SCM Safety Newsletter Spring 2019

 In Tip of the Week

 

 

 

 

 

 

The Goal of Investigating Accidents and Incidents

Photo Credit: Market Business News

 

 

 

 

 

 

 

Do you remember a few weeks ago when Facebook was “down” or non-operational for a few days? Facebook had an interesting reaction to the incident. They identified the person who caused the incident, made sure he had learned from his mistake, and with a degree of humor, went on with their business. The person who made that huge mistake was not publicly disgraced or punished internally. Facebook went back on-line, and business went on as usual.

 

That response is often not how every company handles issues. It is more common that when there is an occupational accident or incident, there is an instinctive response to blame the people involved. Unfortunately, this all too often leads to an ineffective response. We get rid of the “bad apples” but don’t address the real issues. Then we’re frustrated when we never seem to make any progress in our safety performance. In fact, one of the most effective ways to measure safety culture in an organization is to look at how they respond to failures, accidents, incidents, etc. If all they do is point to how the worker screwed up and needs to be retrained or fired, then it’s pretty likely that they have a poor culture.

 

This begs the question – how do we investigate accidents or incidents? Well, as Stephen Covey said – begin with the end in mind. So, first we must ask ourselves what the goal of an accident investigation is. Take a second and thing about it before moving on – what are you hoping to accomplish by investigating accidents?

 

Got your answer?

 

Most likely the answer you gave was something along the lines of – to ensure that it doesn’t happen again. That’s a very important goal and if we have repeated accidents then we should focus in that direction. However, that is not the best goal for an accident investigation for at least two reasons.

 

First, if you really analyze accidents you start to see a striking truth – most accidents happen because of a unique set of factors that come together at just the right time in just the right way. Certainly, there are similarities in some of the factors. If you have two incidents involving electricity, you’re likely to find some similar causes. But the way these factors come together is often very unique. This means that if you do what is necessary to prevent the individual accident you’re investigating, but you may not prevent the next accident. No two accidents are the same, so the way you would prevent one accident may not prevent the next one.

 

This leads to the second point – if all we do is prevent one accident at a time, are we being very inefficient with our time? Think about our electrical example from earlier. We investigate and determine that the employees involved didn’t follow Lockout/Tagout procedures. We then discipline the employees and call for additional supervision for these safety critical tasks.

 

Let’s just assume that these controls are effective enough to ensure that no employees violate any Lockout/Tagout procedures ever again in our organization. Does the employees violating a safety critical procedure like Lockout/Tagout signal perhaps that there might be some troubles in other parts of your safety system? Why did the employees feel like it was okay to violate a procedure? Is this common? Were they ever trained? How are hazards, risks, and safety critical processes identified in the facility?

 

You see, by answering these questions we start to move beyond simply preventing the accident we’re investigating. We start improving the entire safety system. You see, even though each accident is unique, the causes of those accidents are not unique. Think about it this way, if you have a problem with poor supervision or with an inadequate change management process in your organization, would that be a causal factor in numerous different incidents and accidents? Yes!

 

The thing is, those organizational weaknesses, or latent conditions, as they are sometimes called, are sometimes hard to see… until the accident happens. That’s why when we are doing investigations, we need to set our goals higher than simply trying to ensure that the particular accident doesn’t happen again. Before an accident happens, the decisions we make about safety and risk are full of gray areas – we don’t know what’s “safe” and what’s not. But after the accident it’s very easy to see how the decisions we made did or did not allow and the accident to happen. Therefore, we must take advantage of that clarify and do what we need to do to identify and fix any problems we find in the system, even if they were only partially responsible for the accident.

 

This means that the goal of an accident or incident investigation is to improve your organization’s safety system. If our goal is anything less, we may miss key opportunities to reduce risks in our organization, meaning that we are likely going to continue to have problems in the future. Maybe not with the same accident or incident, but with the same underlying latent conditions.

 

So, when you’re doing an investigation set your sights high – we’re out to fix all the problems, not just the obvious ones.

