Dig Deep For Root Causes
The seriousness of an injury is important, but we shouldn't let classifications be our main focus. Two scenarios help explain why:
Going by the bookBill, a pipefitter, was sprayed with acid while removing bolts from a flange. He went directly to a safety shower. Because the acid was thoroughly flushed with water, the injury resulted in minor redness to the skin and was classified as a first aid case.
The incident investigation of a first aid case will be very informal and handled by the immediate supervisor. Finding a root cause may not occur.
If the same incident happened but Bill didn't shower immediately, the acid burn would result in blisters to the skin. The injury would be then classified as an OSHA recordable and thoroughly investigated. A ton of paper work would be generated and Bill would be put in the limelight.
Why is it more important to find the root cause of an OSHA recordable than a first aid case? The potential for serious injury is present in both scenarios. Taking this a step further, the potential of injury and the need to investigate would be present even if there wasn't an injury. If acid blew out, but Bill avoided the spray, we would still need to know about the incident in order to prevent it from happening again.
Tempting fateJim was assisting a crane operator loading pipe onto a flat bed truck. The cable on the crane broke and thousands of pounds of pipe came rolling toward Jim. He jumped aside and fell on the concrete, bumping his knee. Jim was later taken to the nurse's station where a cold compress was applied. This injury was classified as minor or a first aid case.
Because it was a minor injury, the crane incident wasn't looked at closely. The cause was blamed on poor equipment, and the incident was forgotten. Jim knew he had come close to being killed and was concerned when the incident was glossed over.
Two years later another crane incident resulted in a severe injury. After a thorough investigation, it was found that the company supplying the cranes cut corners and did not maintain its equipment.
When the root cause of an injury isn't identified, we tend to put the blame on a person or on something that can be fixed quickly. If we haven't dug deep enough, we stop at the easy answer. In Jim's case we didn't prevent the incident from happening again.
What can be done?Incidents, including near misses, need to be evaluated by asking these questions:
1) How did the incident impact the employee? Even minor injuries can be traumatic.
2) What is the worst-case scenario? When an incident is reported, evaluate the potential for serious injury.
3) What is the likelihood of the incident re-occurring?
4) What can be done immediately to prevent the injury from occurring again?
Here are several long-term steps to change our focus from recordkeeping back to injury prevention:
- Promote the reporting of all incidents. Near miss reporting needs to happen. We can't learn from incidents that aren't reported.
- Evaluate every incident as an opportunity to increase your knowledge of injury prevention.
- Use trained investigators from outside the area where the incident occurred. Investigators need to be proficient at root cause analysis. The simple system of asking a series of "why" questions gets to the root cause in most cases.
Don't get me wrong, we need to pay attention to recordkeeping. The problem occurs when we worry too much about the rating of an injury and how it will reflect on our incidence rate. The work force sees the rating system as nothing more than a numbers game and of little value. Don't get caught in the ratings game.
By Bob Brown, a behavioral training coordinator for a leading Fortune 500 chemical company. Bob is also owner of the consulting firm Blue Collar Safety, and can be reached at (281) 480-1076.