1. Learning from Mistakes
Sean Coleman
Coleman Risk Consulting
Coleman Risk Consulting

2. Risk Management
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3. Risk Management
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4. The Culture EH&S system encourage or prevent incident reporting?
Blame or investigative culture?
Do management and staff understand the benefit of reporting minor ?
Simple or laborious system?
The inverted accident triangle?
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5. The Culture What happens with reports ? Feedback
Do you investigate and action the near hits (misses)?
Do you trend ?
Have you defined type of accidents, injury, location cause, personnel?
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6. Why Determine Causes of Accidents
The Auld Triangle
Why Determine Causes of Accidents
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7. Deming Paraphrase
85% of all the causes of quality problems, production problems, and safety problems are only under the control of management

8. The How Staff and management education the why? and how?
Culture from blame to investigative
Provide feedback
Focus on action and improvement whether there is injury or not
Eventually move to behavioural improvements focussing on underlying causes.
Prevention better than cure
Do it right first
Timely and in particular supervisors are key
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9. ACCIDENT REVIEW PROCESS
Attend to the injured employee
Control hazards and secure the area.
Observe and record conditions and equipment
Interview
Consult experts
Identify root causes
Develop recommendations for corrective action.
Implement recommendations.
Follow-Up.
Attend to injured
Control Hazards
Control Hazards
Observe
Interview
Consult
Identify
Develop
Implement
FOLLOW UP

10. “Getting to the roots by asking
Root Cause
“Getting to the roots by asking
why, why, why, why”
Injury analysis.
Event Analysis.
Systems analysis
The biggest challenge to effective accident investigation is to transition from event analysis to systems analysis.

11. Lack of facts + ambiguity + doubt = legal debate + costs
The Why
Improved reporting and investigation =
better knowledge
Lack of facts + ambiguity + doubt = legal debate + costs
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12. Action in reality
Deaths and serious injuries have almost halved on roads with speed cameras in Northern Ireland. Roads which operate safety camera schemes have seen a 41 per cent decrease in collisions over six years. Four fixed camera sites had a 74 per cent fall in deaths and serious injury.
[Irish Times]
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13. Garda Stats trend Total Killed to 16/06/16 84 Total Killed to 16/06/17
Yearly Comparison
Total Killed to 16/06/16 84
Total Killed to 16/06/17 70
Total Collisions to 16/06/16 81
Total Collisions to 16/06/17 65

14. EL risk management maturity
No controls
EL costs
Physical risks managed
H&S & Claim management
Injury/Case Management
Occupational Health
Cultural
Behavioural Improvements
Uncertainty
Awakening
Enlightenment
Wisdom
Certainty
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Drivers: Legal Moral Financial Vision/Values

15. The Process Learning from Mistakes
Value (x)
Courts Route
PIAB
Inhouse Settlement
Rehab.
Cost
Accident/ Injury
Time

16. In house
Marsh

17. *** The longer a worker is off work with LBP, the lower their chances of ever returning to work. Once a worker is off work for 4-12 weeks they have a 10-40% risk (depending on the setting) of still being off work at one year; after 1-2 years absence it is unlikely they will return to any form of work in the foreseeable future, irrespective of further treatment. Ref/Facc. Of Occupational Medicine London

18. Cost of claim formula
Delay + Lack of facts = Ambiguity + doubt x more complex medical evidence
in turn =
Legal Debate x delayed rehabilitation
Increased Costs + inefficient service delivery
Marsh

19. “Prevention is better than cure”
"A lesson is learned when we change our behaviour."
“Prevention is better than cure”
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