 

Here is what the experts are saying:

 

Sidney Dekker: Just Culture
TRUTH or LIE – A Quiz
Many of our regular readers have let us know that they use our monthly quizzes to test their co-workers on safety topics. Today we are going to give you a variety of safety topics, with three true statements and one false statement (or lie). Can you tell which one is the lie? We will provide the answers at the bottom of the newsletter.
1.  Respiratory Protection: Which of these statements is false?
A.  Respirators are to be used only when engineering or other controls cannot provide adequate protection against atmospheric hazards.
B.  Initially, you must have a medical evaluation before you can wear a respirator.
C.  Respirators must be stored so that they are protected from sunlight.
D.  You only need to be fit tested once, before being assigned a respirator.
2.  Confined Spaces: Which of the listed items is not considered part of the definition of a Permit-Required Confined Space?
A.  It is not large enough to enter and perform work.
B.  It has the potential for a hazardous atmosphere.
C.  It is difficult to get into and out of.
D.  It has the potential for an engulfment hazard.
3.  Control of Energy/Lock-Out/Tag-Out: The following is the order of preparing to work on equipment that can be energized.  Which of these steps is out of order?
A.  The machine or equipment is turned off and shut down.
B.  Locks and tags are applied.
C.  Work is performed on the machine or equipment.
D.  Stored energy is released from the machine or equipment.
4.  Personal Fall Arrest Systems (PFAS):  Which of the following is not a component of a PFAS?
A.  Anchorage.
B.  Connector.
C.  Guardrail.
D.  Lanyard.
5.  Ladders:  Ladders have different ratings, based on the amount of weight they can hold.  Which one is not considered acceptable for use in occupational settings?
A.  IA
B.  I
C.  II
D.  III
BONUS QUESTION:  You can’t have a safety quiz without talking about training.  Which of the following training topics is not required annually?
A.  Respiratory Protection.
B.  Use of Fire Extinguishers.
C.  Confined Spaces.
D.  Hearing Protection.
E.  Bloodborne Pathogens.
NEWS YOU CAN USE:
OSHA:  OSHA now offers a weekly safety tip on their website. Their tip for the week is: “Prevent Trench Collapses” You can find it here: https://www.osha.gov.
CDC:  Measles are making a dangerous comeback in the U.S., in some cases, with a tragic outcome. Vaccinations are crucial for children and some adults should have vaccinations before traveling in some areas abroad.  Find out more through the CDC webpage, linked here: https://www.cdc.gov/features/measles
SCM:
Join us in congratulating our President and Founder, Paul Gantt, on his recent completion of a Ph.D. in Human Services! Look for an upcoming article about his exciting dissertation regarding the Value Proposition of a Certified Safety Professional (CSP).
SCM ON THE GO
April 9 – 12:  Ron Gantt, SCM’s Reflect Consulting Group, spoke at the Mining Safety Conference in Lima, Peru.  That’s his picture, above.
May 14: Paul Gantt, SCM, is speaking at the ASSP San Francisco Chapter Awards Dinner and Meeting at Trader Vic’s in Emeryville, CA.  https://sanfrancisco.assp.org/events/?ee=56
June 10:  Ron Gantt is speaking at the ASSP Professional Development Conference in New Orleans, LA.  https://safety.assp.org
June 25:  Ron is speaking at the Health, Safety and Environmental Congress in Houston. (While this is by invitation only, contact us at info@scm-safety.comif you can attend.)  https://www.hsena.co.uk
September 6 – 12:  Ron and Paul are teaming up to speak at the National Safety Council’s National meeting in San Diego, CA. https://congress.nsc.org/nsc2019/public/enter.aspx
UPCOMING TRAINING
HAZWOPER:
5/31/19: 8 hour HAZWOPER Refresher $159. Register here.
6/17 – 19: 24 hour HAZWOPER. $449. Register here.
6/17 – 21: 40 hour HAZWOPER. $559. Register here
6/20 – 21. 16 hour Crossover Module.$250. Register here.
You can register online through the links provided, or call our office at 925-362-2265.
HAZMATSCHOOL.COM
We offer the California Heat Illness Prevention course, the HAZWOPER First Responder Operations course and the Incident Command course online! See them and register at:
We offer discounts and group rates. To see more about our offers, follow this link: Discounts
ANSWERS TO THE QUIZ:
  1. D
  2. A
  3. D
  4. C
  5. D
Bonus: C
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