Posted by Terry Mathis August 23rd, 2013 at www.safetycultureexcellence.com
In the classic movie, Casablanca, whenever a crime took place the police gathered up the “usual suspects” to show that they were taking action. The usual suspects regularly got blamed but were seldom the true guilty parties. At the end of the movie, even when they were sure of who committed the crime, they simply went through the motions to satisfy those in control...
Investigating industrial accidents can fall into the same trap of substituting action for results.
When reading over a recent set of accident investigation forms, I was alarmed at the cut-and-paste wording that seemed to repeat in so many of them. Corrective actions almost always were the same: either change a condition or blame an individual by imposing discipline or retraining. There were no influences or barriers mentioned. It was as if all accidents were caused strictly by conditions or negligence.
Theoretically, neither a condition nor a behavior can be a true “root cause” since they are both caused or influenced by other factors. Conditions don’t cause themselves and behaviors are not always simply the choice of the individual involved. All this emphasizes the need to ask the question “Why?” when investigating accidents. Why was there an oil spill on the floor? Why did you use pliers instead of a wrench? Without getting to the underlying causes we tend to take the easy action of fixing the blame on the usual suspects instead of truly fixing the problem.