An employee gets injured at your jobsite. You make sure the
employee gets the appropriate medical treatment, you fill out the forms
required by the appropriate regulators and your insurance and then you have an
accident investigation.
This is a pretty standard response. The only real question
is “how”, as in, how are we going to get all this done? Some common questions
asked:
How are we going to investigate the accident?
What methods do we use?
Who do we get involved?
How long should it take?
What do we do with the information we find in the investigation?
There are plenty of resources out there designed to help us
answer these questions. There are books, blogs, seminars, training courses and
websites devoted to how to
investigate an accident. We argue about the best methodologies that will give
us the results we want and who should lead the investigation. We discuss what
types of events should be investigated – is it just accidents or also other
events (e.g., close-calls, near-misses)?
One of the puzzling things to us though is that with all of
this discussion about how to
investigate accidents there is very little discussion about why we investigate accidents. After all,
accident investigations cost resources. Someone (or a group of people) have to
take time out of their normal work schedule, stop producing whatever it is they
normally produce, and conduct a proper investigation. Then the organization has
to devote resources to fix whatever problems the investigators find. So
investigations come with a cost. Are they worth it? Why do an investigation?
Now this probably seems like a trivial question to a few of
you and we totally understand why – everyone knows that the reason to investigate accidents is to figure out what went wrong
so you can prevent it from happening again.
Let’s look at this a bit closer. There’s a key assumption
underlying this reason – accidents are
caused by negatives that must be found and removed from the system (or
prevented from having their effect). Something broke, someone failed in
some way, etc. Therefore, the job of an accident investigation is to find the
thing that broke (i.e., the root cause) and fix it (or replace it). Once fixed,
the system is safe and the accident can’t happen again.
There are some problems with this line of thinking though. The
idea that bad things are caused by something failing or breaking is something
that works great for machines. If you’re trying to figure out why your clock
stopped working you look for the part or parts that failed and fix/replace
them. But, if we’re dealing with people and organizations, it doesn’t work that
way. People do things that help them achieve success (or avoid failure).
Therefore if someone does something that we say leads to an accident, to call
that a failure or an error is often a very narrow and limited view.
To illustrate, lets use an example – someone worked on a
piece of machinery without properly de-energizing it (i.e., locking it out).
From the perspective of a safety professional that is a failure, because they
failed to follow a rule. But the person didn’t do what they did because they
wanted to fail. They acted in a way that they believed would help them achieve
success in the environment they were in. Therefore, from another perspective,
there was no failure.
Now, this doesn’t excuse the behavior, but look at how the
reason we investigate (the why) leads
us to specific conclusions. If we take the perspective of finding the broken
part we would often stop here. The employee broke a rule, that’s the broken
part. We might decide to go a little further, look at the supervisors, the
managers, etc. But our inquiry is about why the person didn’t care enough or
didn’t know enough to do what was necessary to stop the accident. Therefore we
always end up in the same place – blame. Someone, somewhere failed. People are
the enemy of safety. Corrective action – name, blame, shame and retrain.
What happens if we take a different perspective – the reason we investigate accidents is to
learn about how our system is working and improve it? This is based on the
idea discussed above, that people do things that help them achieve success, but
sometimes these things also cause accidents. Success and failure (accidents)
have the same causes. Therefore, looking for what broke and trying to fix it
doesn’t work. Instead, figure out how things normally work, i.e., why things
are normally successful, to understand why it didn’t work this time.
Notice right away that by changing why we investigate accidents it changes how we investigate accidents. For example, if we accept the idea
that success and failure have the same cause then methods designed to identify the
faults or failures that led to the accident won’t be very effective. We need
methods that help us understand success, not things that only model failure.
Looking at our example above, if our goal is to learn and
improve it leads us down multiple paths. We can start asking questions about
equipment, working conditions, incentives, communication, culture and how all
of these elements worked together to lead to the behavior in question. In the
process we are free to ask questions unrelated to the accident. We aren’t
constrained by only looking for “cause” anymore. We look at the instance as a
special case of normal work, so if we find something we don’t like, we fix it,
just like we would during non-accident conditions.
So if you want to get more out of your accident
investigations, perhaps rather than asking how to do accident investigations
better, start with the question that seems so obvious no one is asking it – why?
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