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Walk the Line….
A comparison of a Blue Line and Black Line investigation
AIHS Visions Conference 2019
Mark Alston, Facilitator
• Stopped on a ramp.
• Driver exited vehicle.
• Vehicle rolled down ramp and hit a shotcrete rig.
Worker failed to follow procedure.
Worker received a written warning.
Operator retrained in operating light vehicles.
• Stopped on a ramp.
• Driver exited vehicle.
• Vehicle rolled down ramp and hit a wall.
Production Pressure
Supervision
Risk Assessment
Incident Investigations
Change Management
Trade offs
Resource constraints
Normalised deviation
Parking area insufficient
Shortcuts
No field leadership
Time constraints
“Saying an event was caused by error
or not following procedure is like
saying an object fell due to gravity:
it’s always true,
it just doesn’t teach us anything”
Conklin, 2018
Traditional Approach (Black Line) Event
(Edwards)
The problem is, the failure probably was not
linear . . .
. . . and there almost NEVER is one root cause.
Why
Why
Why
Root Cause
Edwards
Blue Line Investigation
Latent Conditions
System Weaknesses
Near Misses
Local Factors
Normal Variability
Errors
Flawed processes
Poor communication
Production pressure
Resource constraints
Change in plans
Fear of reportingSystem Strengths
Design shortcomings
(Conklin/Edwards/Baker/Howe)Incomplete Procedures
Weak Signals
Personal Factors
Surprises
Data
Past Success
Unclear Signals
TradeoffsGoal Conflict
Adaptation
Time
Collection of evidence is key
Focus evidence collection on the Task
Evidence is not just collected in a room
Operational Learning Questions
(Conklin/Edwards/Baker/Howe)
Tell me about your work.
How far back in the process should we start for us to understand?
What does a good day look like (for this process)?
What is very unpredictable?
What is the worst thing that could happen in this process / area?
What near misses have we had?
What tools make the job easier?
What does a bad day look like?
What is very predictable?
Where is it easy to make a mistake?
Operational Learning Questions
(Conklin/Edwards/Baker/Howe)
What did you hear/see/think?
What else should I know?
Was there anything different before or at the time of the event?
How do we put it all together?
Time line leading to the
actual event.
How the work is normally done by the
work force.
Procedures, training, instructions, etc.W.A.I.
W.A.N.
W.A.D.
Long
W.A.I.
W.A.N.
W.A.D.
Examine
these gaps
Long
Mark Alston
Plug it into your model
Don’t be linear
• Gaps will often have
multiple paths; follow
each path.
• Examine the
circumstances.
• Look for good outcomes,
not just where things
went wrong.
• Don’t be restricted to a
preformatted template.
Immotus
immotus.com.au
Safety made Simple
THANK YOU
Mark Alston
Facilitator
t: +61 400 181716
e: mark@immotus.com.au
w: immotus.com.au
www.linkedin.com/in/alstonmark

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Mark Alston

  • 1. Walk the Line…. A comparison of a Blue Line and Black Line investigation AIHS Visions Conference 2019 Mark Alston, Facilitator
  • 2. • Stopped on a ramp. • Driver exited vehicle. • Vehicle rolled down ramp and hit a shotcrete rig.
  • 3. Worker failed to follow procedure.
  • 4. Worker received a written warning. Operator retrained in operating light vehicles.
  • 5. • Stopped on a ramp. • Driver exited vehicle. • Vehicle rolled down ramp and hit a wall.
  • 6. Production Pressure Supervision Risk Assessment Incident Investigations Change Management Trade offs Resource constraints Normalised deviation Parking area insufficient Shortcuts No field leadership Time constraints
  • 7. “Saying an event was caused by error or not following procedure is like saying an object fell due to gravity: it’s always true, it just doesn’t teach us anything” Conklin, 2018
  • 8. Traditional Approach (Black Line) Event (Edwards) The problem is, the failure probably was not linear . . . . . . and there almost NEVER is one root cause. Why Why Why Root Cause Edwards
  • 9. Blue Line Investigation Latent Conditions System Weaknesses Near Misses Local Factors Normal Variability Errors Flawed processes Poor communication Production pressure Resource constraints Change in plans Fear of reportingSystem Strengths Design shortcomings (Conklin/Edwards/Baker/Howe)Incomplete Procedures Weak Signals Personal Factors Surprises Data Past Success Unclear Signals TradeoffsGoal Conflict Adaptation Time
  • 12. Evidence is not just collected in a room
  • 13. Operational Learning Questions (Conklin/Edwards/Baker/Howe) Tell me about your work. How far back in the process should we start for us to understand? What does a good day look like (for this process)? What is very unpredictable? What is the worst thing that could happen in this process / area? What near misses have we had? What tools make the job easier? What does a bad day look like? What is very predictable? Where is it easy to make a mistake?
  • 14. Operational Learning Questions (Conklin/Edwards/Baker/Howe) What did you hear/see/think? What else should I know? Was there anything different before or at the time of the event?
  • 15. How do we put it all together?
  • 16. Time line leading to the actual event. How the work is normally done by the work force. Procedures, training, instructions, etc.W.A.I. W.A.N. W.A.D. Long
  • 19. Plug it into your model
  • 20. Don’t be linear • Gaps will often have multiple paths; follow each path. • Examine the circumstances. • Look for good outcomes, not just where things went wrong. • Don’t be restricted to a preformatted template.
  • 21. Immotus immotus.com.au Safety made Simple THANK YOU Mark Alston Facilitator t: +61 400 181716 e: mark@immotus.com.au w: immotus.com.au www.linkedin.com/in/alstonmark