"If at first you don’t succeed, try, try again."*
*Having first conducted a comprehensive safety investigation, which is not carried out to apportion blame or liability but to make evidence-based safety recommendations with the intention of reducing the likelihood of reoccurrence, and in improving overall safety.
The iconic phrase "If at first you don’t succeed, try, try again" is attributed to Thomas Palmer from his 1840 book, titled The Teacher’s Manual. The phrase highlights the importance of the journey to success, despite the challenges that failure may bring along the way. Since 1840, our understanding of failure, its causes, and the importance of systematically learning about the origins of failure has developed considerably. So too has the importance of providing safety investigation professionals with a level of training and education that allows them to analyse failure and make safety recommendations such that organisations can safely "try again".
This blog post is here to discuss education and training within the context of safety investigation. What it will not discuss, however, are the subjects that will be taught or the skills that will be gained. An outline of these can be found in an array of sources; for example, in aviation, the International Civil Aviation Organisation (ICAO) has produced Cir 298 AN/172, "Training Guidelines for Aircraft Accident Investigators". Rather, this blog post will touch on some key aspects of how safety investigator training is currently delivered, and how this may develop in the future.
Achieving gold in safety investigation training
On 25 May, 2018, at 06:50, a diesel freight train struck two track workers, who were conducting repairs to a void that had formed under a railway sleeper. One of the track workers was fatally injured with the other being seriously injured. At 08:30 the investigating team arrived on site and were met by the rail incident officer (RIO) and the coroner’s officer, who had both arrived some time earlier. For some of the investigators this was their first field deployment and their first learning point was not concerning the application of the skills or techniques that they had learned—rather, it was the realisation that pressure ramps up considerably from the moment you enter the site.
OK, so this was a simulated accident staged on a heritage railway for Cranfield University’s Fundamentals of Accident Investigation short course, and hence injuries were limited to the occasional bruised ego; however, the realism of the scenario is by no means fake. Fidelity is maintained by the painstaking development of a realistic scenario, which is designed to maximise learning and develop competencies that reflect occupational requirements.
This leads onto another crucial aspect, which is that credible training cannot be delivered from an isolated institute—rather, it must be delivered by an organisation that operates from within the heart of the safety investigation community. As safety technology and our understanding of accident causation have progressed, so too has the apparent complexity of the causes and factors that influence an accident.
This presents two factors that have an influence on investigator training. Firstly, there is an increasing need for specialist expertise within an investigation. This concept is also relevant for the delivery of investigator training; there is no substitute for a specialist subject being delivered by a professional, who is qualified, experienced, and who is at the forefront of knowledge. This is reinforced by the second factor, which concerns the downward trend in fatal accidents seen in some sectors. As the frequency of accidents reduces, so too does the opportunity for a national investigation agency to be exposed to major accidents. Therefore, there is a greater emphasis on learning from knowledge that has been established within the wider community of practice.
As Wenger, McDermott and Snyder (2002) state: "This type of knowledge is much more a living process than a static body of information. Communities of practice do not reduce knowledge to an object. They make it an integral part of their activities and interactions, and they serve as a living repository for that knowledge."
Therefore, it is key for safety investigator training to deliver not just from the body of information available, but to operate with representation and support from the community which it is designed to serve.
Nonetheless, teaching and learning is not solely a one-way process where knowledge is transferred from the teacher, to the learner. Training courses aimed at professional investigators, whether newly recruited or experienced, have the added benefit of the experience within the classroom. Each course contains like-minded delegates from many locations throughout the world, all with a significant amount of experience behind them. This makes for enhanced teaching through peer-to-peer learning and, equally as significant, the making of friendships that may reunite one day in the middle of an accident site.
The ever-moving goal posts
In January 2016, business, political, and academic leaders from around the word attended the World Economic Forum being held at Davos, Switzerland. The title of the conference was "Mastering the Fourth Industrial Revolution". Professor Klaus Schwab, founder and executive chairman of the World Economic Forum, described the Fourth Industrial Revolution as: "Previous industrial revolutions liberated humankind from animal power, made mass production possible and brought digital capabilities to billions of people. This Fourth Industrial Revolution is, however, fundamentally different. It is characterized by a range of new technologies that are fusing the physical, digital and biological worlds, impacting all disciplines, economies and industries, and even challenging ideas about what it means to be human" (World Economic Forum, 2018).
The safety investigation community has already benefited from the exponential rise in capabilities of lightweight unmanned aerial vehicles, otherwise referred to as drones. Not until recent years have national investigation agencies had the opportunity of adding a camera-equipped drone to their go-kit, which can be deployed to an array of accident sites, performing duties such as aerial photography, site-mapping, and providing an eye-in-the-sky to assist with identifying missing evidence or potential hazards. The post-processing capabilities of these captured images has also accelerated, with 3D site maps being easily created by the investigation team using powerful and intuitive software.
This is, however, just one very small example of the exponential rise in capabilities of cyber physical systems, and the greater integration into our lives of the internet of things, and networks. So far, we have seen the rise of distance learning and e-learning courses; courses which enable students to access courses remotely and fit within the demands of our busy daily lives. We have also seen course designs developed to place more emphasis on supporting active learners, in creating environments for collaborative working, and in utilising peer learning.
So, what is next regarding the training of accident investigators? It is perhaps too early to say with any certainty. However, whatever direction it takes, it is likely that it will involve greater integration between the investigation community of practice, the learner, and the teaching institute. It is also likely that it will adapt to take advantage of the latest in computer processing power and network connectivity. It has been demonstrated in recent years that significant investigative work can still be undertaken despite limited access to the physical wreckage. This too may be replicated in simulation training, thereby enabling simulations to be created on major investigations, without being constrained by the need to have a physical accident site.
One thing is for sure, though—the importance of delivering training from within the heart of, and in collaboration with, the investigation community will remain.
Wenger, E., McDermott, R., and Snyder, W. M., (2002) A Guide to Managing Knowledge: Cultivating Communities of Practice. Boston: Harvard Business School Press