Accident investigations, when done well, provide information that can forever change the safety processes of a facility and of the people involved. Too often, employees see the investigation as management trying to fix blame, and management sees the process as an opportunity to show they are doing a good job, but the employees just don’t follow rules.
Once during an accident investigation, I spoke with an employee who was thrown 20 feet by electrical shock when he attempted to emulate something he had “seen the electrician do”. His eyebrows were singed and he was sore from the fall, but otherwise OK.
Tim: Why do you think that you ended up getting shocked, but that didn’t happen to the electrician when he did it?
Victim: I don’t know, I was just unlucky I guess.
Tim: You mean you were lucky, right?
Victim: No sir. Lucky would have been that I fixed the problem.
If he had done that – reset the breaker and never got a shock, it would likely have been one of the worst outcomes. He would have had a near-miss, a near fatality, and not learned from it. Destined to try and kill himself another day.
We can’t learn from mistakes we don’t recognize. That is why it is important we are willing to observe each other and mention those unseen hazards – rocking the chair backward, rushing down the hallway, picking up a load incorrectly. Does your evaluation process for managers include their positive impact on safe behavior? Perhaps it should.
Thanks, and let’s be careful out there!