Investigating Industrial Accidents in a Postmodern World
This seminar is meant for postgraduate students, coroners, police officers, and industrial accident investigators with field experience.
All participants will receive a copy of the book and are asked to pre-read 6 short essays (accidents and disasters) that will be examined during 5 lessons. The seminar is taught by Marc-André Poisson with or without the assistance of Clinton Marquardt, one of Canada’s top Sleep & Fatigue Specialists and former Transportation Safety Board of Canada Human Factors Investigator.
Uncovering and Communicating Failure in Five Phases
Lesson 01 “Whodunit – Deployment Mindset“
Before you deploy to an occurrence site, you must have a basic understanding of how humans make errors — big and small — in everyday life and why it is always easy to find someone to blame.
Participants will be able to understand the basic science of human error and identify the limits to human performance. The dialogue will focus on preparing to uncover human error and human performance during a deployment.
Topics covered:
- Truth comes in different forms
- The science of error
- Slips, lapses, and mistakes
- Poorly adapted plans
- Human performance
Lesson 02 “Whodunit – Using Accident Theories to Pursue Data Gathering“
Back at the office, the investigation team starts digging further into the event, examining the players, the systems, and the environments. This lesson will present how accidents are theorized. You will discuss data gathering and how to develop the factual section of your report.
Participants will be able to understand the science of accident investigation and how to sketch a plan to complete data gathering.
Topics covered:
- Multiple-point failures
- How accidents are theorized
- The dawn of determinism
- The reason for reasoning
- Putting theories into practice
- Work-as-done versus work-as-imagined
Lesson 03 “Whodunit – The Accident Story and Human Factors“
This seminar covers the social perspective of faults. We discuss how we see things according to our birthplace, our gender, our cultural background, and our position in a work environment. This seminar also discusses the steps to take if you want to develop a draft report plan.
Participants will be able to understand the basic science behind social dynamics in a work environment and how to write an outline to an investigation report.
Topics covered:
- Team dynamic and training
- Cultural differences in the workplace
- Gynocentric and traditional perspectives
- Uncovering the human factors behind accidents
- Non-events are not non-factors
Lesson 04 “Whodunit – Finding Common Ground“
We have learned how to develop a story, but we may not all agree on the safety messages. We may not all agree on the story, either. You need to find common ground on what are the salient unsafe acts, unsafe decisions, and unsafe conditions. The common ground is extracted from the result of knowledge accumulated during the investigation. This seminar will discuss that your goal is to produce the safety messages that will render the best safety outcomes and protect the environment.
Participants will be able to understand the need for their organization to agree to an emotional purpose behind their investigation report.
Topics covered:
- Intersubjective view of the world
- Constant evolution of true science
- Positivism has its negative side
- Accumulating knowledge versus sharing wisdom
- The system that creates disasters
- The whodunit effect – going beyond the observed objective phenomena
- Emotional purpose of investigations
Lesson 05 “Whodunit – Communicating in a Post-Modern World“
We now have a story to tell. We now need to learn about the environment in which you will be communicating your findings. This includes stopping and thinking about how the occurrence was perceived at the onset, how people perceive messages and how they might perceive you, the spokesperson. This seminar will help you sketch out a communication plan in our post-modern world.
Participants will be able to better understand the landscape involved in communicating safety messages to companies, various actors (workers), witnesses and the public.
Topics covered:
- Communicating knowledge
- Lying and deceiving come naturally
- Motivated, skeptical, biased, segmented… the public
- Perception vs. reality – an eternal struggle
- Trust is a rare commodity