Making safety-based decisions and learning from mistakes

In any project there are many decisions that need to be made under pressure, and they always need to be correct decisions.

Author: Chris Farrell, Safety, Health and Wellbeing Panel

'Engineering problems are under-defined, there are many solutions, good, bad and indifferent. The art is to arrive at a good solution. This is a creative activity, involving imagination, intuition and deliberate choice.' Ove Arup

Making good decisions and judgements requires the use of knowledge and experience; and the wisdom to do so. This in turn requires having relevant knowledge and experience, whether acquired directly or indirectly. Whilst everyone should have a good grasp of key issues, no one can be expected to know everything, but should know where information or guidance can be found. Similarly, there is a skill to being able to make a good decision, weighing up alternatives, and being appreciative of options and consequences. Lessons learned from mistakes, both by the individual and by others, contribute to this.

Safety-based decision making

London 2012 Olympic and Paralympic Games - Adoption of positive and good practice
In the build for the London 2012 Olympic and Paralympic Games, Safety culture on the Olympic Park, Research Report 942, profiled the safety culture instilled and exhibited across the delivery of the project. The Olympic Delivery Authority were committed to ensuring that this was the ‘safest and healthiest build on record’. Through the correct prioritisation of health and safety during the design and build this was the only Olympic build in modern times to be delivered without a fatality.

Many organisations present safety as their number one priority. These businesses have a responsibility to their employees and others; however, their primary goal is to make profit. A director’s statutory duty is to promote the success of the company, usually construed as its financial success. Negative impacts of poor health and safety management are not the top priority. Safety can be one of the company’s values, but financial profitability and business sustainability can often take precedence.

Successful decision-making requires recognition and understanding of many requirements and objectives, their relative importance and how to assess options. Such mitigation requires a specific skill and the selection of who is best placed to advise is an important decision. Those who raise issues may not be best to mitigate - a holistic overview is required.

Each party must have understanding and technical knowledge of their own discipline to be able to contribute to the reasoning, and be appreciative of other disciplines. All must share a commitment to such interfaces. Interdisciplinary knowledge and trust, co-operation and collaboration are key.

Lessons learned from mistakes

Catastrophic events in construction - Low probability but high consequence
In 2011 Research Report 834 was published which focused upon low probability but high consequence safety hazards. It looked to raise awareness around the potential for more major or catastrophic events to occur. It also provided guidance and recommendations. Construction statistics exhibit higher rates of fatalities and lost time due to injuries, and a higher incidence of ill health, compared to other industries. These high probabilities should be recognised and measures put in place.

Lessons learned from failures or good practice can be used to make better decisions in the future. It is important to be aware of possible outcomes from design choices, and historical information can assist in this awareness. In engineering there is probably more written about failures than successes, which is human nature, and more tangible information appears to be learned from failures, through investigations, reports and recommendations. A near-hit - a near-miss is a misnomer - can also provide learning without having an impact upon people, assets or the environment.

Consequences of failure and the results of incidents have impacts upon individuals, their colleagues, and families that far outweigh any improvement or prohibition notices or prosecutions. It is real people that are injured, maimed, or worse. This is not just a statistic, financial cost, or loss of freedom. The physical and psychological impacts of being involved in an incident where someone has been maimed or killed should not be underestimated.

This article does not provide a compendium of lessons learned. It will however share a number of examples to illustrate a few principles.

Lessons are also to be learned and shared from what may appear less hazardous and simpler activities and operations. Significant hazards demand attention and these are usually well-addressed. High risk activities tend to be planned and closely monitored; the oil and gas, petrochemical and utilities industries all adopt process safety to achieve this. Ostensibly simpler activities or operations receive less scrutiny both during design and execution, eg considerations of lateral and longitudinal support in the design, exclusion zones around lifting operations, and the operation or movement of construction plant.

Offshore Windfarm Project Fatality - High profile incidents provide key learning opportunities
In 2010, a worker laying ducts onshore to bring power from an offshore windfarm project was killed after the trench he was working in collapsed. In 2016, this top tier one contractor was fined £2.6m for failing to make an adequate assessment of the works or control the process by which the excavation took place. It is often a combination of failures that results in such incidents, however deeper thinking and a simple analysis of root causes indicates that it was probably lack of information which led to a series of changes that resulted in the death.

