Last week, we talked about a common response to failure – blame the people involved. Unfortunately, this all too often leads to an ineffective response. We get rid of the “bad apples” but don’t address the real issues. Then we’re frustrated when we never seem to make any progress in our safety performance. In fact, one of the most effective ways to measure safety culture in an organization is to look at how they respond to failures, accidents, incidents, etc. If all they do is point to how the worker screwed up and needs to be retrained or fired then it’s pretty likely that they have a poor culture.
This begs the question – how do we investigate accidents or incidents? Well, as Stephen Covey said – begin with the end in mind. So, first we must ask ourselves what the goal of an accident investigation is. Take a second and thing about it before moving on – what are you hoping to accomplish by investigating accidents?
Got your answer?
Most likely the answer you gave was something along the lines of – to ensure that it doesn’t happen again. That’s a very important goal and if we have repeated accidents then we should focus in that direction. However, that is not the best goal for an accident investigation for at least two reasons.
First, if you really analyze accidents you start to see a striking truth – most accidents happen because of a unique set of factors that come together at just the right time in just the right way. Certainly there are similarities in some of the factors. If you have two incidents involving electricity you’re likely to find some similar causes. But the way these factors come together is often very unique. This means that if you do what is necessary to prevent the individual accident you’re investigating, but you may not prevent the next accident. No two accidents are the same, so the way you would prevent one accident may not prevent the next one.
This leads to the second point – if all we do is prevent one accident at a time we are being very inefficient with our time? Think about our electrical example from earlier. We investigate and determine that the employees involved didn’t follow Lockout/Tagout procedures. We then discipline the employees and call for additional supervision for these safety critical tasks.
Let’s just assume that these controls are effective enough to ensure that no employees violate any Lockout/Tagout procedures ever again in our organization. Does the employees violating a safety critical procedure like Lockout/Tagout signal perhaps that there might be some troubles in other parts of your safety system? Why did the employees feel like it was okay to violate a procedure? Is this common? Were they ever trained? How are hazards, risks, and safety critical processes identified in the facility?
You see, by answering these questions we start to move beyond simply preventing the accident we’re investigating. We start improving the entire safety system. You see, even though each accident is unique, the causes of those accidents are not unique. Think about it this way, if you have a problem with poor supervision or with an inadequate change management process in your organization, would that be a causal factor in numerous different incidents and accidents? Yes!
The thing is, those organizational weaknesses, or latent conditions, as they are sometimes called, are sometimes hard to see… until the accident happens. That’s why when we are doing investigations we need to set our goals higher than simply trying to ensure that the particular accident doesn’t happen again. Before an accident happens the decisions we make about safety and risk are full of gray areas – we don’t know what’s “safe” and what’s not. But after the accident it’s very easy to see how the decisions we made did or did not allow and the accident to happen. Therefore, we must take advantage of that clarify and do what we need to do to identify and fix any problems we find in the system, even if they were only partially responsible for the accident.
This means that the goal of an accident or incident investigation is to improve your organization’s safety system. If our goal is anything less we may miss key opportunities to reduce risks in our organization, meaning that we are likely going to continue to have problems in the future. Maybe not with the same accident or incident, but with the same underlying latent conditions.
So when you’re doing an investigation set your sights high – we’re out to fix all the problems, not just the obvious ones.
Next week we’ll talk about how we do this. Stay tuned!