Sometimes, even after all the best prevention and correct health and safety measures have been put in place accidents occur, resulting in damage to either personnel, the environment, assets, or to company reputation. All too often the subsequent actions taken, if any, are carried out without a sufficient process or procedure in place to aid in carrying out a thorough investigation.

It is often observed that organisations have no memory; that is to say that the same mistakes are made over and over again. These may be at a low, seemingly trivial, level most of the time; however these trivial slips, mistakes and rule violations can be the pre-cursor to a chain of events which leads to a major accident or incident. It is imperative therefore in order to improve safety performance, that these incidents are thoroughly investigated and that the outcomes are properly communicated to all staff.

The aim of many investigations appears to be to absolve management of any blame whilst making scapegoats of employees, rather than to look at underlying (root) causes and lessons for the future. In part at least such actions by management are understandable; it stems from a fundamental surprise1. The distinction between a situational and a fundamental surprise was made by Lanir in his analysis of the Yom Kippur war and can be extended to other investigations with comparative ease; for instance in the analysis of the Three Mile Island nuclear plant incident2. With what we consider to be good safety management systems in place, it is hard for us to accept that a serious accident or incident could occur unless through the fault of the person who is injured. As a result the investigation is relatively superficial and tends to seek external, incidental reasons for the event when it should include a holistic re-examination of the chain of events that has led to the incident. Whilst sometimes a painful process in acknowledging poor procedures and flawed management, if we are to gain real insight from the process we must be prepared to put our perceptions and deeply-held beliefs on one side.

Field activities in oil spill response represent a particular challenge in their safety management. There are potential conflicts between the need to act quickly to prevent environmental and reputational damage and the need to conduct a full safety assessment and to undertake the clean-up activities safely. Whilst generic risk assessments and safe methods of work can be prepared for a number of pre-identified scenarios, each spill response is different with variables in terrain, oil type, weather conditions, infrastructure, security and so on. There is not access to Fully Developed Safety Case which has been comprehensively reviewed as would be the case, for instance, in the offshore production sector (see, for instance,3). The safe conduct of oil spill clean-up operations places a high reliance on the individuals undertaking the tasks and on the safety culture which is embedded in the organization. Safe working methods are driven by locally produced dynamic risk assessments rather than from static risk assessments, which have been translated into standard operating procedures. Where accidents or incidents do occur it is imperative that they are investigated properly and learning points disseminated across the organization.

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