Improving Incident and Accident Investigations in the South African Construction Industry

Improving incident and accident investigations in the South African construction industry: A human factors/ergonomics perspective

The South African construction sector has been plagued by several highly publicised accidents in the last two years and beyond. This includes, but is not limited to, the following accidents that received wide coverage on news networks, social media and many professional forums:

While these accidents rightly deserve attention, they serve as confirmation that construction safety management systems are safety-critical and remain vulnerable to unwanted events such as accidents and fatalities. The recurrence of similar types of accidents is not only an indication of a failure to learn (Stemn et al., 2018) but suggests that systemic contributory factors that were prevalent before accidents remain in place after the accident and following investigations and implementation of recommendations. These accidents, like many others that do not receive public scrutiny or those that do not get reported or investigated, are a symptom of sub-optimally designed construction safety management systems at various levels and life cycle phases of construction organisations. They further expose the ineffectiveness of currently applied investigation processes that are predominantly framed to find fault in personnel at the sharp end, instead of understanding the prevailing conditions and events that cultivate the conditions that enable accidents.

Based on a review of a number of construction accident investigation reports and findings, there is a consistent pattern of investigations focusing heavily on rule violations and “operator error” while under-reporting contextual factors linked to system design, organisational contributors such as ineffective work planning, limited budgets, insufficient crew for the job demands, production pressure, role ambiguity, subcontractor interfaces and inadequate ergonomic design, among numerous other systemic contributory factors.

The narrow “human-focused” lens typically adopted when conducting construction investigations often produces over-simplified “neatly packaged” root causes or linear cause-effect explanations and a lack of appreciation of the complex, systemic contributors. This often leads to the development of recommendations that are not able to effectively address the factors that negatively contribute to unwanted events. Moreover, these are less likely to lead to sustained positive changes within the construction organisations and system, which ultimately increases the likelihood of recurrence. It should therefore not be a surprise that construction sector incident and injury statistics remain high when compared to other industries. Moreover, the prediction by various industry experts that similar construction accidents are likely to be repeated is not unfounded and should be an urgent call for the construction sector to implement alternative ways to conduct investigations.

The focus should be on shifting the narrative around investigations, using investigation tools that enable systemic reviews of contributory factors, and delving beyond workers’ contributions to accidents in favour of understanding the systemic factors that enable accidents to occur in the first place. Changing the narrative/ discourse around how accidents are viewed will not only shape the investigation approaches/ processes but will also improve the output of investigations. Several practical, human-factors/ergonomics-oriented changes that construction organisations can work towards implementing are provided below.

Five actionable human-factors improvements required for investigations

1. Adopt a systems approach when framing or understanding system outcomes (including accidents and injuries)

2. Context matters

3. Improving the reporting culture for all incidents and near-misses and using accidents as learning opportunities is critical

Linking punitive actions to accidents and other unwanted events has been shown to have a negative impact on the reporting culture (Heraghty et al., 2021). When workers are deterred from reporting, the organisation becomes blind to risks that may manifest or contribute to accidents. While many organisations may feel that a just culture with a no-blame approach reduces accountability and personal responsibility (Sherratt et al., 2023), research has shown that a just culture approach in investigations fosters a learning environment, improves learning, and encourages workers at all levels to report near misses, unsafe conditions.

The recent construction accidents are not due to isolated factors but are a consequence of sustained systemic weaknesses that are not always effectively investigated and addressed in construction organisations and the wider industry. Although construction accidents and incidents may be unwanted events, they present an opportunity for organisations, personnel and even external stakeholders such as clients and safety authorities, to improve their ability to learn from and reduce the likelihood of similar occurrences (Dodshon and Hassall, 2017).

To make meaningful progress in curbing the accidents and injuries across the construction sector, there is a need to use systems-based human factors/ ergonomics methods, frameworks, and approaches. This will allow the construction industry to more proactively manage systemic risk factors and reinforce the need to embed safety earlier in the life cycle phases of construction projects and systems, and may further enable the construction industry to move systematically towards an open, learning environment where accidents investigation outcomes are used an effective safety improvement tool. Human factors and ergonomics research and case studies provide evidence that shifting from reactive, blame-based, superficial investigations to proactive, system-level, learning-oriented investigation methods and approaches can positively assist organisations to more comprehensively identify and manage systemic risks that contribute to occurrences.

Sma Ngcamu-Tukulula (CPE) | Smart Ergonomics