Police, Health and Safety Executive (HSE) investigations and considerations by experts take time and create an understandable delay between the incident and the decisions of a court. The Crown Prosecution Service and HSE decide which cases are tried and base their decisions on what can be proven, which often does not appear to be the root cause of the incidents. HSE post-case reporting is necessarily limited to what has been proven in court. Similarly, journalists usually constrain their reporting to HSE press releases and this may not make the learnings obvious. This means that good and useful learning can be overlooked unless some effort is made to elicit the key points.

Liverpool Tower Crane Collapse - The delay potential in sharing lessons learned
The Liverpool tower crane collapse occurred in 2009 and the Court decision was in 2013. This delay required a high-level consideration of facts available at the time of the incident to enable any improvements to practice to be made as soon as possible to prevent reoccurrence.

Sources of knowledge

The professional bodies of the Institution of Structural Engineers (IStructE), Institution of Civil Engineers (ICE) and Association for Project Safety (APS) all have considerable resources of data and information to enable practitioners to become better informed. The HSE and Collaborative Reporting for Safer Structures UK (CROSS-UK) websites are also excellent resources.

The APS is a representative professional body dedicated to working in partnership to eliminate deaths, tackle ill-health, and manage risks throughout the whole life of any project in the built environment.

The HSE is a British public body responsible for the encouragement, regulation and enforcement of workplace health, safety and welfare.

The Institution of Fire Engineers (IFE) is a global professional body for those in the fire sector that seek to increase their knowledge, professional recognition and understanding of fire.

CROSS-UK is a confidential reporting system which allows professionals to report on fire, building regulations and structural safety issues. They are supported by the IStructE, ICE, IFE and HSE. CROSS-AUS and CROSS-US carry out similar roles in Australasia and the United States of America.

Other professional and trade bodies can be considered for their subject expertise and the wisdom of their members.

Using information

Finding relevant information on occasions can require perseverance or direction. So how may this information best be used? The key questions must be:

Does the information exist?
Is it discoverable?
Is it readily accessible?
Can it be readily understood?
Finally, can something be made of the information?

Data can be processed to provide information and may be interpreted to provide knowledge. The challenge is to take the knowledge and convey this as wisdom or learning that can be shared and acted upon. Clearly there are those who can interrogate data and others whose time and skillset are best spent implementing the learning. Not everyone can interrogate data and information in their raw form - it may be better if someone else can do this and provide an overview that can be acted upon. The result will be something more useful and understandable to a larger audience.

Summary

Decisions can only be made with the information and resources that are available. If there is limited information a conditional decision may be made. Timely, accurate and verifiable information aid good decision making. There are a number of roles within this process and these should be recognised as they all contribute to arriving at a correct decision. Information and experience can be drawn internally from within an organisation or externally from recognised sources of knowledge.

Lessons can be learned from within the engineering and construction industry as well as other industries. When an incident report or findings are shared these can be reviewed to see if they are applicable or relevant to our own activities or operations. Realistically could this or something similar impact upon our works or ourselves? Best to learn from the fortune or indeed misfortune of others.

Once a decision has been made and a good solution arrived at it will need to be to communicated. This can include recording it, sharing it and its subsequent implementation. On some occasions the decision may be conditional and reliant upon other factors. If that is the case the addtional factors must be clearly communicated so that they may be recognised and managed. A follow up will verify successful application or identify any shortcomings.

Decision making takes account of many factors and like other aspects of engineering and design there is no substitute to knowledge and experience. Guidance is generally available for most incidences, it is rare for a new scenario to present itself, however when it does, we can all learn from it.

Never be afraid to ask the questions:

What is the worst that could happen?
What if?
Could it happen here?

Finally

This article was prepared in response to the Structural Safety priorities identified in the Institution of Structural Engineer’s 2024 Action Plan introduced at the beginning of 2024. With the internet, there is a myriad of information available, not all of which can be validated or verified. It is crucial to use credible and verifiable sources of information.

No reference to artificial intelligence (AI) has been made. Good engineering skills are still crucial to any adoption of AI as an aid to design, decision-making, as well as management and use of data. A possible benefit may be that it becomes possible to fail faster and learn more quickly, hence working smarter not harder.