).

Also noted is that when toolbox talks were identified as an action, they “were often included as a corrective action without further explanation of required content; the intended audience; what the toolbox was to achieve or how its effectiveness could be measured” (p6).

A number of findings were covered for whom corrective actions were assigned to. I’ve skipped most of these findings but quite interestingly, 100% of the reports allocated at least one or more corrective actions to the safety adviser, but only 36% reports allocated a corrective action to the project manager (a person who usually has far more clout and control of project resources).

In discussing the findings and the suitability of systems thinking for construction, it’s noted that accident investigation processes and the investigation templates “appear to prevent analysts from adequately considering factors beyond the operational level” (p8).

The existing focus on operational levels of construction systems doesn’t support investigators in considering the influence of multiple actors and factors and their relationships across the sociotechnical system.

Contributory factors that were identified didn’t venture beyond the company level and mostly focused at the lower hierarchical levels.

Corrective actions appear to excessively focus on lower-level aspects not aligned with operational and company-level contributing factors

Corrective actions that were aligned to company and management-level factors were consistently allocated to safety advisers, who may be “unable to influence the implementation of the required actions” (p8).

The paper then discussed several other factors including the focus on operational management and staff factors over higher-level factors and the limited evaluation of relationships between the factors – which I won’t cover here save for one point.

On the latter regarding relationships between factors, it’s noted that the investigation reports didn’t examine the relationships between management inaction, culture and developing robust safety management systems on management or staff-level practices or beyond.

Link in comments.

Authors: Matthew J. I. Woolley, Natassia Goode, Gemma J. M. Read, Paul M. Salmon, 2018, Human Factors and Ergonomics in Manufacturing & Service Industries