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Taking Action on Incident Investigations

Incidents suck. I know.

But you know what's even worse?

When you have an incident and it's all in vain. No one learns anything. The safety program doesn't improve. Somebody just gets hurt or property gets damaged and every feels like crap and morale goes down and everyone goes on their merry (aka shitty) way. It doesn't have to be that way. Incidents suck, but there CAN be positives that come from them. Read on, friend...

Why did it happen?

Incident investigations aren't good or bad, they're learning opportunities. Yes, the incidents themselves can be bad, but the investigations should start with the goal of "let's figure out how we can stop incidents like this from every happening again". If we conduct a thorough incident investigation but we can't prevent similar incidents from happening, then all that effort is in vain.

In the March 2020 issue of Occupational Health & Safety, Robert Pater's article "Dynamic Leadership Means Going Beyond Asking 'Why?'" really highlights this idea. If you've ever had to conduct an incident investigation you've had to keep asking the "why" questions to get to the root cause of the incident. Maybe you're looking at an incident where someone tripped over some materials.

Q: Why were the materials being stored on the ground? 
A: Because the designated storage rack was full.

Q: Why was the storage rack full?
A: Because we only ordered 1 rack for this project.

Q: Why did we only order 1 rack...

So, you can keep asking "why" until you run into the root cause. Yes, there are steps and methods for determining what's a root cause and what's an intermediate cause, but hopefully you get the idea.

What can I do?

So we've got the answer to our "why" questions: the root cause. Now what? We address the root cause: we make sure people are properly trained, we make sure we have adequate resources to the job, we make sure the people who need to know about changes have been informed, etc... but now we have to ask some "uncomfortable" questions. These questions start with "how" or "what", questions like "How did our safety culture allow this to happen?", or "What can you and I do to prevent the conditions/attitudes that caused the incident?".

With that last question, we're not asking how to prevent a similar incident, we're asking how to prevent the conditions and attitudes that led to the incident happening in the first place. These questions might make some people squirm because they are a bit uncomfortable, but assure participants that the goal is to improve safety, not place blame. 

How did I let this happen?

If you think your workers are uncomfortable with the "what" and "how" questions, now it's your turn to be uncomfortable. Are you an owner? Manager? Partner? Well, you get to ask yourself some uncomfortable questions too. Questions like, "What is our safety culture?", and "Does our safety culture fit with our company vision?" should require deep thought.

If you read our previous blog post where we talked about a manager saying "You're not done the investigation until you tell me why I'm to blame" you can now take that one step further. For owners, managers, and supervisors instead of asking "What is the root cause" you can now ask "How did I let this happen?" and that's a way tougher question, but it will have more satisfying results.

 

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