What's wrong with 'accident investigations'?
The word 'accident' implies 'a chance occurrence' outside your immediate control. When a child has an 'accident' in his pants, we presume he was not in control. He couldn't help it.
And what about the word 'investigation'? Doesn't this term imply a hunt for some single cause or person to blame for a particular incident, as in 'criminal investigation?' How can we promote fact-finding over fault-finding with a term like 'investigation' defining our job assignment?
To truly learn more about how to prevent injuries from an analysis of an incident, we need to approach the task with a different mindset. It's not 'accident investigation' ? it's 'incident analysis.' This simple substitution of words can have a great impact. We can get more employee participation in the process, and in fact, reap more benefits from the entire process. Here are five reasons to change our thinking ? and our language ? when it comes to the old 'accident investigation.'
Gain a broader understandingA common myth in the safety field holds that injuries are caused by one critical factor - the root cause. 'Ask enough questions,' advises the safety consultant, 'and you'll arrive at the critical factor behind an injury.'
Do you really believe there is a single root cause?
Consider the three sides of 'The Safety Triad:' environmental, behavioral and personal factors that affect safety performance. Environmental factors include tools, equipment, engineering design, climate and housekeeping. Then you have the behaviors, the actions of everyone relating to an incident. Finally, there are the personal, internal states of feeling of the people involved - their attitudes, perceptions, and personality characteristics.
Take a systems approach in your analysis of environmental, behavioral, and personal factors. Then decide which of these factors can be changed to reduce the chance of another unfortunate incident. Environmental factors are usually easiest to define and improve, followed by behavioral factors. Most difficult to define and change directly are the personal factors, but many of these internal feelings can be affected positively by properly influencing behaviors.
Improve communicationTo find and correct the potential contributors to an incident, people need to talk openly about the various environmental, behavioral, and personal factors. But this won't happen if the goal of an 'investigation' is to find a single reason for the 'failure.' People want nothing to do with a failure.
It's human nature. Kids will blame the other kid - 'he made me do it.' Adults will just keep their mouths shut. To get people to open up, we need to approach incident analysis as an opportunity for success. Let's get away from the perspective of incident-equals-failure. The focus should be on how an incident gives us the chance to learn and improve. This can lead to more reports of personal near misses and property damage. The more we report and analyze, the more opportunity we have to correct problems before a major injury to a friend or coworker occurs.
Increase involvementYou can expect more participation in incident reporting and analysis if you involve workers in the actual correction phase of the process. People will contribute more if they have a say in the outcome. Of course, management needs to approve and support the corrections recommended by the workforce. But workers know more than anyone else about what it will take to make environmental, behavioral, and personal factors more safe. Use their critical expertise and you'll motivate more ownership and involvement in the entire process.
Apply systems solutionsHere's how an accident investigation is usually wrapped up: The safety manager presents a report to management, and the recommended solution to eliminating the 'root cause' is implemented in the work area where the incident occurred. An equipment guard might be replaced, or a certain employee might be 'retrained' or even punished (incorrectly referred to as 'disciplined' in the safety literature).
You'll get broader interest and involvement in an incident analysis process if corrective action plans are applied to all relevant work areas. This also promotes a systems perspective rather than the piecemeal, 'band-aid' approach common to so many work cultures. Look at the bigger picture. Use the results of an incident analysis to improve relevant environmental, behavioral and personal factors plant-wide. This sends the kind of actively caring message that not only promotes participation, but also makes that participation more constructive.
Promote accountabilityBoth the quantity and quality of participation in incident analysis depend on the numbers you use to evaluate success or failure. The bottom-line measure - the total recordable injury rate (TRIR) - provides neither instructive guidance nor motivation to continue a particular safety process. It doesn't tell us enough about why we're succeeding or failing.
Instead, keep track of the various components of incident analysis. Monitor the number of near misses, property damage, and injury reports. Track the number of corrective actions implemented for environmental, behavioral and personal factors. Now you have an accountability system that facilitates participation.
Keep the focus on successfully completing these various steps of the process. Keep score of your process achievements rather than only waiting to see a reduction in injuries. This is a more valid and instructive measure of your success than any outcome measure currently available.