Forest safety Learning: away from the blame

Published Forestry Bulletin 31 March 2017

Industry’s aim to bring all the guys ‘n girls home safely is one step closer.

Tests of a new blame-free incident investigation model are promising for rapid foresry safety culture change in New Zealand.

“The overall objective is to learn from the incidents that have plagued the industry in past years causing fatalities and injuries, according to Forest Industry Safety Council national safety director Fiona Ewing.

“There is certainly an appetite for change from all in the industry,” she believes. “We want to move away from blame and punishment to learn more from the incidents. It is important to find out HOW something happened rather than WHAT happened.”

In 2015, FISC commissioned Scion human factors scientist Brionny Hooper to lead the Learning Review research work, which is supported by WorkSafe. This young researcher – winner of the inaugural Young Forest Scientist of the Year last year – is well versed in working with tough crews having had forays into other high risk industries, such as fire, mining, aviation and healthcare.

She found use of a model by the United States Forest Fire Service over the past decade, alongside regulatory bodies and industry organisations, meant that a US industry first was achieved in the 2015 Twisp River fire where three firefighters died.

“No blame has been placed under the use of the Learning Review process. In fact, no law-suits have been filed and the US Worksafe-equivalent did not prosecute or issue a violation for the first time in history after a wildfire fatality.

“It’s a completely blame-free system that has made such a change in such a litigious society, with more than 30,000 workers in the wildland fire service,” she says.

Brionny Hooper has adapted the US model specifically for New Zealand conditions. Because the New Zealand forest industry is relatively small and is a high-risk occupation with an openness to safety culture change, she sees the potential for that change to be made rapidly.

“It’s also a unique opportunity for the forestry industry to take a leadership position in testing a process that could be applied to any industry.”

The current investigative technique is based on cause finding, she notes. “It’s designed to look for the simplest answer, which means learning cannot take place,” she says.

Phase One of the Learning Review, which had WorkSafe funding, took place last year. The pilot looked at a cable logging incident to test the model developed by Brionny Hooper and took a structured, phased approach putting the incident into the context of the work environment and all the complex influences common to daily work.

“We were basically looking at why it made sense for the incident participants to do what they did.”

Brionny Hooper says the focus group with the crew involved revealed “little golden nuggets of learning” and was a really “eye-opening experience” for her. In the blame-free environment, she found the crew was sharing the tricks they had learned to avoid similar situations.

“The beauty about this process is that the learning comes from operational people rather than being imposed from the top by health and safety.”

Phase Two adds to the Phase One pilot success and is building capability through a series of five incident case-studies being worked on this year. In one of the case studies, Brionny Hooper is working with Nelson Forests’ health and safety manager Les Bak on an under-cables incident last year.

Brionny Hooper recently made a visit to meet Nelson Forests contracting crews. She is working with Nelson Forests Health and Safety Facilitator Les Bak. He says the first contractor meeting in Rai Valley went very well and provided good learnings and outcomes. He says the crew was engaged by Brionny Hooper’s positive and personable process and her genuine interest in their operations and how the work gets done.

“They all seem to have lots to say and like the opportunity to share their stories and information,” he says, adding the focus on human factors is well aligned with Nelson Forests’ current investigation process.

“But it brings a whole new level of analysis to this approach.”

He believes the new model will benefit Nelson Forests’ approach to learning from incidents because it includes a review group bringing people together from across crews or industry to review the incident.

“This will give us great insight into best practices and methods to reduce influencing conditions and pressures leading to incidents. It also involves more people in the crew so they will quickly pick up on the approach and be able to investigate and review their incidents with greater skill and knowledge.”

Is it the ‘next step’ for forest safety? Les Bak notes industry has been asking for a process like this that actually shares incidents in a way that learning is achieved and further incidents prevented.

“What more could you ask for? If we focus on the high potentials and the near misses, all the better. If we can learn from the golden nuggets then we will prevent a lot of injuries – or worse – in industry.”

“Forestry culture will change rapidly.”

Brionny Hooper acknowledges the approach is going against human nature, realising how things happened, acknowledging they happened and ignoring the instinct to blame.

“It is quite an internal fight and hard to break out of the pattern,” she says. But, based on the US experience, she anticipates industry will be quickly asking to have this process applied to their incidents which will mean that forestry safety culture will change rapidly.

“The tipping point will be when 60 percent of companies are engaging in the process,” she says.

From Fiona Ewing’s FISC perspective, the approach is less adversarial and the work has found the crews really appreciated being listened to, without fear or blame.

“At the end of the day we all want to get the guys home to their families.”

FISC will take the nuggets of learning from the pilot and case studies and communicate them across all levels of industry, using the Learning Review information sheet, a series of Learning Review alerts, animations and workshops.


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