How does a shift in the accident analysis process impact a learning culture

Abstract

The accident process is one of the foundation stones on which all other safety-related learning can be built. The post-accident treatment of the actors involved not only determines the level of learning gained, it can influence overall perceptions and attitudes towards both safety and the organisation. In recent years, there has been a growing appeal within academia for industry to adopt accident models with a greater capacity to understand complexity. Some scholars have also suggested that this requires a move towards a restorative justice approach. However, there is scant empirical evidence to show that the latter is more suitable for learning than an approach which uses retributive justice mechanisms. This thesis sets out to understand the question, ‘How does a shift in the accident analysis process impact a learning culture?’. The research presented within this thesis was conducted within a construction organisation and specifically on a new build nuclear power station in the United Kingdom. The overall study has four key focus areas, each written as individual research papers. These four papers include a literature review of safety justice and studies on the impact of a retributive accident process, the impact of a restorative accident process and the influence of language within accident reporting. The studies carried out on the retributive and restorative accident processes used semi-structured interviews as a means to capture the raw data. The examination of the restorative accident process and its impacts was an ethnographic study over an eight-month period; this research approach helped to provide a deep understanding of the lived experience of the accident process. A separate study was carried out to understand the influence on the reader of the language and framing within an accident report. Data was gathered through a survey method. The accident process is exposed to the same tensions and conflicting goals which exist within the organisational system. The need for alignment with stakeholders, both external and internal, influences the type of accident process used, the initial treatment of those involved and the organisation’s approach to accountability. This in turn affects how different actors respond following an accident and the level of learning gained as a result. Though the primary goal of this thesis was initially to understand whether a change in the accident process affects the organisation’s ability to learn, its most significant scientific contribution is not in this area, but in challenging the understanding of the true intentions of the accident process and how the societal system has influenced this. Where the societal justice system is predominantly retributive, organisations require the means to defend themselves and the accident process is a manifestation of this. Prior to this study, the accident process was viewed only as a means for organisations to learn and hold those responsible accountable. Future studies of the accident process must now take into consideration the fact that its primary purpose is not for either of these but as a form of protection. The project and its findings make a methodological contribution to the study of accident analysis by showcasing the benefits of an ethnographic approach. The thesis also makes a significant theoretical contribution by creating a bridge between the theory of language and decision making and the theory of ‘just culture’. In addition to these scientific contributions, this research also makes a practical contribution to understanding the challenges of implementing a change to an accident analysis process. This thesis also considers the future work that could help expand on the learnings gained through this dissertation. Further analysing areas such as the influence of a countries’ justice system on accident processes within their domain, measuring success based on behaviours as opposed to outcomes, and analysing a change with an organisation where the accident process has transitioned from root cause analysis to system-based are all key areas for consideration.