Investigating Safety Incidents: The Importance of Reasonable Reliance
Following a serious incident, the investigation process typically starts with documentation but goes beyond that initial step. Certificates, maintenance records, and procedures are scrutinized to ensure competence, compliance, and responsibility. These elements demonstrate that safety was well-planned and managed, establishing diligence in the process.
However, the focus of post-incident scrutiny shifts towards a more precise question: Was it reasonable to depend on the protective system when it was needed the most? This distinction, though subtle, plays a crucial role in evaluating safety management.
Traditionally, safety systems have been designed to showcase preparation through specified, tested, installed, inspected, and maintained processes. These steps provide assurance that the system should function as intended, forming the basis of safety governance within organizations.
Legal accountability, on the other hand, delves into the judgment made in real conditions rather than just the preparation aspect. It evaluates whether decisions taken during critical moments were defensible and reasonable.
When relying on alarms, escape routes, fire doors, or protective devices, a decision is made based on the belief that protection is available. Post-incident investigations focus on determining whether this belief was justified, honing in on the concept of reliance.
While certificates, maintenance records, and inspection reports demonstrate compliance with standards, they do not necessarily reflect the operational state of the system when it was actually relied upon. This gap between compliance and actual operational condition poses a challenge in post-incident scrutiny.
Modern safety systems are dynamic and subject to gradual degradation, configuration changes, and interactions with other systems. The interval-based assurance model, focused on verification at defined points, may not capture the real-time operational state of the system when reliance is placed on it.
As a result, organizations may struggle to demonstrate the condition of protection at critical moments, despite adhering to recognized practices. The issue lies in the visibility of the operational state of the system when reliance is necessary.
Accountability post-incidents becomes complex not due to inactivity but because of the inability to show what was reasonably known about the system’s condition at the time of reliance. Legal expectations emphasize reasonable action based on available information rather than predicting every failure.
Post-incident examinations often go beyond compliance to evaluate reasonable reliance on safety systems. Compliance ensures that appropriate processes were followed, while reasonable reliance examines whether trust in the system was justifiable when it influenced behavior.
Historically, periodic verification served as a proxy for demonstrating the operational condition of safety protections. However, in dynamic modern environments, the gap between compliance and actual operational state becomes more apparent, posing challenges for governance.
Paul Mincher, the Founder and CEO of SAFE-Matter Ltd, introduces the concept of the “Unknown Present” in safety governance, addressing the evidentiary gap between regulatory compliance and demonstrable safety in cyber-physical systems. His research focuses on how organizations can evidence the operational condition of safety protections at critical moments of reliance.
For more information on Paul Mincher and his work, you can visit his LinkedIn profile or reach out to him at [email protected].
